Families and End–of–Life Treatment Decisions An International Perspective

Just published, Families and End–of–Life Treatment Decisions: An International Perspective, analyzes the current status and role of family and other surrogates at the end of life.  Numerous European national laws are compared and bench-marked against other practices, in North and South America, in Africa and in some Asian countries.  The chapters include:Loved ones’ role in end of life care: evaluating deontological and utilitarian ethical...

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Renewing the Conversation: Respecting Patients’ Wishes and Advance Care Planning

This week, there was a good hearing before the Senate Special Committee on Aging, titled "Renewing the Conversation: Respecting Patients’ Wishes and Advance Care Planning."  A video of the hearing is available here.  Witnesses included:  James Towey, Founder, Aging with Dignity and President, Ave Maria UniversityHarriet Warshaw, Executive Director, The Conversation ProjectAmy Vandenbroucke, Executive Director, National Physician Orders...

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New Informed Consent - from Videos to Video Games

There has been a lot of coverage about how videos can significantly improve patient understanding and informed consent.  Perhaps even better might be the more interactive nature of video games.  A guest post over at PalliMed reviews a new way to "experience" canc...

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Liverpool Care Pathway - Problems

The Liverpool Care Pathway (LCP) is a checklist devised to help hospital doctors and nurses assist patients to a humane, dignified and pain-free end.  It basically transfers the hospice model of care into other care settings. But clinicians at the British Medical Association's Annual Representatives Meeting in Edinburgh admitted that there are some serious problems with the LCP.  (Daily Mail) (Telegraph)  The problems...

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Do-It-Yourself Funerals

Of the nearly 2.5 million people who will die in the United States this year, 99 percent will travel through a funeral home. That’s a big problem, according to Joshua Slocum of the Funeral Consumers Alliance, a political lobbying group based in Burlington, Vermont. In this mini-documentary by Vocativ, we see how the $11 billion “death-care” industry is taking advantage of bereaved consumers at a time when they are most vulnerable—even going so far as to purposely mislead people into thinking embalming is mandated by law (it isn’t).  The Funeral...

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Mandela v. Mediclinic Heart Hospital

Nelson Mandela, 94, has been in Pretoria's Mediclinic Heart Hospital, since June 8.  But, earlier this week, his frail health took a turn for the worse.  (Wall Street Journal)It is unclear exactly what treatment recommendation the hospital is making to the Mandela family.  But it seems that a plan for "comfort measures only" will not be accepted.  His eldest daughter Makaziwe Mandelane spoke out to say he is "at peace" and "only...

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Guidance for Healthcare Ethics Committees (paperback)

This book provides definitive, comprehensive education for members of healthcare ethics committees who find themselves confronted with ethically challenging medical situations.Chapters are written by nationally and internationally-recognized experts in bioethics and include learning objectives, case presentations, and discussion questions to facilitate committee conversation. This is essential reading for every member of a healthcare ethics...

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Force Feeding of Patients Is Rampant

U.S. Senators and the most distinguished bioethicists in the world have been calling on the military to stop force feeding the Guantanamo Bay prisoners.  But where is the outcry over the force feeding of patients, U.S. citizens, right here in the United States every day?  The Vancouver Sun is running (follow-up column here) a compelling story about Margot Bentley, about how providers refuse to respect patient rights to VSED (voluntarily...

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Hospice in Prison

Maine State Prison Hospice RoomThe Main Public Broadcasting Network is doing a 3-part series on end-of-life care in prison.  Part one is available here.  With a prison population in the United States of 1.6 million and many of these inmates getting older, end-of-life care options are a pressing issue. Just as prisoners, unlike the rest of us, have a Constitutional right to healthcare, they also have a Constitutional right to appropriate...

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Ontario Appeal Court Rules No Consent Required for DNAR Order (Cefarelli v. Hamilton Health)

This week, the Court of Appeal for Ontario issued an opinion that, at first glance, seems to directly contradict its June 2011 ruling in Cuthbertson v. Rasouli (the appeal of which is still pending before the Supreme Court of Canada).  But Cefarelli v. Hamilton Health Services is consistent with Rasouli, which held that consent is always required to stop life-sustaining treatment.  The Cefarelli case concerns end-of-life...

