Death by ICU: End-of-Life Care in America

MedSmart has released a new free report, Death-by-ICU: End-of-Life Care in America.MedSmart generally advocates for greater caution in assessing your medical interventions generally. The reason is that our medical interventions – not just invasive procedures, but medications as well – can often cause more harm than benefit.  Many consumers have too much fear of death and disease and too little fear of the injury possible with medical interventions that may hasten their death with treatment-induced disease.  And if aggressive...

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What should medicine do when it can't save your life?

The modern healthcare system has become proficient at staving off death with aggressive interventions.  And yet, eventually everyone dies--and although most Americans say they would prefer to die peacefully at home, more than half of all deaths take place in hospitals or health care facilities. A new book, At the End of Life: True Stories About How We Die, tackles this conundrum head on.  These twenty-two compelling personal-medical...

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Video of Rasouli Hearing

The video of the hearing on Hassan Rasouli's motion to quash the appeal is now available here on the Supreme Court's website.  The Court denied the motion, permitting the appeal to proce...

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Finally - Measuring Use of Texas Futility Law

The Texas Hospital Association has launched a survey to measure use of the TADA dispute resolution process.  Hopefully, this will provide some much-needed light to the frequency and manner in which this is us...

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Combining Scholarship and Service

I am in San Francisco, this week, for the AmericanThoracic Society International Conference. This is the third year in which I was invited to present at thisconference.  And it is always a thrilland an honor.  After all, I research andwrite a great deal about the law concerning end-of-life medicine.  ATS is the main conference for critical carephysicians, those most frequently and directly affected by end-of-lifelaw.  So, this is a great opportunity tohear from them in-person.But I am fortunate to be involved, here, in...

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Defending the Slow Code

At the end of 2011, Lantos and Meadow published “Should the ‘Slow Code’Be Resuscitated?” in AJOB.  (Lantos also discusses the article in this BioethicsChannel podcast.)  I applaud Lantosand Meadow for defending the slow code (or at least the short code).  As John Stuart Mill said in defending freedom ofexpression:First, if any opinion is compelled to silence,that opinion may, for aught we can certainly know, be true. To deny this is to assumeour own infallibility.             Secondly, though the...

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Massachusetts to Require End-of-Life Counseing

Massachusetts may soon join California and New York in statutorily requiring end-of-life counseling.  Here is the relevant text of amendment to Senate No. 2260:(b) The commissioner shall adopt regulations requiring each licensed hospital, skilled nursing facility, health center or assisted living facility to distribute to appropriate patients in its care information regarding the availability of palliative care and end-of-life options.(c) If a patient is diagnosed with a terminal illness or condition, the patient’s attending health care practitioner...

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Futility Scuplture

I walked over to the de Young art museum, to take a break from end-of-life discussion at the ATS.  And what do I see but futilis, the leaky vessel.&nb...

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Rasouli - Going Where Betancourt Refused to Go

An editorial in the Globe & Mail rightly praises the Supreme Court of Canada, calling it "right" when it agreed to hear the case of Hassan Rasouli, despite shifting medical facts.  The case stands in stark contrast to Betancourt v. Trinitas Hospital in which the Appellate Division of the New Jersey Superior Court declined to provide the same sort of guidance when changing facts in that case similarly made it moot.The Editorial notes that the court "is expected to provide much-needed guidance on end-of-life treatment.   The...

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Variability in ICU Practice - 34 days on ECMO

Most end-of-life treatment conflicts concern more familiarinterventions such as ventilators, dialysis, and CANH.  Clinicians are far more comfortablewithholding and withdrawing less familiar and exotic interventions such as ECMO.  Therefore, this report in the March 2012 ICU Director comesas a surprise.  After two failed lungtransplants, a patient was maintained on ECMO for 34 days.  Her physicians did not think that this wasmedically...

