Thứ Tư, 30 tháng 5, 2012

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 medical interventions pose a greater-than-appreciated risk for the average patient, don’t you think the risk is even greater for vulnerable patients at death’s door?


  • Patients with end-stage disease will likely live longer without having their frail and vulnerable bodies subjected to the invasive trauma of fruitless surgeries and interventional procedures that very likely cause more harm than good;

  • Studies indicate that when dying patients were shown videos of what their final days would be like in a hospital intensive care unit (ICU) they chose to reject ICU care – unanimously;

  • ICU physicians have described their dying patients kept “alive” on ventilators as “broken survivors” existing in a state of suspended animation; and

  • Billions of dollars we can no longer afford are wasted on futile medical interventions on frail patients with end-stage disease.


This list of bullet points above is a pretty powerful cumulative argument for reconsidering our assumptions and our approach to end-of-life care.  Because we appear to have been wrong all along about what’s actually best for our loved ones confronting death – and what they’d actually want if they knew how intensive treatments would adversely affect their quality of life in their final days and hours of life.  We don't want the guilt of thinking we did anything less than we could have for parents and other loved ones who may have done so much for us. There’s nothing more normal or understandable.  But that does not make it right – not if we’re wrong in our assumptions and end up making their final memories of life filled with unnecessary pain and suffering.




Prior generations did not have as many technological options for artificially prolonging the dying process. And as these patients themselves seem to recognize better than the rest of us, prolonging the dying process is not necessarily the same as extending the living process.  Indeed, the report cites a study where the patients who rejected so-called “heroic” intensive medical measures in favor of comfort-focused palliative care lived about 33% longer – and were over 50% less depressed about dying – than those who chose death-by-ICU.




MedSmart's Report suggests that maybe all our angst about dying, for all its good intentions, is simply wrong-headed – and counter-productive for those we’re concerned about.  If what we’re doing with all this aggressive late-stage treatment is not extending our loved one’s lives – and may even hasten their demise – then maybe we need to rethink our attitudes and choices about this most delicate of decisions.


Thứ Ba, 29 tháng 5, 2012

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 narratives explore death, dying and palliative care, and reveal the inner workings of a system in which doctors, patients and their loved ones battle to hang on--and to let go. 





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 proceed.


Thứ Bảy, 26 tháng 5, 2012

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 used.


Thứ Sáu, 25 tháng 5, 2012

Combining Scholarship and Service




I am in San Francisco, this week, for the American
Thoracic Society International Conference

This is the third year in which I was invited to present at this
conference.  And it is always a thrill
and an honor.  After all, I research and
write a great deal about the law concerning end-of-life medicine.  ATS is the main conference for critical care
physicians, those most frequently and directly affected by end-of-life
law.  So, this is a great opportunity to
hear from them in-person.







But I am fortunate to be involved, here, in something even more
exciting.  This is the second year in
which I have been a member of two drafting committees.  One is writing a policy on when clinicians
can exercise a conscience-based objection to providing a healthcare
service.  The other committee is writing
a policy on the prevention and resolution of medical futility disputes.  While these policies will ultimately be
published in medical journals, they have a special status.  As official medical society recommendations,
they will materially shape and guide practice. 





It is rewarding to know that one’s efforts will have a real practical
impact.  I was thrilled to have the New
Jersey Appellate Division cite my work in a published
opinion in 2010
.  But I did not know
that would happen when I wrote the article in 2007.  In contrast, I already know that these ATS
projects are destined to be popular and authoritative.     



Thứ Năm, 24 tháng 5, 2012

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 Bioethics
Channel podcast
.)  I applaud Lantos
and Meadow for defending the slow code (or at least the short code).  As John Stuart Mill said in defending freedom of
expression:




  1. First, if any opinion is compelled to silence,
    that opinion may, for aught we can certainly know, be true. To deny this is to assume
    our own infallibility.
                 

  2. Secondly, though the silenced opinion be an
    error, it may, and very commonly does, contain a portion of truth; and since
    the general or prevailing opinion on any subject is rarely or never the whole
    truth, it is only by the collision of adverse opinions that the remainder of
    the truth has any chance of being supplied

  3. Thirdly, even if the received opinion be not
    only true, but the whole truth; unless it is suffered to be, and actually is,
    vigorously and earnestly contested, it will, by most of those who receive it,
    be held in the manner of a prejudice, with little comprehension or feeling of its
    rational grounds.

