Fatigue and the Care of Patients

  • Richard J. KellyEmail author
  • Chen Nisynboim


This chapter examines the ethical questions that are raised by fatigued medical professionals in the care of their patients. The chapter starts with a review of the science of sleep deprivation and explains why fatigued physicians are at high risk for medical errors. The chapter then provides an ethical analysis of fatigue in the context of physicians’ duties to their patients and arrives at the conclusion that physicians who treat patients while impaired by fatigue violate certain ethical responsibilities to their patients. The chapter finishes up with a review of the current regulation of physician work hours in the United States and shows that, while progress has been made, there may be a need to establish coherent and enforceable limitations on work hours for all practicing physicians.


Fatigue Ethics Sleep Deprivation Physician Work Hours 


  1. 1.
    William Osler BM. A life in medicine. Oxford: Oxford University Press; 1999.Google Scholar
  2. 2.
    Dinges DF, Kribbs NB. Performing while sleepy: effects of experimentally-induced sleepiness. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester: Wiley; 1991. p. 97–128.Google Scholar
  3. 3.
    Bonnet MH. Sleep deprivation. Princ Pract Sleep Med. 2000;2:50–67.Google Scholar
  4. 4.
    Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26(2):117–26.CrossRefPubMedGoogle Scholar
  5. 5.
    Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep. 1996;19(4):318–26.CrossRefPubMedGoogle Scholar
  6. 6.
    Dinges DF, Pack F, Williams K, Gillen KA, Powell JW, Ott GE, et al. Cumulative sleepiness, mood disturbance and psychomotor vigilance performance decrements during a week of sleep restricted to 4–5 hours per night. Sleep: J Sleep Res Sleep Med. 1997;20(4):267–77.Google Scholar
  7. 7.
    NHTSA. National Highway Traffic Safety Administration Report [online]. Available from URL: Accessed 15 May 2015.
  8. 8.
    Alhola P, Polo-Kantola P. Sleep deprivation: impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3(5):553–67.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Dorrian J, Lamond N, Dawson D. The ability to self-monitor performance when fatigued. J Sleep Res. 2000;9(2):137–44.CrossRefPubMedGoogle Scholar
  10. 10.
    Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28(11):1392–402.CrossRefPubMedGoogle Scholar
  11. 11.
    Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235.CrossRefPubMedGoogle Scholar
  12. 12.
    Carskadon MA, Dement WC. Cumulative effects of sleep restriction on daytime sleepiness. Psychophysiology. 1981;18(2):107–13.CrossRefPubMedGoogle Scholar
  13. 13.
    Cohen DA, Wang W, Wyatt JK, Kronauer RE, Dijk DJ, Czeisler CA, et al. Uncovering residual effects of chronic sleep loss on human performance. Sci Translat Med. 2010;2(14):14ra3.CrossRefGoogle Scholar
  14. 14.
    Downey R, Bonnet MH. Performance during frequent sleep disruption. Sleep. 1987;10(4):354–63.CrossRefPubMedGoogle Scholar
  15. 15.
    Jewett ME, Wyatt JK, Ritz-De Cecco A, Khalsa SB, Dijk DJ, Czeisler CA. Time course of sleep inertia dissipation in human performance and alertness. J Sleep Res. 1999;8(1):1–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Van Dongen HP, Baynard MD, Maislin G, Dinges DF. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep. 2004;27(3):423–33.PubMedGoogle Scholar
  17. 17.
    Van Dongen HP, Vitellaro KM, Dinges DF. Individual differences in adult human sleep and wakefulness: Leitmotif for a research agenda. Sleep. 2005;28(4):479–96.CrossRefPubMedGoogle Scholar
  18. 18.
    Smith SS, Kilby S, Jorgensen G, Douglas JA. Napping and nightshift work: effects of a short nap on psychomotor vigilance and subjective sleepiness in health workers. Sleep Biol Rhythm. 2007;5(2):117–25.CrossRefGoogle Scholar
  19. 19.
    Asaoka S, Fukuda K, Murphy TI, Abe T, Inoue Y. The effects of a nighttime nap on the error-monitoring functions during extended wakefulness. Sleep. 2012;35(6):871–8.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Smith-Coggins R, Howard SK, Mac DT, Wang C, Kwan S, Rosekind MR, et al. Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med. 2006;48(5):596–604. e1–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Sugden C, Aggarwal R, Housden C, Sahakian BJ, Darzi A. Pharmacological enhancement of performance in doctors. BMJ (Clinical Research Ed). 2010;340:c2542.CrossRefGoogle Scholar
  22. 22.
    Crozier TW, Stalmach A, Lean ME, Crozier A. Espresso coffees, caffeine and chlorogenic acid intake: potential health implications. Food Funct. 2012;3(1):30–3.CrossRefPubMedGoogle Scholar
  23. 23.
    Aggarwal R, Mishra A, Crochet P, Sirimanna P, Darzi A. Effect of caffeine and taurine on simulated laparoscopy performed following sleep deprivation. Br J Surg. 2011;98(11):1666–72.CrossRefPubMedGoogle Scholar
  24. 24.
    Killgore WD, Kahn-Greene ET, Grugle NL, Killgore DB, Balkin TJ. Sustaining executive functions during sleep deprivation: a comparison of caffeine, dextroamphetamine, and modafinil. Sleep. 2009;32(2):205–16.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Gallopin T, Luppi P, Rambert F. Effect of the wake-promoting agent Modafinil on sleep-promoting neurons from the ventrolater-al preoptic nucleus: an in vitro pharmacologic study. Sleep. 2004;27(1):19–25.PubMedGoogle Scholar
  26. 26.
