While regulations have been put in place to restrict the work hours of doctors in training, no such regulations exist for fully trained physicians. An editorial in this week's New England Journal of Medicine argues that sleep-deprived physicians should not be permitted to proceed with an elective surgery without a patient's informed, written consent.
According to the authors, "This approach would represent a fundamental shift in the responsibility patients are asked to assume in making decisions about their own care and might prove burdensome to patients and physicians and damaging to the patient-physician relationship." They further write that "this shift may be necessary until institutions take the responsibility for ensuring that patients rarely face such dilemmas."
Studies have shown that sleep deprivation impairs psychomotor performance as severely as alcohol intoxication. A 2009 study in the Journal of the American Medical Association showed a significant increase in the risk of complications in patients who underwent elective daytime surgical procedures performed by attending surgeons who had less than a six-hour opportunity for sleep during a previous on-call night. Further complicating the matter, people who are sleep-deprived are often not able to accurately assess their degree of self-impairment. Surveys have also revealed that the majority of patients undergoing elective surgery would request a different provider if they knew that their surgeon was sleep deprived.
"Sleep deprivation affects clinical performance. It increases the risks of complications. And it is clear from survey data that patients would want to be informed if their physician was sleep deprived and that most patients would request a different provider," said Michael Nurok, M.D., Ph.D., an anesthesiologist and intensive care physician at Hospital for Special Surgery who is first author of the editorial. "We think that institutions have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians."
These days, some hospitals take steps to minimize the likelihood that a surgeon will be scheduled to conduct an elective surgery in a sleep-deprived state. For example, some busy practices prohibit scheduling surgeries for physicians on post-call days. But not enough is being done. "A lot of institutions are not going to be able to take that leap immediately, so as an interim step, we believe that patients need to be informed," Dr. Nurok said. "This is going to be a policy issue that develops. Elective surgery is the low hanging fruit because there is no urgency to doing it and it can be rescheduled -- ideally as a priority with institutional support. It's a nice place to start to think about policy approaches."
The editorial argues that sleep-deprived physicians should be required to inform patients of their condition and the potential hazards that can come with this impairment. If patients opt to proceed as planned, they should be required to sign a consent form on the day of the procedure in front of a witness. Patients should be given the opportunity to go ahead with the procedure, proceed with a different physician if possible, or reschedule. The Sleep Research Society and American Academy of Sleep Medicine have argued that legislation is needed to address fatigue.
The editorial authors identify a number of barriers that may make this informed consent and surgery rescheduling unpopular with patients and physicians. Patients may have made logistical provisions for their surgery and may be unhappy if they have to reorganize their schedule again. Clinicians may lose cases to colleagues and thus income. Departments and institutions may lose income if patients reschedule and seek treatment elsewhere.
And while the study authors acknowledge that there may be financial and administrative costs associated with any informed consent plan, they argue that the costs may be offset by improved surgical outcomes and reduced complications.
"There has been widespread discomfort with the idea that patients are having procedures performed by physicians who are fatigued," Dr. Nurok said. "New policies are needed."
Dr. Nurok is also a member of the Department of Global Health and Social Medicine at Harvard Medical School.
Co-authors of the study include Charles A. Czeisler, M.D., Ph.D., of the Division of Sleep Medicine at Brigham and Women's Hospital and Division of Sleep Medicine at Harvard Medical School; and Lisa Soleymani Lehmann, M.D., Ph.D., from the Center for Bioethics at Brigham and Women's Hospital and the Division of Medical Ethics at Harvard Medical School.
- Michael Nurok, Charles A. Czeisler, Lisa Soleymani Lehmann. Sleep Deprivation, Elective Surgical Procedures, and Informed Consent. New England Journal of Medicine, 2010; 363 (27): 2577 DOI: 10.1056/NEJMp1007901
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