Ethical issues in the perioperative management of neurologic patients

The perioperative care of patients who have diseases of the nervous system provides the setting for challenging ethical issues. In the preoperative period, these issues include obtaining informed consent for surgery and its complications, surrogate decision making for the neurologically incapacitated patient, the use of advance directives for medical care, and the temporary suspension of do-not-resuscitate orders during the perioperative period. During postoperative care, ethical issues include establishing and communicating prognosis in patients who are brain damaged, a trial of therapy when prognosis remains uncertain, surrogate consent and refusal of life-sustaining therapy in the neurologically impaired patient, and the management of brain death. Each of these topics is analyzed briefly, its essential aspects reviewed and an approach offered that the author finds most useful in practice. Space limitations prevent an exhaustive review of each topic, many of which are complex and remain controversial. The interested reader can find an analysis of most of these topics in greater detail in the author's monograph on neurologic ethics [1].