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LIFE-SAVING MEDICAL CARE.
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Examines medical, legal & ethical aspects of roles of physician, hospital, patient & family in deciding to withhold care for dying patient.... More...
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Paper Abstract:
Examines medical, legal & ethical aspects of roles of physician, hospital, patient & family in deciding to withhold care for dying patient.
Paper Introduction:
SHOULD PHYSICIANS DETERMINE WHEN A PATIENT SHOULD BE
DENIED LIFE SAVING CARE?
Introduction
Who should have the final word in determining when a patient should be denied life saving care remains a topic of controversy. This paper describes the controversy and points out different perspectives from the physician, hospital, and patient/family.
Controversy
Medical futility is a term that describes a situation where a patient demands and a physician objects to a provision of certain medical treatment, on the grounds that no medical benefit to the patient will be provided by the treatment. The U. S. Court of Appeals for the Fourth Circuit handed down a decision
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Clear documentation that supports eachcondition should be required. When patients or familiesdisagree with a physician's care, they may be referred to the hospitalethics committee to mediate the dispute (Daar, pp. Others believe that this definitionreflects the physicians' personal values and denies legitimate therapeuticchoices to patients and families. Health & Social Work, 21(2), 115-123.----------------------- 9 Physician autonomy must also be considered; whether a physicianshould be forced to render treatment that he believes is medically andethically inappropriate, remains unanswered. Assessment is an additional problem, for example, diagnosing thepersistent vegetative state is sometimes difficult. Looking living death in the face. Additionally, nearly all cases where the patient has soughttreatment and the doctor objected on the grounds of medical futility,courts have ruled in favor of the patient (Daar, 1995). However, anytreatment with the purpose to cause death is outside standard medicalpractices which aim at promoting health, healing, and alleviatingsuffering. Craft, N. Estimations state thatthere are up to 15 patients in the persistent vegetative state inBritain. Parameters would need to includethe following: promotion of comfort care as standard treatment for thedying patient; standard practice guidelines for last resort treatment ofunrelievable suffering; a committee review mechanism; and publicaccountability (pp. 221-24 ). The court stated that hospital physicians are obligated underthe federal Emergency Medical Treatment and Active Labor Act (EMTALA) toprovide treatment (ventilator support) to an anencephalic infant in theemergency room (Baby K). Taylor, r. (1995). Both laws requirethe physician who does not wish to comply with a disagreeing patient orsurrogate, to make reasonable efforts to transfer the patient to anotherphysician. However this right should be safeguarded by established policyguidelines. In the Maryland Health Care Decisions Act, a statute enacted in 1993contained procedures to make advanced directives and designate surrogatedecision makers in the absence of a patient nomination. Application of these terms appears to beunsubstantiated, mechanical, and conclusory (Daar, 1995). It has been suggested thatfor a treatment to be futile, it must be concluded that in the last 1 cases, the treatment was useless. 11 -125). Argumentexists regarding the meaning of medical futility. 11 -125). Daar, J. (1995). Two recentstatues appear to break from the patient-based model and offer greaterrecognition to the physician's values. If a patient retains some degree of awareness, their quality oflife must be maximized and inappropriate withdrawal of tube feeding isprevented. In the case of Baby K, the mother stated that herchild should receive all available treatment, including mechanicalbreathing assistance if unable to breathe on her own (Daar, pp. UCLA firmly supports physicianautonomy; it offers solid policy while court decisions still vary (Daar,pp. For some, thevegetative state dependant on feeding tubes is more horrifying thanstopping treatment (Craft, 1996, p. The patient has the right to befree of unwanted bodily invasion. Theimportance of an accurate diagnosis is recognized, however, confusionexists regarding the definition of quality of life. 5). The politics of medicalfutility. S. Wesley, C. UCLA Medical Center has a Life Sustaining Treatment Policy; itprovides that an adult patient with abilities for decision making, will bethe final decision maker regarding treatment. Weijer, C. 3-12). Courts and lawmakers haveill-defined policies which leaves them susceptible to patient claims forlimitless treatment. 