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NEW: Guidance for Healthcare Ethics Committees

A book project with which I was pleased and honored to be a part will be available in June:  Guidance for Healthcare Ethics Committees (Cambridge University Press).  Here is the table of contents:Part I. The Context of Healthcare Ethics Committee Work:1. Introduction to healthcare ethics committees D. Micah Hester and Toby Schonfeld2. Brief introduction to ethics and ethical theory D. Micah Hester and Toby Schonfeld3. Ethics committees...

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Algorithm for End-of-Life Decision Making

Ralf Jox and colleagues in Germany have a nice schematic algorithm of treatment decision making in their new Journal of Medical Ethics article, "Medical Futility at the End of Life: The Perspectives of Intensive Care and Palliative Care Clinician...

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Defensive Medicine

Just as in other areas of medicine (see chart below), physicians are overwhelmingly successful when sued for unilaterally withholding or withdrawing life-sustaining treatment, they usually cave into surrogate demands for continued treatment that they think non-beneficial, inappropriate, and cruel.  Why?  For the same reason that there is so much defensive medicine elsewhere.  Because even prevailing parties pay transaction costs.  This...

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Scary 'Bad Language' Stories

There is a growing emphasis on the quality of end-of-life communication.  Already widely discussed is the widespread move from "DNR" to "DNAR" and "AND."  But, today, at the ATS conference, I heard two examples of misunderstandings that caught me by surprise.1.  "Comfort care" - a resident thought that she had obtained family consent for "comfort care."  In fact, the family thought that they were just consenting to keeping the patient "comfortable."  Lesson:  use "CMO."  It more clearly indicates what exactly...

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Eliminating Default Surrogates in New Hampshire

Some states, like New York, recently celebrated finally authorizing default surrogates.  Other states, like New Hampshire, are actually considering legislation removing the authority of default surrogates.  There is no explicit statutory authorization of default surrogates in New Hampshire.  But there is settled custom and practice that might be legislated away. This recent legislative hearing indicates some serious mistrust of not only physicians but also of family membe...

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What are the boundaries of acceptable medical practice near the end of life in ICUs?

I am in San Francisco, thisweek, at the American Thoracic Society InternationalConference,  to present "LegalMechanisms To Resolve Futility Disputes" in a broadersession titled "What arethe boundaries of acceptable medical practice near the end of life in intensivecare units?  I am also meeting with two policy writing committees todiscuss, polish, and hopefully finish-up policies on conscientious objectionand on...

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The Immortal (art by R. Cohen)

Revital Cohen is adesigner who develops critical objects and provocative scenarios exploring thejuxtaposition of the natural with the artificial. Her work spans across variousmediums and includes collaborations with scientists, bioethicists and animal breeders.   In The Immortal a number of life-support machines are connectedto each other, circulating liquids and air in attempt to mimic a biologicalstructure. The Immortal investigates human dependence on electronics, thedesire to make machines replicate organisms and our...

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Advantage of POLST

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The Amateur’s Guide To Death And Dying; Enhancing The End Of Life

This new book should help a lot of people:  The Amateur’s Guide To Death And Dying; Enhancing The End Of L...

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Supreme Court of Canada Will Address Medical Futility

This morning, the family of Hassan Rasouli argued its recently-filed motion asking the Supreme Court of Canada to dismiss the pending lawsuit regarding his continued treatment.  The lawsuit had been framed on the understanding that Mr. Rasouli was in a persistent vegetative state.  In 2011, two of his physicians asked the courts to declare that, given Mr. Rasouli's condition, they could stop life-sustaining treatment without consent.  Two lower courts denied the physicians' request.But a few weeks ago, in the middle of the Supreme...

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Advance Directive Status Now on Driver License

A bill just signed into law by the Governor of Hawaii will authorize including the designation "AHCD" on a driver's license if the person has an advance directive.  Bills pending in other states, like New York, would provide the actual name of the healthcare age...

