One Chance to Get It Right: Improving People’s Experience of Care in the Last Few Days and Hours of Life

The Leadership Alliance for the Care of Dying People has just released a 168-page report: One Chance to Get It Right: Improving People’s Experience of Care in the Last Few Days and Hours of Life.



The report is focused on 5 Priorities for Care.  These priorities are that, when it is thought that a person may die within the next few days or hours:

1. This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.


2. Sensitive communication takes place between staff and the dying person, and those identified as important to them. 


3. The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. 


4. The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. 


5. An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.

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A Good Death: A Reflection on Ombudsman Complaints

The Irish Office of the Ombudsman has just released a new report:  A Good Death: A Reflection on Ombudsman Complaints.



The report covers several types of complaints:

• Communications 


• Patient Autonomy 


• Specialist Palliative Care 


• Support for Families and Friends 


• Post-Mortem Examination 


• Returning the Deceased Person’s Belongings 


• Managing Complaints 

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Margot Bentley Does NOT Have Capacity to Revoke Her Prior Instructions to VSED

In the Spring 2014 issue of the Journal of Clinical Ethics, I criticized the British Columbia court's decision in Bentley. 



The court said that because Bentley swallowed when she a spoon was inserted in her mouth, she has the capacity to make the decision about whether to eat and drink.  But Bentley is in stage 7 Alzheimer's.  The case is now on appeal.



Strolling through Dartmouth's Hood Museum, this morning, I was reminded of this common image.  The baby Jesus seems to be blessing people.  This seems to be a paradigm example of "imputing" capacity to someone who clearly does not have it.  Jesus is, of course, an exceptional case.  Margot Bentley is not.  

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Decision Guides on Life-Sustaining Treatment

The California Coalition for Compassionate Care has released Decision Guides on several forms of life-sustaining treatment. 



Decision Guides explain the complex topics of life-sustaining treatments, using consumer-friendly language with evidence-based information. The Guides were developed with the help and guidance of healthcare professionals, and reflect the latest research on these interventions.



TOPICS INCLUDE: artificial hydration, cardiopulmonary resuscitation (CPR), mechanical ventilation, and tube feeding.

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Shocked: Adventures in Bringing Back the Recently Dead

Not too long ago, there was no coming back from death. But now, with revolutionary medical advances, death has become just another serious complication.



As a young medical student, Dr. David Casarett was inspired by the story of a two-year-old girl named Michelle Funk. Michelle fell into a creek and was underwater for over an hour. When she was found she wasn’t breathing, and her pupils were fixed and dilated. That drowning should have been fatal. But after three hours of persistent work, a team of doctors and nurses was able to bring her back. It was a miracle.



If Michelle could come back after three hours of being dead, what about twelve hours? Or twenty-four? What would it take to revive someone who had been frozen for one thousand years? And what does blurring the line between “life” and “death” mean for society?



In Shocked, Casarett chronicles his exploration of the cutting edge of resuscitation and reveals just how far science has come. He begins in the eighteenth century, when early attempts at resuscitation involved public displays of barrel rolling, horseback riding (sort of), and blowing smoke up the patient’s various orifices. He then takes us inside a sophisticated cryonics facility in the Arizona desert, a darkroom full of hibernating lemurs in North Carolina, and a laboratory that puts mice into a state of suspended animation. The result is a spectacular tour of the bizarre world of doctors, engineers, animal biologists, and cryogenics enthusiasts trying to bring the recently dead back to life.



Fascinating, thought-provoking, and (believe it or not) funny, Shocked is perfect for those looking for a prequel—and a sequel—to Mary Roach’s Stiff, or for anyone who likes to ponder the ultimate questions of life and death.

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French Kevorkian Acquitted, Just Like Jack

Nicolas Bonnemaison is a French doctor who actively ended the lives of seven terminally ill patients on their request.



Bonnemaison, a former emergency room doctor, was accused of "poisoning particularly vulnerable people" – five women and two men who died between March 2010 and July 2011.



Like the multiple Michigan juries that acquitted Jack Kevorkian, this week, a French jury acquitted Bonnemaison of all charges. Jurors accepted Bonnemaison’s argument that he had not “played God” but  had taken medically justified decisions to curtail the agony of patients who had only a short time to live.