14 8; & Cranford, 1996, p. Standards regarding comfort care do not include the permittingof death to be caused intentionally (Miller & Orentlicher, 1995, pp. The statutedoes not require a physician to render medical treatment that is viewed asethically inappropriate or medically ineffective. 221-24 ). & Elliott, C. The physician has the moral goal of regardingrelief of suffering when care is no longer effective. (1996). In conclusion, I agree with UCLA, that physicians should haveautonomy and the final word on when a patient should be denied life savingcare. Supreme Court in 199 and by the U.S. The Supreme Court and physician-assisted suicide- the ultimate right. D. The New England Journal of Medicine, 336(1), 5 -53. Further, the policy states that patients will not beoffered treatment that they might want if it is medically inappropriate.UCLA Policy puts the burden on the family rather than the physician forseeking further treatment. (1995). 221-24 ). The withdrawal oflife-sustaining treatment is considered a passive role since the cause ofdeath is the underlying disease. SHOULD PHYSICIANS DETERMINE WHEN A PATIENT SHOULD BE DENIED LIFE SAVING CARE? (1996). Futility has a different meaning for different people. Court decisions favoring patients, contest the doctor's best medicaljudgment as well as the autonomy, integrity, and future of the medicalprofession. 115-123). Maryland law states that the physician may not take actionif the patient or surrogate has expressed disagreement. However, others consider this act to beactive; the patient is dependent on the treatment and to end treatmentwithout the consent of the patient or a proxy, would be considered homicide(Angell, 1997, pp. It also allows that aphysician may withhold or withdraw medically ineffective treatment if thephysician and a second physician certify in writing that the treatment ismedically ineffective and the patient or surrogate is informed. M. Judgement about medicalprobabilities and futility are not conclusive. Reality shows however, that transferring a disputing patient isvirtually nonexistent. Both the Maryland law and the Virginia law are not intended to allowphysicians to unilaterally terminate care against the wishes of the patientor surrogate. Continued debate regards the disagreement amongdifferent observers as to whether the predicted physiologic effect from atreatment is of benefit. As with the Maryland Act, the physician anda second physician must certify in writing that the treatment is medicallyineffective and the patient or surrogate must be informed. Some state that futilityhas a precise meaning arguing that physicians have the right andresponsibility to refuse to provide or even discuss, the use of futiletherapy with patients or families. (1997). Misdiagnosing the persistent vegetative state: an apparently high rate of misdiagnosis demands critical review andaction. In the case of Baby K, courts focused on an acutemedical process and overlooked the patient's overall medical prognosis.Well-developed policies can alert patients, families, and physicians to thehospital's goals and expectations (pp. Laws appear to assist the physician regarding theconcept of futility, however, little or no control is given to thephysician in the event of a conflict. Federal statute did not exemptphysicians from providing care they thought inappropriate (Daar, pp. & Lantos, J. Controversy Medical futility is a term that describes a situation where a patientdemands and a physician objects to a provision of certain medicaltreatment, on the grounds that no medical benefit to the patient will beprovided by the treatment. Terms such as emergency medical condition were unclear, it wasassumed that the absence of stabilizing treatment would result in adeterioration of bodily function. The rights of thephysician to decline to treat a patient when the treatment would becontrary to their medical judgment, are codified by the Act. The physicians' medical judgmentwas overridden to accommodate the goals and desires of the patient'sfamily. Hospital, Physician, & Patient/Family Views For the case of Baby K, the hospital filed an action after the baby'ssecond admission, to ask the court to declare that it had no duty toprovide respiratory or aggressive care since it was medically and ethicallyinappropriate. British Medical Journal, 313(7 48), 5-7. When patients orfamilies demand treatments that are not likely to produce a good outcome,physicians need to disclose all treatment options and outcomes, however,futility as a concept may not offer a solution. Medical futility and implications for physicianautonomy. 