This document discusses differences in perspectives between surgeons and intensivists regarding care of critically ill surgical patients. It notes that while surgeons and intensivists both care for the same patient, they often have different training, cultures, and approaches to decision making. This can lead to a lack of being "on the same page" and mixed messages. The document explores concepts like the "surgical covenant" where surgeons feel a strong responsibility for patients' outcomes, which can conflict with goals of care discussions. It recommends improving communication through early and regular interdisciplinary meetings to resolve contradictions and align on realistic treatment plans and expectations. The goal is for different specialties to work as a coordinated "choir" rather than "parallel universes

1. The implication of the 'covenant of
care’ - are we on the same page?
Hamish Ewing

2. Conflict of Interest
• None to declare

3. Surgeons & Intensivists, are we the same?
“NO”

4. …..……and “YES”!
=

5. My credentials?
• Worked with Prof Corke in the 80’s at RGH
• Recently retired general surgeon from outer
metro hospital
• Involved with RACS training of surgeons, most
recently the TIPS course

6. Are we on the same page?
• All too often…………..”NO”.
• Why is this so?

7. • We are bit like a choir
• We all love music but are singing from
different songsheets
• Or, at best, singing the same song but our
various parts are in different keys or rhythms
• Maybe more than one conductor
………with a discordant result!

8. Who is in our ICU choir?
• Patient
• Patient’s surrogates
• Intensivist(s)
• Non-ICU clinician (surgeon,oncologist,physician)
• Non-ICU clinician’s team
• Nurses
• Social worker
• Allied Health professionals
• Palliative care team
…………………………..Who is conducting this choir ?

9. “What are the differences?”
1. “Surgical covenant”
2. Training (culture)
3. Decision making
4. “Road blocks”

10. 1. Surgical covenant
• Definition
“…is an exchange of promises, & agreement that
shapes the future between two parties” William F May
ie. Surgeon will not abandon patient
• Covenant includes – shared hope
- shared risk
- mutual respect

11. • Carroll - “the surgical covenant is where the patient
agrees to trust surgeon to invade his body & the
surgeon promises to do everything in his/her power
to keep his/her patient alive”
• This translates to “ not dying in ICU post-op”
• Hence conflict over: care goals
mixed messages survival
failure to preserve autonomy
What influences covenant?
- length of history with patient
- surgeon perception of accountability

12. Surgical “Buy-in”: the Contractual Relationship between Surgeons and
Patients that Influences Decisions Regarding Life-Supporting Therapy
Margaret L. Schwarze et al
Crit Care Med. 2010 Mar; 38(3): 843–848
Two scenarios presented to 10 physicians & responses analysed:
• First scenario, elective operation (high risk and specialty
specific) in which the patient remains intubated and on
nutritional support postoperatively. Day 7 patient’s surrogate
presents a previously undisclosed ACD and asks the surgeon
to withdraw life supporting therapy.
• Second scenario, pre-operative assessment & patient brings
an ACD with specific instructions to withdraw life-supporting
measures if they become necessary for a prolonged (but
undefined) period of time.

13. Results
• Informed consent (“the covenant”) is where
patient consents to operation but also
anticipated post-op care
• Result of extensive pre-op discussion
• Informal and undocumented
• Limitation of interventions?
• Days of post-op support defined?
• This can be quite a long shared journey

14. Surgeons
• Responsible for bad outcomes
• Some feel personally taking on patient risk by
operating thus a betrayal if ACD
• Success is expected, thus ACD & post-op
withdrawal support contradictory to goals &
values of surgery.
…….“because we have been educated to be
champions & winners, we have never been
educated to recognise the potential of an adverse
event”

15. • “doing everything” possible protects against error & therefore
defensible psychologically & socially within culture
• “Surgeons see themselves as warrior against disease with absolute
responsibility for the life of the patient that mandates never letting
the patient die”
• “there is an unwillingness to admit defeat”
• Thus …….”they refuse to withdraw support, as any Post-op
Morbidity or Death is personal & not the patient’s failure or failure
of therapy”
• If pre-op ACD, the patient now responsible

16. Patient view
• Surgical “buy-in” may be barrier to obtaining
care in-line with personal preference
• What has been the sell?
• Surgeon physically involved in both consent &
therapy
ie. Responsible for a poor outcome

17. Intensivist
• Often caught in “crossfire” between patient
preference & surgical “rescue effort” having
had no input in pre-op negotiations
• Families (or patient) stress when different
opinions proffered

18. • Can we ethically support “buy-in”?