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UK Supreme Court Judgment & Video on Assisted Suicide

Here is the judgment (also here) in R. (Nicklinson & Lamb) v. Ministry of Justice and a video of the court issuing the judgment. The court stops just short of making a declaration of incompatibility with human rights.

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Conseil d'État - Judgment on Vincent Lambert

Five years ago, 39-year-old fireman, Vincent Lambert, was left in a vegetative state by a motorcycle accident.  His doctors, his wife and most of his brothers and sisters believe that Mr. Lambert has no proper life and no prospect of recovery. They believe that he should be allowed to die.  But Mr. Lambert’s devout Catholic parents, one sister, the French government and a lower court believe that his life should be preserved. 



Today the Council of State ruled that Mr. Lambert's physicians may stop his life-sustaining treatment.  (In France, administrative tribunals settle disputes between a public body (like a government hospital) and a private entity. The Conseil d’État is the supreme administrative court.)



The Council of State relied on evidence that Mr. Lambert had clearly and repeatedly expressed the wish not to be kept artificially alive in the event it would be in a state of dependency.  It was careful to caution that the fact that a person is in an irreversible state of unconsciousness does not characterize, by itself, a situation in which the continuation of treatment would be unjustified on the basis of unreasonable obstinacy. 



Mr. Lambert's parents have appealed to the European Court of Human Rights.  But since the French Court's decision seems squarely in accord with ECHR precedent, it is unlikely they will obtain relief there.

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Tracey v. Cambridge Hospital - Duty to Consult ALREADY the Law in USA

The recent UK Appellate judgment in Tracey v. Cambridge University Hospital establishes a duty on the part of clinicians to consult with patients or surrogates before writing a DNR order.  Notably, British physicians have a duty to consult even though they do not ultimately need patient or surrogate consent to write a DNR order.  



I am pleased to observe that this rule has already long been settled law in the United States.  Both where clinicians have the right to write a DNR order without consent (e.g. Texas; California) and where such a right is unclear (Pennsylvania), clinicians must always do so openly and transparently.  Otherwise, they risk statutory fines and/or tort liability for negligent or intentional infliction of emotional distress.    

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Casey Kasem's Living Will Did Not Work for Dementia: How to Make Sure Your Advance Directive Works

Check out this new video by Stanley Terman.







Casey Kasem received the diagnosis of Lewy Body Dementia in 2007. He created a Living Will with expert legal advice and the wishes he expressed in his 2011 revision were consistent. So why didn't this expression of end-of-life wishes prevent him from extreme suffering during the last chapter of his life?  Why was his designated proxy/agent forced to go to court twice? Why did the man who communicated with such a great voice, in the end, have NO voice?



Similarly, why did the British Columbia Supreme Court rule that Margaret Bentley must continue forced feeding—in the opinions of her husband and daughter (both designated as agents) and her personal physician—as she stated in her Living Will? This former nurse cared for Advanced Dementia patients so she was passionate about wanting to avoid a prolonged dying in Advanced Dementia.



Are there effective end-of-life options for the rest of us? How can we be certain that others will honor our wishes?



This video is a slightly edited version of Stanley A. Terman, Ph.D., M.D.'s presentation on June 18, 2014, to the San Diego Dementia Consortium. Although initially intended for a professional audience, its message is clear for all (even if one does not know that "dysphagia" means swallowing difficulties or needs to learn that "double incontinence" means inability to control both "#1" and "#2"). Dr. Terman is a psychiatrist, bioethicist, and author of four books on end-of-life issues.



The non-profit organization that Dr. Terman leads (Caring Advocates) feels it is so important for people to have Living Wills that will be effective for both Dementia and for the complete relief of pain, that its professional staff will review anyone's Living Will or Advance Directives sent to us at no cost or obligation. See Dr. Terman's other videos here.



Here is the Table of Contents by time in minutes for this video:

0.00 Introduction; "We live in exciting times."
0.46 The horrible disappointment if others do not honor a person's end-of-life wishes
1.29 Casey Kasem's wife did not have legal authority to demand his AMA discharge
1.46 How Casey Kasem suffered before he died.
2.25 What were Casey Kasem's wishes?
2.35 Casey Kasem's 2007 Living Will (excerpt)
3.00 Casey Kasem's 2011 Living Will (excerpt)
3.43 What his Casey Kasem's wife has said
4.42 Margaret Bentley's wishes
5.02 Margaret Bentley 1991 Living Will (excerpt)
5.19 The request, "I ask to be euthanized"
5.29 (Announcing Caring Advocates' offer to give opinion on YOUR Living Will.)
6.39 Our opinion regarding Margaret Bentley's Living Will
7.38 How others hand-feed Ms. Bentley
9.03 Chandler-Cramer Living Will (excerpt) that requests Voluntarily Stopping Eating and Drinking (VSED)
9.29 Nancy Cruzan (1990)
9.54 Can an Advanced Dementia patient VSED?
10.28 Why some consider VSED immoral
10.53 How a Living Will can be consistent with the teachings of conservative religions
11.33 What is "Natural Dying" and how does it differ from VSED?
11.40 The difference between WITHHOLDING and WITHDRAWING (line drawing)
12.09 Some patients might regain function as they undergo dehydration
12.38 Withholding food and fluid could be viewed as euthanasia, which NOT legal
13.54 Other orders included in "Natural Dying"; WHBOF, all Comfort Care
14.45 The "Ironclad Strategy" includes a step that would have been easy for Casey Kasem:
Make an audio (or video) recording that states your precise wishes.
15.25 Advance Care Planning can prevent premature dying based on the Dementia Fear
16.07 "WHAT" and "WHEN" are the two questions that Living Will answer
17.07 Granting Proxies/Agents leeway
17.49 Zero or 100% leeway (which can be understood)
18.01 Example: Double incontinence. Yes
18.47 The Natural Dying Living Will Cards — to decide "WHEN"
20.09 Discussion. How to get physicians to comply? (The "Ironclad Strategy")

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70% of Americans Support Euthanasia: Changing Legal Climate for Physician Aid in Dying

A recent Gallup poll shows that 70% of Americans Support Euthanasia.

  

These survey results help explain the unmistakable trend toward legalizing more end-of-life options and expanding individual liberty regarding the manner of death.  A few weeks ago in JAMA, my co-authors and I reviewed the "Changing Legal Climate for Physician Aid in Dying."   Already since then, Quebec enacted Bill 52, legalizing physician aid in dying.  And a similar bill has advanced in the New Jersey Assembly. 

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More Surrogates Challenged over End-of-Life Treatment Decisions

Last week, the "wife versus daughter" conflict over the treatment of Casey Kasem got worldwide attention.  And, hopefully, that coverage will prompt more and better advance care planning.  



Still, family conflicts over end-of-life treatment remain common.  For example, take this week's case from Jefferson County, Texas.



Last Sunday, 54-year-old Terry Martin's heart stopped beating.  His estranged wife, Debi, permitted Baptist Beaumont Hospital to discontinue life-sustaining treatment.  But she's been estranged from Terry Martin for nine years.  Martin's brother believes that Debi Martin is the life insurance beneficiary of the estate.  Suspecting bad motives, the brother obtained a 14-day TRO, ordering the hospital to continue treatment.

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11th Annual International Conference on Clinical Ethics & Consultation (ICCEC)

The 11th Annual International Conference on Clinical Ethics & Consultation (ICCEC) will be in New York City, from 20-22 May 2015.  



The theme is "Improving Quality and Professionalism of Clinical Ethics Education & Consultation."  Recently clinical ethicists and professional associations have attempted to professionalize our field by developing codes of ethics and proposing formal accreditation of clinical ethicists. Simultaneously, training programs developed new methods for teaching and assessing competency in clinical ethics consultation. This conference offers an opportunity to discuss and analyze these developments. 



Proposals are invited from everyone involved in clinical ethics or clinical ethics education: medical educators, medical historians, nurses, philosophers, physicians, lawyers, standardized patient actors, religious counselors, social workers, therapists, and anyone else involved. Proposals may include individual presentations, panels, poster presentations, workshops, and media presentations. 



Abstracts accepted starting in July 2014.  The deadline for submission of proposals is November 3, 2014.  Possible Topics Include 

• Clinical Cases that Teach Us


• Models of Clinical Ethics Consultation


• Quality Improvement or Evaluation of Clinical Ethics Consultation


• Quality Improvement or Evaluation of Clinical Ethics Education


• Ethics of Clinical Ethics


• The Interface between Clinical Ethics and Research Ethics


• Historical Reflections on Clinical Ethics or its Evaluation

The ICCEC conferences were founded by George J. Agich and Stella Reiter-Theil to promote critical discussion of the many practical, institutional, and ethical issues associated with clinical ethics, ethics committees, and ethics consultation. This year's conference continues that tradition at the following venues.