5 -53). Congress in199 (Patient Self-Determination Act). Hospitals show empathy for the plight of physicians who are asked tocompromise their professional conscience and act against their best medicaljudgment. F. Social work and end-of-life decisions: self-determination and the common good. This paperdescribes the controversy and points out different perspectives from thephysician, hospital, and patient/family. Some view both the doctor's judgement and the patient or family'sjudgement as essential to the decision making process. American Journal of Law & Medicine, 21(2-3), 221-24 . The hospital was asking to treat according to its ownprinciples. Federal law imposed a duty to provide treatment (Daar, 1995, pp.221). In the case of Baby K, physicians argued that comfort carerepresented the standard of care for the patient and aggressive treatmentwas inappropriate; the court ruled against the physician. Thestatute acknowledges the concept of physician autonomy (Daar, pp. Arguments For Physician's Final Say & Conclusion Withdrawal of treatment must be regulated due to its nonstandardmedical practice and its potential for abuse. Patient and family views are needed for a decision that issupported by all parties (Weijer & Elliott, 1995, pp. The stage is set forphysician determination absent patient input. Introduction Who should have the final word in determining when a patient shouldbe denied life saving care remains a topic of controversy. Miller, F. Medicallyineffective treatment is defined as not preventing or reducing adeterioration of health or not preventing impending death, to a reasonabledegree of certainty (Daar, pp. The Baby K decision may have been affected ifthe patient was at UCLA; the patients' families would have been in anoffensive rather than defensive position. Daar states that confusion exists because physicians and hospitalslack clearly defined policies with limits of treatment that they arewilling to provide in any given circumstance. Nursing Management, 26(6), 11 -125. Issues in Law & Medicine, 11(1), 3-12. Cranford, R. Should physiciansbe allowed to assist in patient suicide? Court of Appeals for the FourthCircuit handed down a decision regarding the provision of nonbeneficialcare (1994). Pulling the plug on futility:futility is not the ethical trump card that some would like it to be.British Medical Journal, 31 (6981), 683-684. Studies show a high rate of misdiagnosis for vegetative statepatients, however it is unclear whether samples were representative ofpatients or whether methods used to identify awareness were valid.Hospitals do not have set clinical procedures to deal with these patientsand may use their own methods of assessment. A person has the right to makedecisions and act accordingly with self-values and belief systems (Wesley,1996, pp. 221-24 ). 221-24 ). Physician-assisted suicide andeuthanasia are still not accepted; assisted suicide is illegal in moststates and euthanasia remains illegal in all states. A. Assessments may be short andunsophisticated, and unable to detect higher conscious functioning. What is meant bymedically or ethically inappropriate treatment is presumed to be determinedby the treating physician since the statute provides no guidance. 683-684). Data shows that many hospitals have policies dealing with thetopic of medical futility and withholding or withdrawing treatment; it isrecognized that physicians make such judgments. 221-24 ). References Angell, M. Consultation with another physician should be required toensure that all conditions are met. Miller and Orentlicher referto regulatory policies for physician-assisted suicide, that may beapplicable to withdrawal of treatment. The realities of patient autonomy have been advanced (Daar, 1995).Since 1976, the right to stop treatment has been repeatedly recognized; itwas affirmed by the U.S. Furthermore, doctors' judgmentsregarding individual cases are not accurate enough to allow them to claimreliably that a patient has less than a one percent chance of responding toa treatment. Cost of treatment may also be an issue; futilitymay avoid the issue of using expensive treatments with marginal benefit tomore assure adequate medical care for all members of society (Taylor &Lantos, 1995, pp. G., et al., & Orentlicher, D. 221-24 ). BritishMedical Journal, 313(7 69), 14 8. The policy states that thephysician does not need to provide treatment they consider medicallyinappropriate. Physicians stated that this treatment wasmedically and ethically inappropriate. (1996). The U. The concept of medical futility isdependent on the assumption that it can be accurately predicted whethermedical treatments will provide no benefit for a patient and shouldtherefore be withheld. (1995). The Virginia legislature amendedthe state's Health Care Decisions Act (1992) to include that the act doesnot require the physician to prescribe or render medical treatment if it isdetermined to be medically or ethically inappropriate. It is not clear if the burdenof obtaining treatment should fall on the patient, the physician, or thehospital (Daar, 1995). People are concerned about suffering in the last stages of life andabout maintaining dignity and control. The court ruled that a hospital must provide treatment neededto prevent the material deterioration of a patient's emergency medicalcondition.
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