19. Ethical Issues in Surgical Critical Care: The Complexity of
Interpersonal Relationships in the Surgical Intensive Care Unit
Malini D. Sur, MD, Peter Angelos, MD, PhD
J Intensive Care Med 2016,Vol31(7) 442-450
Stress is experienced by all when complications
- surgeon-patient covenant
- intensivist to balance other patients needs
- patient/surrogates other issues
Transition from curative to palliative
Surgeon - Intensivist
Physician -
Surrogate
Surgeon - Patient Patient - Intensivist Patient - Surrogate

20. Surgeon - Patient
• Surgeon has capacity to help or hurt
• Covenant influenced by first meeting
• Tension between beneficence, non-maleficence &
autonomy
• Pre-emptive - limitations of care
- prolonged life support
* complete “buy-in” = prolonged fight for life
* “hesitance” = easier to withdraw
Emergency “easier” than elective
Effect of surgical error

21. • Intensivist “warrior against suffering”
• Surgeon “warrior against death”
• Pre-op contact improves relationship
- ICU doorway meet is emotionally charged
- leads to distrust as not “fellow traveller”
- patient/surrogates doubt advice
• Risks in rotating responsibility
- Mixed messages – LOS
-End of life
Patient - Intensivist

22. • ICU administrative model important
• Conflict over “futile” & “wasteful”
• 90% Surgeons view they communicate freely &
well
…………… but Intensivists say surgeons run at 23%
Surgeon - Intensivist

23. What about non-Surgeons?!
• Oncologists are also “different”
• ?same reason of ‘buy-in’?
• Often long association with patient
• Widespread overestimation of chemo benefit
• Greater variety of therapies (‘pharmaceuticalization’)
• Admission to ICU is valid but recognising QOL poorly
appreciated

24. Ethical juggling act
Avoid
over -
treat
No
precitpitous
change
Real
expectations
Avoid
prolong
dying
Maintain
ethical
principles

25. 2. Training (culture)
• “Everybody’s business is nobody’s business”
• “Surgery is done by a committee of one”
• Should this read……………“Surgery is done by a
committee that acts as one”?

26. • “The surgeon may in some degree share his
responsibilities with others , but the chief
responsibility must always lie with him. And
being his must be exercised not only during
the operation but also before, perhaps long
before, and also after, perhaps long after, the
operation is performed.”
Berkeley Moynihan, 1865-1936

27. Sociologist Charles Bosk described the heightened sense of ownership
surgeons feel for their patients.
- “ Operative cures and smooth recoveries are seen as personal successes,
while intraoperative complications and poor outcomes are seen as personal
failures”.
- Present complications at M&M conferences they are asked to identify what
was ‘done wrong’ and ‘what could have been done differently’?
- Taught to avoid ‘‘blaming the patient’’ thus never suggesting that the
patient’s own disease-related factors caused a negative outcome
-Complications are usually attributed to technical and judgment errors by the
surgical team, no matter how serious the underlying disease process.
- Interpretation Hippocrates
“First do no harm” =“ First do not allow the patient to die”
but
Death = “I am not good enough”
- guilt, regret, frustration, anger and shame may follow

28. Informal contracts, shared decision-making and the covenant of care
Timothy G Buchman, MD
• Aggressive care on behalf of their patients is a normative
behaviour among surgeons,
…… thus, failure to pursue rescue of a deteriorating patient
is widely regarded as a “normative error”.
• A decision to withhold certain classes of care is thus seen as a
failure to pursue rescue & seeds the discussion of
“unprofessional behaviour” or (worse) evidence of moral
defect.
• Surgeons are thus socialized to use every device and drug in
the armamentarium as a lifesaving tool.
• Perhaps even comforting:?………… patient’s at the edge of life
need the strongest advocates if they are to survive.