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Treating Patients in PVS is Unreasonable Obstinacy

This may the the holding of the French Council of State in the case of Vincent Lambert.  The 17 judges will announce their decision on Tuesday, June 24.  (Le Figaro; Le Monde) 

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Detoxifying the Concept of Rationing

In the Journal of Clinical Ethics 25, no. 2 (Summer 2014): 116-9, James Sabin has a piece titled "Detoxifying the Concept of Rationing."  Sabin argues that Andrew Hantel’s proposal for dealing with cancer drug shortages exemplifies the kind of clinician-led discussion of rationing that the U.S. political process requires. 



Sabin argues that the U.S. will not get a grip on healthcare cost escalation until we set true budgets for healthcare. We will not be able to do that until the public accepts that rationing, done right, is an ethical necessity, not an ethical abomination. Because endorsing rationing is a third rail for politicians, “top down” leadership is currently impossible. As a result, health professionals must lead a “bottom up” educational process. 



Andrew Hantel's article shows how this can be done. It is titled "A Protocol and Ethical Framework for the Distribution of Rationed Chemotherapy."  The Journal of Clinical Ethics 25, no. 2 (Summer 2014): 102-15.  Here is the abstract:

Shortages of generic, injectable chemotherapeutics have been increasing in prevalence since 2006. Due to the lack of access to first-line, lifesaving treatments, physicians have been forced to ration chemotherapy between patients. Although the scarcity has been managed with good intentions, it has been done in an ad hoc manner, without the benefit of an ethically grounded and standardized schema.

Using an approach based on the “accountability for reasonableness” method by Daniel and Sabin, I establish a framework and protocol for rationing that is specific to chemotherapy. Prior to the state of true shortage, I present guidelines for the use of an adequate supply of chemotherapy with knowledge of upcoming scarcity. Within the rationing framework itself, I first prioritize emergency use of chemotherapeutics and those already receiving treatment at the time of shortage. I advocate for stratifying patients based on the prognostic indicators of their cancer type, using a combination of clinical-trial-based initial response and longer term survival, followed by the patients’ line of treatment. All patients who are not able to receive their “best” treatment must receive a sequent, next-best treatment, and their treatment team must have the ability to appeal to a rationing committee in special circumstances.

I reject the ideas of stratification based on the intention of the treatment, perceived quality of life, pre-existing condition not impacting performance status, the classical “sickest first” argument, and giving preference to pediatric cases. Lastly, I advocate for any system of rationing to be transparent to those it affects and acknowledge the difficulties it presents to patients and physicians 

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Paternalistic Opposition to Court Judgment in Tracey

I was surprised to see this letter, titled "Useless Resuscitation," printed in this morning's Daily Telegraph (emphasis added).



SIR – Do Not Resuscitate orders (report, June 18) are usually in the patients' best interests. Dying is hard and often unpleasant. Why do it twice in quick succession? But doctors now have a legal obligation to inform and consult with patients and relatives if they wish to place such an order. This is desirable but often impractical.



The same doctors do not have an obligation to provide cardiopulmonary resuscitation if they believe it to be medically futile. The change in the rules will simply lead to fewer DNR orders being signed and patients will suffer for it. A colleague once stated that when he got to a certain point in his sixties he would tattoo "Don't even think about it" across his chest, having seen the horrors of inappropriate resuscitation.



If patients and their relatives had practised medicine they would be able to make an informed decision, but they haven't and they can't. This new legal duty serves no useful purpose.



Dr Alexander Barber Camberley, Surrey

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Do Clinicians Always Need Consent to Stop Life-sustaining Treatment?

Do Clinicians Always Need Consent to Stop Life-sustaining Treatment?  I will answer this question, tomorrow morning, in a webinar for the Arizona Bioethics Network.  



I will address the question in the context of two situations: brain death and persistent vegetative state.  My slides are posted here.

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Lawyers & Clinicians: Ethical Obligations to Older Adult Clients & Patients

Join us at Hamline University, on Wednesday July 9, for an expert presentation on "Lawyers & Clinicians: Ethical Obligations to Older Adult Clients & Patients."



The Minnesota Board approved this event for 1 ethics CLE credit.  This event also qualifies for social work and nursing continuing education credits.