    Lagarde D, Milhaud C. Electroencephalographic effects of modafinil, an alpha-1-adrenergic psychostimulant, on the sleep of rhesus monkeys. Sleep: J Sleep Res Sleep Med. 1990;13(5):441–8.CrossRefGoogle Scholar
  27. 27.
    Lin J, Gervasoni D, Hou Y, Vanni‐Mercier G, Rambert F, Frydman A, et al. Effects of amphetamine and modafinil on the sleep/wake cycle during experimental hypersomnia induced by sleep deprivation in the cat. J Sleep Res. 2000;9(1):89–96.CrossRefPubMedGoogle Scholar
  28. 28.
    Tourev M, Sallanon-Moulin M, Jouvet M. Awakening properties of modafinil without paradoxical sleep rebound: comparative study with amphetamine in the rat. Neurosci Lett. 1995;189(1):43–6.CrossRefGoogle Scholar
  29. 29.
    Edgar DM, Seidel WF. Modafinil induces wakefulness without intensifying motor activity or subsequent rebound hypersomnolence in the rat. J Pharmacol Exp Ther. 1997;283(2):757–69.PubMedGoogle Scholar
  30. 30.
    Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243–6.Google Scholar
  31. 31.
    Lamond N, Dawson D. Quantifying the performance impairment associated with fatigue. J Sleep Res. 1999;8(4):255–62.CrossRefPubMedGoogle Scholar
  32. 32.
    Mercurio MR, Peterec SM. Attending physician work hours: ethical considerations and the last doctor standing. Pediatrics. 2009;124(2):758–62.CrossRefPubMedGoogle Scholar
  33. 33.
    Czeisler CA, Pellegrini CA, Sade RM. Should sleep-deprived surgeons be prohibited from operating without patients’ consent? Ann Thorac Surg. 2013;95(2):757–66.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Blum AB, Raiszadeh F, Shea S, Mermin D, Lurie P, Landrigan CP, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Pellegrini CA, Britt LD, Hoyt DB. Sleep deprivation and elective surgery. N Engl J Med. 2010;363(27):2672–3.CrossRefPubMedGoogle Scholar
  36. 36.
    Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ (Clin Res Ed). 2008;336(7642):488–91.CrossRefGoogle Scholar
  37. 37.
    West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–67.CrossRefPubMedGoogle Scholar
  39. 39.
    Van Eaton EG, Horvath KD, Pellegrini CA. Professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. Arch Surg. 2005;140(3):230–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Mukherjee S. A precarious exchange. N Engl J Med. 2004;351(18):1822–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285(4):201–3.CrossRefPubMedGoogle Scholar
  42. 42.
    Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;318(12):771–5.CrossRefPubMedGoogle Scholar
  43. 43.
    N.Y. Comp. Codes R. & Regs. tit. 10, § 405.4.Google Scholar
  44. 44.
    Gefell AW. Dying to sleep: using federal legislation and Tort Law to cure the effects of fatigue in medical residency programs. J Law Policy. 2002;11:645.Google Scholar
  45. 45.
    Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000.Google Scholar
  46. 46.
    Ulmer C, Wolman D, Johns M, editors. Committee on optimizing graduate medical trainee (resident) hours and work schedules to improve patient safety, Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press; 2008.Google Scholar
  47. 47.
    de Virgilio C, Yaghoubian A, Lewis RJ, Stabile BE, Putnam BA. The 80-hour resident workweek does not adversely affect patient outcomes or resident education. Curr Surg. 2006;63(6):435–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):975–83.CrossRefPubMedGoogle Scholar
  49. 49.
    Leibrandt TJ, Pezzi CM, Fassler SA, Reilly EF, Morris JB. Has the 80-hour work week had an impact on voluntary attrition in general surgery residency programs? J Am Coll Surg. 2006;202(2):340–4.CrossRefPubMedGoogle Scholar
  50. 50.
    McElearney ST, Saalwachter AR, Hedrick TL, Pruett TL, Sanfey HA, Sawyer RG. Effect of the 80-hour work week on cases performed by general surgery residents. Am Surg. 2005;71(7):552–5; discussion 5–6.PubMedGoogle Scholar
  51. 51.
    Åkerstedt T. Shift work and disturbed sleep/wakefulness. Occup Med. 2003;53(2):89–94.CrossRefGoogle Scholar
  52. 52.
    Son M, Kong JO, Koh SB, Kim J, Harma M. Effects of long working hours and the night shift on severe sleepiness among workers with 12‐hour shift systems for 5 to 7 consecutive days in the automobile factories of Korea. J Sleep Res. 2008;17(4):385–94.CrossRefPubMedGoogle Scholar
  53. 53.
    Crowley SJ, Lee C, Tseng CY, Fogg LF, Eastman CI. Complete or partial circadian re-entrainment improves performance, alertness, and mood during night-shift work. Sleep. 2004;27:1077–88.CrossRefPubMedGoogle Scholar
  54. 54.
    Leff DR, Aggarwal R, Rana M, Nakhjavani B, Purkayastha S, Khullar V, et al. Laparoscopic skills suffer on the first shift of sequential night shifts: program directors beware and residents prepare. Ann Surg. 2008;247(3):530–9.CrossRefPubMedGoogle Scholar
  55. 55.
    Kamine TH, Barron RJ, Lesicka A, Galbraith JD, Millham FH, Larson J. Effects of the new Accreditation Council for Graduate Medical Education work hour rules on surgical interns: a prospective study in a community teaching hospital. Am J Surg. 2013;205(2):163–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA. 2008;300(10):1197–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of Anesthesiology and Perioperative Medicine, Health Policy Research InstituteUniversity of California Irvine School of MedicineOrangeUSA
  2. 2.University of California Irvine School of LawIrvineUSA

Personalised recommendations