29. Common observation is that therapeutic
alliance of ‘choir’ unravels near end of
patient’s life

30. 3. Decision making
Factors influencing Surgeon’s (?non-Intensivist) spin
• Shared journey taken to treatment consent
- acute vs elective
- co-morbidities
- easy or difficult (coercion??)
• Informed consent complete & honest?
- unreasonable expectations
- minimisation of real risk

31. What are the elements of
professional decision making?
 Adequate knowledge and skills
 Situational awareness
 Objectivity
 What is best for the patient?

32. Professional Decision Making
 Avowed
 Unavowed
 Disavowed

33. Professional Decision Making
 Avowed
Patient-centred
 Unavowed
System-centred
 Disavowed
Self-centred

34. Scenario
• Frail, 80-year old woman with obstructing
rectal cancer underwent anterior resection.
Day 3 patient deteriorated with pneumonia &
suspicion anastamotic leak
• Returned to theatre in spite of ACD, &ICU
team suggesting end-of-life decisions, surgeon
adamant all should continue.

35. Avowed decision
“I had to return to theatre, because there
was just too much infection and I was
concerned that the patient might die after all
my efforts undertaking the surgery for her
three days ago”

36. Unavowed decision
“I took her back to theatre as the family (her
surrogates) were insisting that everything
should be done to save the life of their
relative in spite of ACD. If otherwise, I would
not have embarked on this procedure, nor
the initial one”

37. Disavowed decision
“I took her back to theatre, in spite of the
ACD, as I felt guilty for not really exploring
alternatives to surgery for the obstructing
cancer during consent process and also
underselling the implications of post-op
complications and their management.”
Might medicolegal factors influence too?

38. 4. ‘Road Blocks’
• ICU administration model
• Handovers
• Visiting vs full-time
• Age & experience of physician
• Ego

39. ICU-style
‘Surgeons, intensivists, and the covenant of care: Administrative
models and values affecting care at the end of life”
Joan Cassell, PhD; Timothy G. Buchman, PhD, MD; Stephen Streat, FRACP; Ronald
M. Stewart, MD. Crit Care Med 2003 Vol. 31, No. 5
• Studied administrative models & values affecting end-of-life care
• 3 models:
- Open
- ‘semi-closed’
- Closed

40. Open unit
Surgeon led ICU
• “little conflict”!
• “technological imperative” & “keeping alive by
electricity”
• Families consulted when odds “extremely
poor”
• Families seem to take final decision

41. Semi-closed
Surgeon & Intensivist share responsibility
• Divergent views
• Talked past one another
• Different ethics
• Different messages to family
• Rank/standing influential final decision
• ICU bed shortage not time to discuss end-of-life
Surgeon
“looked him in the eye & said I’ll take
care of you”
Quality beside the point
Intensivist
Comfort care
Responsible for all patients in ICU

42. Closed unit
Intensivist led
• Controlled entry as limited access to $’s &
equipment
• End-of-life decisions taken earlier or limits
placed on time of support
• Group decisions - consensus view
• Doctors decide time withdraw care – “not
prolonging dying”

43. Handovers
• Different approach of different staff
• Issue surgeon availability
Me too!
‘Help!’

44. Still more roadblocks
• Visiting vs Full time
• Age & experience
• Ego & past history

45. Way forward?
• if the responsible surgeon
cannot or will not
acknowledge that the
rescue attempt is failing.
• Maybe this is the mirror
to be holding-up?
• But held up with a more
understanding hand
perhaps?