  4.  Fourthly, the meaning of the doctrine itself
    will be in danger of being lost, or enfeebled, and deprived of its vital effect
    on the character and conduct: the dogma becoming a mere formal profession,
    inefficacious for good, but cumbering the ground, and preventing the growth of
    any real and heartfelt conviction, from reason or personal experience.
     











Still, I cannot agree with Lantos & Meadow’s core thesis.  I just stomach the lack of transparency.   And I
am too aware that even well-meaning subterfuge is the too-common breeding
ground for the operation of bias and prejudice. 
In short, the risks are too high. 







But there is something else in the same Lantos and Meadow article that
I really like:  a summary of the three
approaches to futility disputes:




  •          Conversational – try to convince the surrogate

  •          Deferential – accede to the surrogate’s wishes

  •          Confrontational – refuse and override the
    surrogate









The conversational approach is always appropriate and should always be
undertaken first.  If, in the rare
instance in which a conversational
approach is not successful, a deferential
approach might sometimes be appropriate. 
A common example is the classic short-term accommodation until the out-of-town
relative can arrive at the hospital to say “goodbye.”  Other times, a confrontational approach is most appropriate.  Too often, however, providers take a deferential
approach, when a confrontational approach would be most appropriate.





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 shall offer to provide the patient with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including, but not limited to: (i) the range of options appropriate to the patient; (ii) the prognosis, risks and benefits of the various options; and (iii) the patient’s legal rights to comprehensive pain and symptom management at the end of life.  The information and counseling may be provided orally or in writing.  Where the patient lacks capacity to reasonably understand and make informed choices relating to palliative care, the attending health care practitioner shall provide information and counseling under this section to a person with authority to make health care decisions for the patient.  The attending health care practitioner may arrange for information and counseling under this section to be provided by another professionally qualified individual.



Where the attending health care practitioner is not willing to provide the patient with information and counseling under this section, the attending health care practitioner shall arrange for another physician or nurse practitioner to do so, or shall refer or transfer the patient to another physician or nurse practitioner willing to do so.



(d) The department shall consult with the Hospice and Palliative Care Federation of Massachusetts, in developing educational documents, rules and regulations related to this section.


Thứ Tư, 23 tháng 5, 2012

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. 


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 issue - who decides - has been a divisive, emotional one. Giving doctors unilateral decision-making power seems extreme, yet it is equally perverse for families of incapable patients to insist upon costly interventions of no medical benefit and some potential harm. The absence of direction has left a policy vacuum, and potentially treatment vacuums in Canadian hospitals. Will physicians hesitate to start trials of therapy in critically ill patients if they think they cannot withdraw them when later deemed futile?"


Variability in ICU Practice - 34 days on ECMO






Most end-of-life treatment conflicts concern more familiar
interventions such as ventilators, dialysis, and CANH.  Clinicians are far more comfortable
withholding and withdrawing less familiar and exotic interventions such as ECMO.  Therefore, this report in the March 2012 ICU Director comes
as a surprise.  After two failed lung
transplants, a patient was maintained on ECMO for 34 days.  Her physicians did not think that this was
medically appropriate.  So, then why was
it done?  It was done, apparently, because of the
legal and reputational risks that the patient’s parents threatened.







There is enormous variability across physicians and institutions
regarding use of ventilators, dialysis, and CANH in the ICU.  Is that same variability invading (and
undoing the standard of care for) other ICU interventions?



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 Schonfeld

2. Brief introduction to ethics and ethical theory D. Micah Hester and Toby Schonfeld

3. Ethics committees and the law Stephen Latham

4. Cultural and religious issues in health care Alissa Swota



Part II. Consultation:

5. Mission, vision, goals: defining the parameters of the ethics consultation Marty Smith

6. Ethics consultation process Jeffrey Spike

7. Informed consent, shared decision making, and the ethics committee Randall Horton and Howard Brody

8. Decision-making capacity Art Derse

9. Family dynamics and surrogate decision making Lisa Soleymani Lehmann

10. Confidentiality Toby Schonfeld

11. Advance care planning and end-of-life decision making Nancy M. P. King and John Moskop

12. Medical futility Thaddeus Mason Pope

13. Ethical issues in reproduction Anne Drapkin Lyerly

14. Ethical issues in neonatology John Lantos

15. Ethical issues in pediatrics D. Micah Hester



Part III. Policy Development and Organizational Issues:

16. Ethics committees and distributive justice Nancy Jecker

17. Developing effective ethics policy Anne Lederman Flamm

18. Implementing policy to the wider community Mary Faith Marshall and Joan Liaschenko

19. Ethics in and for the organization Mary Rorty



Part IV. Educating Others:

20. The healthcare ethics committee as educator Kathy Kinlaw

21. Education as prevention Kayhan Parsi

22. Understanding ethics pedagogy Felicia Cohn


Thứ Ba, 22 tháng 5, 2012

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 Clinicians."