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Practical Approaches to Advance Care Planning

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Federal Research Public Access Act of 2012

The Federal Research Public Access Act of 2012 (still pending in committee) is long overdue legislation.  Basically, it requires that each Federal agency with extramural research expenditures of over $100,000,000 develop a Federal research public access policy.  Among other things, the policy must include "free online public access to such final peer-reviewed manuscripts or published versions as soon as practicable, but not later than 6 months after publication in peer-reviewed journal...

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Who Decides End of Life? - The Rasouli Case

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Family Seeks Injunction against OPO Removing Life Support

I am just pulling a copy of the complaint in this case justfiled in Sacramento Superior Court.  Gloria Woods was in an auto accident on April 30 and is in criticalcondition at the UC-Davis Medical Center.  The family was soon "contacted by Sierra Donor Services and advised thatDepartment of Motor Vehicle records indicated that Gloria Woods was an organdonor." At that time Sierra Donor Services inquired of plaintiffs whenthey would be able to harvest Gloria Woods' organs. Plaintiffs responded thatGloria Woods was still alive. "Thereafter,...

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Professor Pope to Meet with White House about Judicial Vacancy Crisis

Tomorrow, I will travelto Washington, DC, to meet with White House officials about the vacancy crisis. Nearly one out of every ten federal judgeships remains vacant, and morethan 250 million Americans live in a community with a courtroom vacancy.  The Minnesotanstraveling to Washington with me are: ThaoMee Xiong, Public Policy Specialist, Minnesota Coalition for BatteredWomenSee Vang Thao, AttorneyWe will join 150advocates (including many other law professors from Penn, Georgia State, FIU, andother law schools) from 27...

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The Texas Advance Directives Act: A Threat to Catholic Identity?

In the just-released issue (20(2): Spring 2012) of CHA's Health Care Ethics USA, Elliott Louis Bedford has a feature article titled "The Texas Advance Directives Act: A Threat to Catholic Identity?"  Here is his conclusion:In conclusion, it seems that, with certain qualifications, Catholic hospitals should support laws that use the TADA as a model because, in the rare case that the process is actually implemented, it allows physicians to practice according to professional conscience and seeks the...

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Cat Hospice

The CAT PRACTICE has offered care for elderly or terminally ill felines for years.  But, this week, they announced a home-based hospice program.  It costs $75 dollars per week, which includes the cost of office visits and gives patients access to veterinarians at all times. Medications can cost a great deal more, although the clinic has partnered with a pharmaceutical firm to provide discounts.  The clinic is also...

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Supreme Court Should Rule in Rasouli Case

In Wednesday's Globe & Mail, Law professor Hilary Young rightly calls on the Supreme Court of Canada to decide the Rasouli case even if, because of the patient's cognitive improvement, the case has become moot.  She writes that "given the importance of the issues at stake and the uncertainty in the law, the Supreme Court should take this opportunity to clarify the law."I agree.  This was a key point of a recent JAMA article that I published with critical care physician Doug White.  Two of the reasons that we called on courts...

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Revising CPR Default Status

Craig Blinderman and colleagues have, in a recent issue of JAMA, a persuasive and succinct three-part approach to offering CPR based on the likelihood and degree of potential benefits and harms.Where relative benefits and harms are uncertain, consider CPR as a plausible option.Where there is a low likelihood of benefit and a high likelihood of harm, recommend against CPR.  They note that despite such a recommendation, some patients or surrogates may request that CPR be attempted.  Blinderman and colleagues conclude that it is ethically...

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Critical Care Physicians Getting Surrogate Consent through Lying

Last July, I wrote about how some range of the high  (90%+) consensual resolution rate of end-of-life conflicts is illusory because the surrogates may consent based on incomplete information and understanding.  A new study by David Brush and colleagues in Critical Care Medicine lends support to concern that some physicians deliberately misrepresent information in order to obtain surrogate consent to their proposed treatment plan.  This...

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