46. • We all need to prepare
• All need to communicate regularly
• All need to respect one another as doctors
• Appreciate our different journeys to this point
• Resolve contradictions before family meetings
• Early & regular inter-disciplinary meetings

47. Some composer’s notes for the choir
• “Doing something is sometimes worse than doing nothing”
Gail Waldby
• “It’s just easier to offer false hope than bitter truth”
Mark Pleatman
• “A palliative operation should palliate the patient, not the
surgeon”
• “ The surgeon whom I would select to tend my family must
first know when not to cut, how to cut, and when to stop
cutting”
Charles W Mayo, 1865 - 1939
Surgeons in the
^

48. Summary
“Yes, non-ICU physicians may be different”
but
“Yes, we are all caring for the same patient”
and
“ Yes, we can definitely do better”
Like an ‘a capella’ choir, we do need to ‘hear’ one another’s
song-line during the choral performance
…..as the song is our patient
“Thank You”

50. Interdisciplinary Meetings
• Early and often as needed
• Involve surgeon, ICU and other staff
• Communicate beforehand ? Check-list roles
• ACD or patient prior wishes documented
• Treatment plans + realistic risk:benefit ratio
• Time limited trials helpful….refocus/cope with
change
• “Triage tool” required?

51. 5th International Consensus
Conference in Critical Care
…….“decision to limit treatment in the ICU should be based on
autonomy, the certainty that the applied treatment benefits &
does not harm & the fair resource allocation”
• Transition from curative to palliative difficult
• Role for 6-day trial
• Avoid overtreatment
• Avoid precipitous withdrawal care
• Do not raise unrealistic expectations
• Document patient wishes on admission ICU
• ‘quality of dying’ important not the ‘prolonging of death’

52. It’s a Parallel Universe – An analysis of
communication between surgeons & intensivists
Haas et al
• Good = shared challenge
• + valued expertise
• Bad = working to different goals
• + expertise not valued
• Two parallel communication systems

53. “It’s parallel universes”
Communication Structures and Processes: Organizational
Factors
Formal communication structures and processes
• Documentation in the medical record
• Paging system
• Morning rounds
• Communication networks based on heirarchy
Informal communication structures and processes
• Texting, instant messaging, e-mail
• Unplanned, face-to-face communication
• Communication networks based on personal relationships

54. Surgical “buy-in” Schwartze

55. A response to this article
“For these reasons, we maintain that a focus on primary
or ultimate responsibility is a distraction from the critical
matter of providing patients with the multidisciplinary
care they need. To achieve this goal, the focus should be
on teamwork, communication, and collaboration in a
nonhierarchical, collegial manner, not on who is captain
of the ship.”
Michael Nurok, MBChB, PhD, Cardiac Surgery Intensive
Care Unit, Division of Cardiothoracic Surgery, Cedars-Sinai
Heart Institute

56. • Pre-op contact improves relationship
• ICU doorway meet is emotionally charged
• Leads to distrust as not “fellow traveller”
• Surrogates doubt advice
- “no chance survival” 64% doubt opinion
- “1% survival” 32% favour ongoing ventilation
- “no survival” 18% favour ongoing ventilation
Physician - Surrogate

57. • What is the role of ACD?
• Only 25% had documented surrogate nominated
• NZ demands ACD or “ care goals” be
documented prior to leaving ED for all
emergency admissions
• Issues of patient & surrogate based factors
Patient - Surrogate

58. Critically ill cancer patient in intensive care unit: Issues that arise
Eirini Kostakou, MD, Nikoletta Rovina, MD, Magdalini Kyriakopoulou, MD, Nikolaos G. Koulouris, MD, Antonia
Koutsoukou, MD,
Journal of Critical Care 29 (2014) 817–822
• 20% of patients not admitted because they were
considered “too well” died before hospital discharge,
and 25% of the patients who were not admitted
because they were considered “too sick” survived.
• Early intervention prevents ‘self-fulfilling’ prophecy
• Inaccurate clinical judgment by the intensivists; thus a
need for reliable predictors of outcome

59. Drugs, cancer and end-of-life care: A case study of
pharmaceuticalization?
Social Science & Medicine
Volume 131, April 2015, Pages 207–214
• Intensive chemotherapy use near the end-of-life
is not, in itself, evidence of harm.
• But a number experience poorer QOL & poorer
death
• Do not live longer than patients not receiving
such therapy.
• On the contrary, in one recent randomized
study less use of intravenous chemotherapy was
strongly associated with increased survival.