PROGRAM DESCRIPTION



Representing older adults presents especially difficult and tricky ethical questions.  For example, who is your client: the elderly individual or her adult child?  What do you do when your client is clearly incapacitated?  What do you do when you suspect, but are not sure, that your client is incapacitated?  



Professor Martyn will review Minnesota Rules of Professional Conduct 1.2, 1.6, and especially 1.14.  Notably, the program will be interactive and will engage the audience.  The program will be built around brief hypothetical situations designed to reveal the relevant professional rules and principles that guide lawyers, physicians, and other clinicians who represent and treat older adults.  The problems raise issues such as:

1. When should an older adult's capacity be questioned and/or evaluated?


2. Are the legal and medical standards for capacity similar?


3. How should friends and relatives be included or excluded in providing legal or medical services?


4. What ethical standards govern the representation and treatment of elder adults?

Lawyers, physicians, nurses and social workers will share their viewpoints and clarify their professional goals in providing elder adults services.  Written materials (including the rules, court cases, and journal articles) will be distributed in advance to registered participants.  



FACULTY / PRESENTER



Susan R. Martyn, is a distinguished visitor at Hamline Law this summer.  Professor Martyn is a national authority on issues of legal ethics and has served on two of the most important national bodies to shape the law governing lawyers in the past twenty years.  



She was an advisor to the American Law Institute’s Restatement (Third) of the Law Governing Lawyers from 1987 until its publication in 2000.  And she served on the American Bar Association’s Standing Committee on Ethics and Professional Responsibility from 2007 to 2010 as well as the American Bar Association’s Ethics 2000 Commission from 1997 to 2002.



WHEN



Wednesday, July 9, 2014

5:30 p.m. Reception

6:00 p.m. to 7:00 p.m. Presentation



WHERE



Hamline University Health Law Institute

Anderson Center Room 111 & Live Webcast

774 Snelling Avenue

Saint Paul, Minnesota 55104

Map: http://tinyurl.com/czjonl8



REGISTER



Register here

Free for the Hamline community

$35 for outside guests earning CLE credit



QUESTIONS



Kari McMartin

Program Manager

Health Law Institute

651-523-2130

kmcmartin02@hamline.edu

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Tracey v. Cambridge University Hospital - Duty to Consult on DNR Orders

Almost three years ago, David Tracey filed a lawsuit against Cambridge University Hospital.  Tracey alleged that CUH clinicians wrote a DNR order for his wife without her consent and without any discussion with her.



Today, Tracey finally obtained a favorable judgment from the Court of Appeal.  I posted a copy of the judgment here.   



Although British law makes clear that the final word on such issues lies with medical staff, there has been an apparent lack of clarity over just how far they have to go in consulting a patient or their families about their wishes.  Indeed, the Tracey case is hardly unique.  As I have blogged extensively, there have been dozens of recent cases in which DNAR orders were written not only without consent but also without even consulting the patient or family.



Today, the Court clarified  that when it comes to withholding or withdrawing life-sustaining treatment, there is a presumption in favor of patient involvement.   

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Even Patients with Advanced Illness Have REVERSIBLE Medical Problems

Here is a great short case study and reminder that even among people with advanced illnesses, it is often reasonable to treat reversible medical problems.



Even if the patient has previously completed a POLST or advance directive declining aggressive interventions, it might be appropriate to discuss addressing problems like UTIs, especially if the treatment is not too burdensome and there is a good chance of recovery.  The author concludes that it is often reasonable to try a time-limited trial of more intensive treatment, with a plan to reassess within a day or two.

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Films on Death & Dying

This site collects some excellent documentaries and other films on death and dying.  Many, including previously broadcast shows from Frontline and PBS, are available for free.

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Student Bioethics Prizes

Two student prizes are offered through the Australasian Assiciation of Bioethics & Health Law Conferences

• The John McPhee prize in health, law and ethics: a topic related to health, law and ethics


• The Max Charlesworth prize in bioethics: ethical issues arising in relation to medicine, the health sciences or health care in general from any of the disciplines that offer a perspective on such issues, including philosophy, bioethics, law, social theory, sociology, anthropology, psychology, feminism, linguistics, cultural studies, history, literary theory and literature

Format

• Not to exceed 5000 words


• Essay should conform to the requirements for submission to the Journal of Bioethical Inquiry and submitted as a word document attachment 

Date of submission

• Friday 27 June 2014 (by COB)

Prize

• The winner[s] will be invited to present their paper at this year's conference. 