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 short study in the Archives of Internal Medicine shows that the mean time for resolution of a non-litigated claim is one year.  The mean time for resolution of a litigated claim is two years.  During all this time, physician defendants pay in terms of lose practice time, stress, and reputational damage.







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 is involved.





2.  "DNR" - a resident had placed DNR orders on all her patients.  When asked what was going on, she replied that she thought "DNR" was for those patients for whom the discussion had not yet occurred.



Thứ Hai, 21 tháng 5, 2012

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 members.


Chủ Nhật, 20 tháng 5, 2012

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



I am in San Francisco, this
week, at the American Thoracic Society International
Conference, 
 to present "Legal
Mechanisms To Resolve Futility Disputes" in a broader
session
 titled "
What are
the boundaries of acceptable medical practice near the end of life in intensive
care units?  




I am also meeting with two policy writing committees to
discuss, polish, and hopefully finish-up policies on conscientious objection
and on medical futility.










Thứ Bảy, 19 tháng 5, 2012

The Immortal (art by R. Cohen)


Revital Cohen is a
designer who develops critical objects and provocative scenarios exploring the
juxtaposition of the natural with the artificial. Her work spans across various
mediums and includes collaborations with scientists, bioethicists and animal breeders.   In The Immortal a number of life-support machines are connected
to each other, circulating liquids and air in attempt to mimic a biological
structure. The Immortal investigates human dependence on electronics, the
desire to make machines replicate organisms and our perception of anatomy as
reflected by biomedical engineering.



Thứ Sáu, 18 tháng 5, 2012

Advantage of POLST

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 Life


Thứ Năm, 17 tháng 5, 2012

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 Court appeals process, Mr. Rasouli was re-diagnosed as being in only a minimally conscious state.  Mr. Rasouli's attorney moved the Supreme Court to dismiss the appeal as moot.  He argued that his this rediagnosis development "radically changed" the nature of the case and rendered it an unsuitable legal vehicle upon which to decide when to withdraw life support.




However, the physicians' attorney urged the court to seize the opportunity to provide doctors with a legal framework they can use to determine when mechanical life support can be withdrawn based on an assessment of the proper standard of medical care.  "It is not that these cases don't come before the courts. . . .  But the patient dies before decisions can go through appeals. If this case is not heard, the law will be at loose ends for a long time to come."  (Globe & Mail)




The court denied the family's motion.  Fortunately, the court does not consider the legal issues to have lost their importance because of improvements in Mr. Rasouli’s medical status.



Thứ Bảy, 12 tháng 5, 2012

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 agent.


Thứ Năm, 10 tháng 5, 2012

Practical Approaches to Advance Care Planning




Thứ Tư, 9 tháng 5, 2012

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 journals."



Thứ Ba, 8 tháng 5, 2012

Who Decides End of Life? - The Rasouli Case




Family Seeks Injunction against OPO Removing Life Support


I am just pulling a copy of the complaint in this case just
filed in Sacramento Superior Court.  Gloria Woods was in an auto accident on April 30 and is in critical
condition at the UC-Davis Medical Center.  The family was soon "contacted by Sierra Donor Services and advised that
Department of Motor Vehicle records indicated that Gloria Woods was an organ
donor." At that time Sierra Donor Services inquired of plaintiffs when
they would be able to harvest Gloria Woods' organs. Plaintiffs responded that
Gloria Woods was still alive. 





"Thereafter, Sierra Donor Services contacted plaintiff again and
advised that it had the right to make the decision to remove Gloria Woods from
life support and then to harvest the organ
s
of Gloria
Woods in light of the Department of Motor Vehicle records."





The family seeks a restraining order and
injunction against Sierra and the UC-Davis Hospital, preventing them from
removing Gloria from life support and from harvesting her organs.  They
claim, quite reasonably, that "irreparable injury would result" if
her organs are harvested.






Chủ Nhật, 6 tháng 5, 2012

Professor Pope to Meet with White House about Judicial Vacancy Crisis


Tomorrow, I will travel
to Washington, DC, to meet with White House officials about the vacancy crisis.
 Nearly one out of every ten federal judgeships remains vacant, and more
than 250 million Americans live in a community with a courtroom vacancy.  