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How to Reduce Medical Overuse

In a recent JAMAInternal Medicine article, Allison Lipitz-Snyderman and Peter B. Bach identify three types ofoveruse of healthcare services:Benefits small relative to risksBenefits small relative to costsService unwanted The first two require especially difficult value-laden choices and tradeoffs. What dollar cost per QALY is too much?  When are the benefits toolow?  But the third type of overuse seems far less...

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Institute of Medicine Committee on Transforming End-of-Life Care - July Meeting

The Institute of Medicine Committee on Transforming End-of-Life Care will hold its 3rd meeting on July 22 and July 23, 2013, at Texas Children's Hospital.The topic for this meeting is "Aging, Health Care Workforce, Health Services, Coverage, and Access, Public Health, Quality and Patient Safety."  There will be a public session on July 23 featuring panel sessions on ethics and spirituality. An opportunity will also be available for the public...

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Quality Measurements, Payment, and the Law: Disincentives to Physician-Patient Discussions of End-of-Life Care

“Quality Measurements, Payment, and the Law:Disincentives to Physician-Patient Discussionsof End-of-Life Care” is the title of a new article by Missouri health lawyer Harvey M. Tettlebaum in theJournal of Health & Life Sciences Law.  Here is theabstract:With passage of the Affordable Care Act, thegovernment is playing a dramatically increasing role in not only paymentfor healthcare but also the standards by which care is delivered.Therefore,...

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The New Patient Self-Determination Act

My latest Legal Briefing column, “The New Patient Self-DeterminationAct,” has just been published in The Journal of Clinical Ethics 24(2).  In this Article, I cover recent legaldevelopments involving the Patient Self-Determination Act (PSDA).  Enacted inthe wake of the U.S. Supreme Court’s Cruzan decision in 1990, the PSDA remainsa seminal event in the development of U.S. bioethics public policy.  But thePSDA has long been criticized...

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Clinicians May Not Administer Life-Sustaining Treatment Without Consent: Civil, Criminal, and Disciplinary Sanctions

My 84-page article, "Clinicians May Not Administer Life-Sustaining Treatment Without Consent: Civil, Criminal, and Disciplinary Sanctions," has finally been published at Journal of Health & Biomedical Law 2013; 9(2):213-296.  A PDF is available here.  Here is the abstract:  Both medical and legal commentators contend that there is little legal risk for administering life-sustaining treatment without consent. In this Article, I argue that this perception is inaccurate. First, it is based on an outdated data set,...

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British Medical Bodies Revising Guidance on DNAR Orders

The Guardian reports that, amid concerns over whether DNAR orders are being properly implemented, the British GMC and BMA are revising guidance to doctors and nurses on decisions about whether or not to resuscitate patients.  There have been quite a few recent cases in which clinician wrote a DNAR order without patient or family consent (something they are allowed to do) but also without even informing the patient or family.  The new guidance...

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Medical Futility Remains Major Reason for Ethics Consults

Andrew G. Shuman and colleagues at Memorial Sloan-Kettering Cancer Center have published a new study in the Journal of Oncology Practice, reviewing and describing clinical ethics consultations (2007 to 2011) at two National Cancer Institute–designated comprehensive cancer centers.They found that the most common primary issues leading to ethics consultation were:Code status and advance directives (25%)Surrogate decision making (17%)Medical futility...

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New Publication: Legal, Medical, and Ethical Issues in Minnesota End-of-Life Care

In November, the Hamline University Health Law Institute and the Hamline Law Review hosted a symposium, titled "Legal, Medical, and Ethical Issues in Minnesota End-of-Life Care."  The Law Review is publishing a volume of articles on the Symposium theme.  I prepared this introduction to the special issue.  The printed volume should be available late next mon...

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"Staying Alive" vs. "Another One Bites the Dust"

The universal algorithm for adult CPR requires compression of at least 2 inches and a compression rate at least 100 per minute.  How fast is 100 compressions per minute?  I was surprised to learn that many clinicians use Queen's Another One Bites the Dust to maintain the best rhythm for performing CPR.  Sure, it might have 100 beats per minute.  But is that the message the clinician should have in her head when trying to resuscitate someone?Surely more appropriate is the Bee Gees' 103-beat-per-minute Staying Alive.  Other...

