Medical ethics play a role in all specialties. However, the medical ethics literature specific to the field of urology is underdeveloped. We present the case of an elderly man with dementia who needs consideration for transurethral prostatectomy (TURP) because of urinary retention. The goal of this case presentation and literature review is to analyze the complexities of ethical decision making and how it applies to a clinical case that a general urologist will see on a regular basis. Just in this brief and common case, the topics of advance directives (ADs), decisional capacity, surrogate decision making, best interest, substituted judgment and informed consent can arise. There exist complicated ethical scenarios, some of which are unique to urology, that need to be presented and discussed as part of the larger ethical discourse.

Introduction and Literature Review

Urologists are faced with ethical dilemmas on a daily basis, but the essential textbooks of urology have little to no significant discussion of ethics in multivolume sets. ^1,2 One of the few such statements surrounds the issue of postmortem sperm retrieval and states that “the ethical appropriateness of such retrieval is the most important issue surrounding its use” without any specific guidance as to what is ethically appropriate. ¹ The Accreditation Council for Graduate Medical Education (ACGME) has identified 6 general ethical competencies for residents in training, which include respect for patients, responsiveness to patients’ needs, accountability, commitment to furthering one’s own education, confidentiality and cultural competency. It is unclear from published studies and sources to what extent urology residency programs are providing training or education in these areas.

There are few published articles addressing ethical issues in clinical urology. One article highlights the great variability in how medical professionals of different ages and levels of training respond to different ethical dilemmas. ³ In the paper, a group of urologists, medical students, residents and risk managers were presented with 10 ethical dilemmas in urology. The authors found that younger practitioners were less likely to hold a paternalistic view of shared decision making. This study also identified a lack of understanding of mandatory reporting, the laws surrounding sexually transmitted infections testing disclosure in adolescents and the need to disclose a cancer diagnosis. There is little concordance among the different groups on how to handle ethically challenging scenarios. In another paper, Mohan discusses several areas of ethical interests to urologists. ⁴ One discussion relates to whether true informed consent is obtained when a surgeon workshop utilizes a visiting surgeon. A second discussion includes the conflict of interest that exists between conducting clinical trials with new pharmaceuticals or surgical products and what is in our patients’ best interests. Lastly, there are issues with surgical innovation when new technology that does not have to meet institutional review board approval has outcomes that are unknown and untested. Thomas explored ethical and legal issues in urology practice, encouraging physicians to remain knowledgeable about local and federal laws that regulate them as well as the increasing litigation of physicians practicing in good faith. ⁵ Despite this acknowledgment, guidance on how to address each dilemma from an ethics standpoint is lacking. ³

We present and analyze a typical urology case to highlight the numerous ethical concepts inherent in the case, reviewing each of them in turn. We hope that this case analysis will help urologists to think about how they make the decisions they make every day during clinical care of their patients.

Case Presentation

Mr. Jones is a 75-year-old male with mild dementia who presents with immediate urinary retention following an emergent cholecystectomy for acute cholecystitis. He otherwise did well postoperatively and recovered well from the anesthetic. During his hospitalization, he experiences delirium with waxing and waning decisional capacity. During an episode of delirium, he experiences urethral trauma when he pulls out his catheter while confused. He has a history of mild dementia and resides in a memory care unit of a nursing home. His daughter is his closest relative, and he also has 2 sons. The daughter and patient present to the office to discuss management of his urinary retention. He has tolerated the catheter better at the nursing home but he clearly has periods of agitation related to its presence. He has been on tamsulosin and finasteride for management of his benign prostatic hyperplasia for 3 years prior to this episode. A voiding trial is attempted in the office, where he is only able to void 80 ml, with a post-void bladder volume of 400 ml. The indwelling catheter is replaced because he cannot cognitively master the ability to perform in-and-out catheterization. The urologist begins the discussion about TURP with the patient and daughter.

Does the Patient Have Written Advance Directives?