The Minnesotans
traveling to Washington with me are:




  •  Thao
    Mee Xiong,
     Public Policy Specialist, Minnesota Coalition for Battered
    Women

  • See Vang Thao, Attorney





We will join 150
advocates (including many other law professors from Penn, Georgia State, FIU, and
other law schools) from 27 states in a day of discussions with White House
staff. A deal between Senate Republicans and Democrats to allow judicial
nominations to proceed in the Senate expires May 7th, and we are urging the
Senate to hold final up-or-down votes on all pending nominees.






After the White House meeting, we will visit the offices of key
senators, including Senators Klobuchar and Franken, to urge them to work to end
the delays that have plagued the Senate confirmation process since the
beginning of the Obama presidency.





Despite the delays, the overwhelming majority of Obama’s nominees
have garnered tremendous bipartisan support, such as Susan Nelson who was
confirmed to the U.S. District Court for the District of Minnesota by unanimous
voice vote in December 2010.  We hope our
conversations in Washington will help national leaders understand how harmful
the confirmation delays have been to Americans who are seeking justice.





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 good of the patient by preventing the harmful prolongation of the dying process while avoiding euthanasia. Furthermore, evidence from those who have reviewed experiences of cases that invoked the process indicates that, in general, the law tends to improve the quality of the end-of-life care in the most difficult circumstances because it increases communication between staff and families. Specifically, it often provides relief to families struggling with the weight of the decision to remove LST from their loved one.




The general concern regarding the law’s compatibility with the ERDs highlights another important point: the TADA establishes minimums. Catholic hospitals can make internal policies regarding the implementation of the TADA that go beyond the minimums that the law establishes. For instance, a hospital might adopt a policy extending the waiting period or requiring a second opinion before the physician can submit the case to the review committee. Additionally, it could even revise the policy for the implementation of the TADA process to specify that it cannot be applied to a case in which the patient is merely receiving MANH. In fact, the law encourages developing just such a policy. While other means of resolving conflicts over medically inappropriate treatment are highly successful, used comparatively often, and should be explored before turning to legal means for resolution, laws like the TADA are, and should be, a last option that is nonetheless worthy of qualified support by Catholic hospitals.


Thứ Bảy, 5 tháng 5, 2012

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 partnering with a psychologist, to help owners come to terms with loss. 




Hospice may not be the proper choice in all situations and sometimes euthanasia is a better option for extremely ill pets.  But advancement in medications and treatments can give owners more choices while still doing what's best for the animal.   (Detroit News)


Thứ Sáu, 4 tháng 5, 2012

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 to resolve these cases are:



(1) To Shine a Spotlight on an Unresolved Social Issue. Because the public debate on futility has largely stagnated without achieving satisfactory clarity for patients and physicians, renewed public debate may be an important step toward better policy.



(2) To Cast a Shadow that Allows Extrajudicial Solutions.  Because less than 6% of all serious lawsuits are tried, the most important thing that Courts do is to cast a shadow of legal rules within which litigants can craft their own custom-made settlements.”  Roberts v. Stevens Clinic Hosp., Inc., 345 S.E.2d 791 (W.Va.,1986).



Some may argue that state legislatures are better positioned (than courts) to deliberate about how to balance the competing interests at stake in such cases.  Indeed it is true that legislatures can conduct more extensive, resource-intensive hearings.  But the lack of legislative movement on this topic suggests that the futility debate is “too hot” for the political branch of government, especially in the wake of the highly-charged public rhetoric regarding “death panels”.  A Pennsylvania court hearing a right-to-die case summarized this sentiment as follows:  “Legislatures are often slow to act, and where the legislature has failed to act, the Courts must respond to protect individual rights.”  In re Jane Doe, 45 Pa. D. & C.3d 371 (1987).


Thứ Tư, 2 tháng 5, 2012

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.




  1. Where relative benefits and harms are uncertain, consider CPR as a plausible option.

  2. 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 acceptable to acquiesce "so long as it is grounded in the patient's wishes and goals and there is a potential for a modicum of benefit."

  3. Where the patient will die imminently or has no chance of surviving CPR to the point of leaving the hospital, physicians should not offer CPR.  If a patient or surrogate continues to insist, request an ethics consult.  If the consult concurs, then the patient/surrogate should be informed that CPR will not be attempted and psychological/emotional/spiritual support should be made available.  Blinderman and colleagues do note that even here CPR might be attempted if the patient has "highly unusual values or goals."  




Thứ Ba, 1 tháng 5, 2012

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 seems like a serious informed consent violation, especially in Wisconsin where physicians must often disclose options even if they think they are inappropriate.