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New Demos Report Analyzes Inequalities in End-of-Life Care

Demos UK has just published a new report, Ways and Means.Many receive end-of-life care of varying quality, often characterized by delays, a lack of information and an insufficient say in their end of life journey.  Ways and Means highlights several factors that contribute to these kinds of inequalities at the end of life. It reveals that the likelihood of what can be described as a ‘good death’ – one where the wishes of the patient and...

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Appropriate Attack on Terri Schiavo Life & Hope Network

I missed Pittsburgh Post-Gazette columnist Sally Kalson's article earlier this spring, titled "We Spend Too Much in Dying."Here are two excerpts from the beginning and end of her article:If Medicaid is really as unsustainable as Republican governors insist, then the Terri Schiavo Life & Hope Network is not helping matters. . . .Health care rationing sounds evil, but the fact is we're already doing it, based on who's covered and...

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Minnesota Appeals Court to Hear Assisted Suicide Case against Final Exit Network

In April, Dakota County, Minnesota Judge Karen Asphaug ruled that Minnesota's assisted suicide statute was unconstitutionally over-broad as applied in a criminal case against Final Exit Network and some of its members involved in the 2007 death of Doreen Dunn.  The district attorney appealed that ruling.  The Court of Appeals denied a petition to stay proceedings pending the outcome of the related Minnesota Supreme Court case, State...

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Public Health Paternalism Blog

I have started a new blog on Public Health Paternalism:  HealthPaternalism.com.  Medical Futility will continue to cover developments in end-of-life law, ethics, and policy.  Health Paternalism, in contrast, will cover the balancing of individual liberty and the promotion of public health.  Paradigm examples are helmet laws and sugary food bans.  But coverage will be range from specific public policy proposals to deeper Millian...

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ECMO - The Next Medical Futility Battleground?

The use of ECMO has been growing.  In contrast to dialysis, CPR, and mechanical ventilation; clinicians can usually more confidently refuse to offer or provide ECMO when they deem it medically inappropriate.  Yet, one wonder whether expanding use will result in "indication creep."  CPR and dialysis were originally intended for only certain populations.  Yet, they are now regularly offered to 100-year-old patients with numerous...

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Nevada Enacts POLST Statute

Nevada has just become thelatest state to legislatively adopt POLST.  Last week, Nevada GovernorBrian Sandoval signed A.B. 344.In April, Indiana also enacted a POLST statute.  Before that, 18 states already had POLST statutes.  So, if my math is right, 20 states now have POLST statutes.  Other states have implemented POLST through regulations or through clinical consensus. &nb...

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POLST Authorizes Unilateral DNAR Orders

In both Maryland and Vermont, a clinician can write a POLST order indicating "no CPR" even without patient or surrogate consent.  Regulations in both states authorize the entry of a "do not attempt resuscitation" order on a POLST on the basis that CPR would be "futile" or "medically ineffective."  This "no consent" option is clearly printed right on the POLST form.California law similarly provides that while "a health care provider shall...

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Clinicians Accede to Surrogate Decisions

It is well documented that clinicians frequently cave-in to surrogate demands to continue non-beneficial treatment.  What I had not focused on is a finding by sociologist Susan Shapiro. Clinicians also accede to surrogate requests to stop life-sustaining treatment even when those surrogates lack legal authority to make such requests.  Here is an excerpt from a summary of Shapiro's research:Shapiro found many reasons why families were...

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New Book Review of WRONG MEDICINE

Wrong Medicine: Doctors, Patients, and Futile Medicine remains the best book-length treatment of medical futility and non-beneficial treatment.Last year, I reviewed the second edition in the American Journal of Bioethics.  This week, Robert C. Young posted a new book review of Wrong Medicine to Oncology Times.  &nb...

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Edmund Pellegrino Has Died

Edmund Pellegrino, one of the world's most distinguished bioethicists, has died at 93.  He would have turned 94 next week.  I was luck to intersect with him at Georgetown University and then later at the President's Council on Bioethi...

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New Hastings Center Guidelines on Medical Futility

The new Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life do not have very much useful guidance on medical futility disputes.Page 14 provides:  The right to refuse treatment does not establish a right to demand any and all treatment a patient or surrogate chooses.  The goal of respect for persons should not be reduced to "do whatever the patient wants" or "do whatever the surrogate thinks...