• Complimentary registration fees at the conference


• Assistance to travel to the conference may also be provided


• One year’s subscription to AABHL membership


• The winner[s] should submit the winning essay to the Journal of Bioethical Inquiry. Mention should be made in the cover letter that the paper has been awarded the prize.

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Palliative Care Fast Facts - Now for iOS

Since 2000, Fast Facts and Concepts has provided concise, practical, peer-reviewed, and evidence-based summaries on key topics important to clinicians and trainees caring for patients facing life-limiting illnesses.



Fast Facts are designed to be easily accessible and clinically relevant monographs on palliative care topics. They are intended to be quick teaching tools for bedside rounds, as well as self-study material for health care professional trainees and clinicians who work with patients with life-limiting illnesses.



For the past few years, Fast Facts have been published and supported by the End of Life/Palliative Education Resource Center (EPERC) at the Medical College of Wisconsin.  Now, a new, free app for iPhone and iPad devices provides mobile access to the Fast Facts database.



Features of the new app: 

• Includes every Fast Fact article in a format that is easy to search and reference from anywhere.  


• Ability to browse the Fast Facts database by chronology or by subject


• Search the Fast Facts database in real time


• Share individual Fast Facts articles via email to others.


• Adjustable article text size, background and font color


• Future versions will incorporate a Case of the Month section that highlights clinician submitted cases of the month from various palliative care programs throughout the United States and world

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The ‘Unbefriended’ Challenge PA/LTC

I am quoted and cited in this nice front-page coverage of the challenge of the unbefriended in the post-acute and long-term care setting.  I am delighted to see the issue getting this attention.  

Medical decision making for incapacitated patients and residents without surrogates remains a very big yet under-examined problem.  I am working on an update that summarizes 2014 legislative responses. 

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Dying with Dignity in the Intensive Care Unit - NEJM Poll

The New England Journal of Medicine is conducting a poll on an ICU case.  Read the case below and decide how decisions should be made about this patient’s further treatment.  Participate in the poll and, if you like, submit a comment supporting your choice. The editors’ recommendations will appear on the NEJM site along with a link to the related review article, on June 26.

Presentation of Case

A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment required 15 days of treatment in the intensive care unit (ICU) of a university hospital for septic shock due to fecal peritonitis from a perforated sigmoid colon. After surgery, he was placed on a mechanical ventilator. 



Complications during his ICU stay included mild disseminated intravascular coagulation and acute hepatic necrosis associated with acetaminophen treatment. After being transferred to the surgical floor, he had an unwitnessed fall from his bed, and cranial computed tomography showed an acute subdural hematoma with underlying hemorrhagic contusion on the left side and 5-mm displacement of the midline intracranial structures. 



(In the previous installment of this case, there were 2898 votes on how to treat the patient’s traumatic brain injury. More than two thirds of the respondents [67%] favored evacuation of the acute subdural hematoma, placement of an external ventricular drain, and admission to the ICU for active management of increased intracranial pressure. Another 26% favored evacuation of the acute subdural hematoma and admission to the ICU without monitoring of intracranial pressure, whereas 6% opted for conservative management with the rationale that there was no prospect for functional recovery.)



He was taken to the operating room and underwent a craniotomy for evacuation of the subdural hematoma. Twelve days after this procedure, during which he received no sedative medications, he remains in a coma with a best motor response of abnormal flexion on the left side. He is still receiving mechanical ventilation. The consensus opinion of treating clinicians is that he will most likely not make a functional recovery.

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Justice Based Reasons for Resisting Inappropriate Demands for Antibiotics and ICU Treatment

Last week, the LA Times printed this true story: 

A fellow with a cold came to see Dr. John Santa asking for antibiotics. Santa carefully explained that antibiotics wouldn't do the man any good because his cold was caused by a virus, and antibiotics only work on bacterial infections. The patient stomped out of the office, fulminating bitterly . . . .

Every day, in offices all around the country, patients request antibiotics that will do them no good, and all too often their doctors, unlike Santa, prescribe them. "Sadly, the easiest solution, rather than to just say no and potentially anger the patient, is to do what they ask," says Santa, now the director of the Consumer Reports Health Ratings Center. 



