The New England Journal of Medicine has published an article by Michael Nurok, M.D., Ph.D., Charles A. Czeisler, Ph.D., M.D., and Lisa Soleymani Lehmann, M.D., Ph.D., N Engl J Med 2010; 363:2577-2579 December 30, 2010 discussing the ethical and legal issues of doctors who perform elective surgeries while sleep deprived.
As the article references, we all know that a lack of sleep can significantly interfere with our ability to concentrate and to perform our work. Sleep deprivation adversely affects clinical performance and impairs psychomotor performance as severely as alcohol intoxication. See Pellegrini, Carlos A., Britt, L.D., Hoyt, David B., (2010) Sleep Deprivation and Elective Surgery. New England Journal of Medicine 363:27, 2672-2673. Chronic sleep deprivation degrades one’s ability to recognize the impairments induced by sleep loss. Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state, and they should not be permitted to decide whether or not to proceed with elective surgery without obtaining the patient’s informed consent.
What happens when a doctor is sleep deprived and is scheduled to perform an elective surgery. The Accreditation Council for Graduate Medical Education has revised its regulations regarding residents’ work hours to restrict trainees who are in their first postgraduate year to a maximum of 16 hours of continuous work followed by a minimum of 8 hours off duty.2 No such regulations exist for fully trained physicians.
There are a number of different ethical and legal questions that arise when the doctor is sleep deprived and is scheduled to perform an elective procedure.
Does the surgeon have an obligation to disclose to the patient that he or she has not slept during the past 24 hours?
Does a sleep deprived doctor need to obtain a new informed consent from a patient?
Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon?
What is the obligation of the hospital when a sleep-deprived doctor is scheduled to perform an elective procedure?
Fatigue from sleep deficiency may be due to the loss of one night’s sleep, chronic insufficient sleep, repeated interruptions of sleep, or misalignment of the circadian phase – which may be attributable to long work shifts, long workweeks, a sleep disorder, or personal circumstances. Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance.
In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night.
Not surprisingly, the article cites surveys which indicate that most patients would be concerned about their safety if they knew that their doctor had been awake for 24 hours and would want to be informed of sleep deprivation; Most patients, 80% of patients, say they would request a different provider in such circumstances.
Given the data on sleep deprivation, the associated risk of surgical complications, and patient preferences, the authors believe that hospitals should prohibit the performance of elective surgical procedures when an attending surgeon or anesthesiologist is acutely sleep-deprived – and should ensure priority rescheduling of the canceled surgery. They recommend institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived. In addition, patients should be empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.
The Sleep Research Society (SRS) has endorsed model legislation that would require physicians who have been awake for 22 of the previous 24 hours to “inform their patients of the extent and potential safety impact of their sleep deprivation and to obtain consent from such patients prior to providing clinical care or performing any medical or surgical procedures.” The American Academy of Sleep Medicine and the SRS have also endorsed model drowsy-driving legislation stipulating that the functioning of a person who has been awake for more than 22 of the previous 24 hours is impaired by sleep deprivation (www.sleepresearchsociety.org/GovernmentAffairs.aspx).
In keeping with the ethical and legal standards of informed consent, patients awaiting a scheduled elective surgery should be explicitly informed about possible impairments induced by sleep deprivation and the increased risk of complications. They should then be given the choice of proceeding with the surgery, rescheduling it, or proceeding with a different physician. If patients decide to proceed, they should explicitly consent to do so – in writing, on the day of the procedure, in front of a witness, and ideally on a standardized form designed for this purpose.
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