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A Nudge in the Right Direction with a Stick the Size of CMS: Physician-Patient Communication at the End of Life

Saint Louis University School of Law student Katherine B. Ledden has posted (here too) "A Nudge in the Right Direction with a Stick the Size of CMS: Physician-Patient Communication at the End of Life."  This article appears in the Saint Louis University Journal of Health Law and Policy, Vol. 6, No. 2 (2013).  Here is the abstract:   This paper examines the physician-patient relationship at the end of life and recommends...

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Open Forum on AMA Code of Medical Ethics

The AMA Council on Ethical and Judicial Affairs (CEJA) will conduct an Open Forum on Monday, June 17, 2013, from 9:30 a.m. to 11 a.m. at the Hyatt Regency Chicago, Columbus C-D.The Open Forum is open to all AMA members, interested non-members, other guests, and the press.  Open Forum attendees are invited to introduce emerging ethical issues that may warrant attention from CEJA and inclusion in the AMA "Code of Medical Ethic...

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Aid-in-Dying: Is Terminal Illness a Prerequisite?

Dr. Philippe Freiburghaus prescribed sodium pentobarbital to an 89-year-old man suffering unbearable pain who had tried to commit suicide.  But Swiss prosecutors said the doctor had “crossed the line” by failing to follow the legal regulations.  “In prescribing this drug he did not respect the ethical directives, namely the presence of an incurable illness and a short life expectancy."But just a few weeks ago, the European Court for Human...

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Hospital Ethics Committees: Coordinating across Institutions

I was pleased to read that these two New York hospitals coordinate some of their ethics committee activities.  The ethics committees of St. Elizabeth Medical Center and Faxton St. Luke’s Healthcare "meet jointly every month to discuss ethical issues, which are similar at both hospitals."  I am looking for more examples of multi-institutional ethics committees.  I want to bolster my argument that this is the best way to balance...

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Rodger William Kelly Had Sex with Unconscious Neighbor to "Save Her Life"

Rodger William Kelly was charged with the rape of his unconscious neighbor.  But he claims that he only had sex with her in an attempt "to save her life."Kelley told Utah police that he found his 29-year-old neighbor unconscious and began to have sex with her because "he was trying to save her life."  "He said he did place [his penis] inside of her to try and get her temperature up," police said in a probable cause statement filed in 5th...

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Lana Barnes, Surrogate in Futility Dispute, Convicted of Medicaid Fraud

Lana Barnes was the surrogate in the most famous medical futility case in Minnesota.  She insisted on non-indicated treatment at many Minneapolis area hospitals before one hospital challenged her in court and had her replaced as her husband's substitute decision maker.  Last week, Lana Barnes was convicted of Medicaid fraud in connection with her husband's ca...

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Man Oppressed by the Triumphs of Medicine

I enjoyed "The River" by James Guglielmi, yesterday, at the Art Institute of Chicago.  You see 4 women alongside the expanse of blue water, hemmed in by a monolithic concrete riverbank with an industrial landscape in the distance.  There is a vivid contrast between the natural and man-made landscapes.  One critic noted that Gugliemi's work suggests "the theme of man oppressed by his own great triumphs."  This resonates with the...

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African Americans - Medical Mistrust Persists

African Americans still can’t get over the Tuskegee Experiment.  Four decades after the infamous study on syphilis’ impact on black men ended in rural Alabama, mistrust of medical science resonates in the lack of African American participants in potentially life-saving clinical trials and studies.  (Charlotte Post)  We see this same distrust in low advance directive completion rates and higher rates of end-of-life treatment confli...

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Medicare Data Access for Transparency and Accountability Act (Medicare DATA Act)

I recently blogged about two new databases that add transparency to Medicare and Medicaid information.  First, ProPublica launched Nursing Home Inspect.  Second, the Association of Healthcare Journalists launched a hospital inspection database.  These two databases may soon be joined by another.  U.S. Senators Chuck Grassley, R-Iowa, and Ron Wyden, D-Ore., say that despite a recent federal ruling affirming that Medicare data should...

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Wisconsin Bishops - Now and at the Hour of Our Death

The Wisconsin’s Catholic bishops just released the third edition of their pastoral letter on end of life health care decision-making and advance care planning, Now and at the Hour of Our Death. The letter voices the bishops’ concern and compassion for those facing critical health care decisions, and shares a moral and ethical framework for making such decisions.  Fortunately, the letter does not go far as the radical Catholic Medical Association...

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