Should Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent?

Robert M. Sade, MD The effects of sleep deprivation on performance of physicians has been widely studied ever since the death of Libby Zion in 1984, the subsequent campaign by her parents and others to regulate physician work hours, and the passage of the so-called Libby Zion Law by New York State in 1989.[1] Impetus was added to investigations of the effects of sleep deprivation when the Accreditation Council for Graduate Medical Education (ACGME) adopted similar standards for accreditation of residency programs in the U.S. in 2003.[2] While sleep deprivation clearly affects mental and physical functioning, results of investigations of clinical outcomes have been mixed, some finding adverse effects on patient care, others finding no such effects.[3-6] The arguments for regulating work hours of residents have been extended to apply in a more limited way to attending surgeons. In a recent issue of the New England Journal of Medicine, sleep specialists published a paper that opens with this scenario: “A surgeon on overnight call responds to an 11 PM call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to ... perform a bowel resection. By the time the procedure is completed ... it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 AM.”[7] The authors follow the vignette with a series of questions: “Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? “Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? “Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? “Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours?“ After discussion of the effects of sleep deprivation (fewer than 2 hours of sleep in the previous 24 hours), the authors answer these questions in the affirmative, with these statements: “...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.“ In the same issue of the Journal, three leaders of the American College of Surgeons, responded to this paper in a letter to the Editor, agreeing that sleep deprivation could be a problem for surgeons, but disputing the necessity or wisdom of mandating a signed informed consent document. They argued that, instead, surgeons should be better educated about the effects of sleep deprivation as well as other factors that may affect performance, enabling them to weigh all issues in order to provide the best patient care. “A call for mandatory disclosure,” they stated, “essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care.”[8] In the essays that follow, two authors of those publications, Dr. Charles Czeisler and Dr. Carlos Pellegrini, present arguments on either side of the question of whether sleep-deprived surgeons should be required to obtain informed consent from patients before elective surgery.