Written ADs are designed to provide guidance for care and treatment at a future time when patients lose the capacity to make their own decisions. The goals of ADs are to designate surrogate decision makers, stimulate discussions around end of life care, communicate end of life choices and remove some of the burden on the family to make difficult choices when they arise. Unfortunately, only 20% to 30% of adults have some type of advance directive. ⁹ ADs provide a starting point of discussion between the patient and their caregivers as well as a framework within which to understand patients’ authentic preferences. This allows the clinician to consider the risks and benefits of a given treatment option within the framework of the patient’s values and preferences as understood by a knowledgeable surrogate in a more data-rich way. Advance directives have disadvantages, including their lack of specificity, difficulty in interpreting expressed wishes in the context of complex medical circumstances and the lack of updates to the documents as frailty and prognosis change. The “desirability of interventions often changes in the face of this new reality.” ⁶ The Patient Self Determination Act of 1990 requires hospitals to ask for an advance directive on hospital admission but does not specify assistance in facilitating its completion. Examples of ADs include durable power of attorney for health care documents, living wills and physician orders for life-sustaining treatment (POLST).

The living will is a written document specifying preferences for life prolonging treatments at the end of life. A living will can be drawn up at any time in someone’s life with the knowledge that a trauma or life-threatening condition can happen at any time. An attorney is not needed to create a living will, but it does require a witness and/or a notary. The living will can specify comfort measures only or instruct a withdrawal of life prolonging treatments once a terminal diagnosis is made and the physician believes that death is likely. ⁷ It also specifies the desire for and/or refusal of artificial nutrition and hydration in the setting of a terminal illness. ⁸ These documents are encouraged to be updated at least once per decade and are revocable at any time. The limitations of living wills surround the inability to apply them to specific situations, the interpretation by the care providers, the varying ability of patients to cope with new disability and patients’ preferences, which may evolve over time. ⁷

The POLST form is the “physician orders for life-sustaining treatment.” It is a standardized, actionable medical order set that transfers end-of-life care orders between care settings. POLST forms specify that the order set can only be created once a patient has a life expectancy of less than 1 year. The orders address code status, goals of care, antibiotic use and artificial nutrition. The form applies even in an emergency situation and acts as an order for emergency responders. Section A addresses code status. Section B determines if the goal of care is for comfort measures, limited interventions without the use of intubation or intensive care unit services, or full interventions. Section C describes the reason for antibiotic use, such as for therapeutic vs comfort measures only. Section D states whether a patient would desire no artificial nutrition, a time-limited trial or long-term artificial nutrition. For the document to be valid, the POLST requires a physician signature and the patient’s or legal guardian’s signature (appointed guardian, health care power of attorney or health care representative). The document cannot be signed by a default surrogate decision maker. ⁹ The goal of the POLST form is to promote patient autonomy, clarify treatment intentions and facilitate appropriate treatment by emergency medical services. ¹⁰ As of August 2017, there were 23 developing states and 21 endorsed states with POLST forms available. ¹¹ One important part of the legislation is that there is legal protection for physicians who comply with the orders on a POLST form.

In order to proceed with surgery in this patient’s case, it would be appropriate to establish goals of care with the patient and his daughter. Did he determine he would want everything done, including a palliative surgery? Did he wish for comfort measures only on the previous documents? If he wished for comfort measures only, then maintaining the catheter may be the best option as it would be the least invasive method of managing his urinary retention. If he specified more aggressive measures, then consideration of a TURP is appropriate. Mr. Jones does have an advance directive in the form of a living will. It states that “I do NOT want a feeding tube if I have a terminal illness, I do WANT life-sustaining procedures used if I am in a persistent vegetative state, and I do WANT a feeding tube if I am in a persistent vegetative state.” Based on the information in the advance directive and previously giving consent for his recent cholecystectomy, it seems likely he would accept interventions in a state of advanced dementia. ¹² In his advance directive, he was willing to undergo medical procedures even when his physical state was more impaired (persistent vegetative state). This would suggest that this endoscopic surgery aligns with these values and preferences and, therefore, proceeding with the TURP would be consistent with his previously expressed wishes, which predate his dementia.

This article is part 1 of a 2-part series. In part 2, which will appear in the March issue of AUA News, we will examine whether the patient had the capacity to make the decision for surgery, as well as the informed consent process.