The same solution explains the overuse of ICU resources:  it is easier to just cave-in and do what the family wants.  But in both cases the strongest argument for resisting demands for inappropriate medicine does not relate to autonomy or beneficence but to justice.  



Over-prescribing antibiotics helps create resistant bacteria that lead to illnesses that can't be treated. It is a threat to public health.  Similarly, keeping permanently unconscious patients in the ICU means that other patients are left with higher risks of morbidity and mortality in the ED or community hospitals.

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National Right to Life Convention to Address End-of-Life Medicine

The National Right to Life Convention is June 26-28, 2014, in Louisville, Kentucky.  Several sessions address end-of-life medical issues.  I would love to better appreciate what is a perspective nearly 180 degrees different from my own.  Alas, I will be in New Hampshire at an informed consent conference.

• Denial of Treatment Against Your Will: The Battle We’re in Danger of Losing -- Burke Balch, J.D., Tony Lauinger, Elizabeth Graham, and Kathy Ostrowski


• Is Doctor Prescribed Suicide Coming to Your State Next? -- Mary Hahn Beerworth and Jennifer Popik, J.D.


• Dying of Thirst!  Medicine’s Intentional Killing Through Dehydration, and How to Protect the Vulnerable -- Brian Johnston


• Deadly Compassion:  A Nurse and Patient Discuss Euthanasia --  Jeanne Head, R.N., and Wayne Cockfield


• Bioethics War On Humans -- Wesley J. Smith, Ph.D.; Burke Balch, J.D.; and Jennifer Popik, J.D. 

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Texas Right to Life Sues Senator Bob Deuell over Medical Futility Bill

Do NOT mess with Texas Right to Life.   



In the run-up to this year's Republican primary runoff, Texas Right to Life produced radio ads that were critical of Senator Bob Deuell's sponsorship of SB-303.  One of the ads is available here.



SB-303 was a bill that would have improved the procedural fairness of the Texas Advance Directives Act. The radio ads, characterizing Deuell's bill as "an expansion of euthanasia,"were apparently successful.  Deuell lost the May 27 primary runoff.



Nevertheless, Texas Right to Life has filed a lawsuit in Harris County Court, claiming that Senator Deuell illegally interfered with the ads.  Deuell had hired legal counsel to contact at least two of the radio stations with which Texas Right to Life had contracted and demanded the immediate cessation of the broadcasting.  Both Cumulus Media and Salem Communications halted the radio ad.

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UK Court of Protection - Model for End-of-Life Treatment Dispute Resolution in USA

What can the United States learn from British jurisprudence on end-of-life treatment conflicts?  



Two things.  First, the Court of Protection regularly authorizes clinicians to withhold or withdraw life-sustaining interventions in a certain range of clinical circumstances.  For example, this week, Mr Justice Mostyn said it would be lawful for doctors not to resuscitate a man if he suffered a "cardio-respiratory arrest" and lawful not to treat him with antibiotics if he developed an "overwhelming infection."  The man had suffered a significant brain injury and was in a persistent vegetative state. (Jersey Evening Post)  



Indeed, if one collects and reviews Court of Protection opinions from the past few years, one may discern a bright-line rule:  withholding critical care for PVS patients is appropriate.  (Less settled is whether ongoing critical care like ventilation and CANH can be withheld.)



Second, the very fact that these cases go to the Court of Protection means there is independent oversight.  In the United States (e.g. in Texas), these cases are often resolved by healthcare ethics committees comprised primarily or entirely of hospital insiders.  Such decision makers are hardly as neutral as a court.

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World Right to Die Conference

Plan to attend he 20th World Right to Die Conference in Chicago, September 17-21, 2014.



Hear about the exciting developments in Scotland from Peter Warren, legislative assistant to the late, great Margot MacDonald.  Attend Chris Docker's seminar on methods of self-deliverance.



Also meet the courageous leaders of the movement in Quebec who are close to changing the law in that mostly Catholic province as well as legal and other development in the rest of Canada from DWD leader, Wanda Morris. And so much more -- Sean Davison from South Africa, Carole Sweney in New Zealand, Dr. Rodney Syme from Australia, Dr. Petra de Jong head of NVVE in the Netherlands, and Dr. Soichiro Iwao head of the Japan RTD Society (with more than 125,000 members).



Derek Humphry and Faye Girsch will chair an all day program on Saturday on new technologies. All of these RTD leaders -- and many more.

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Florida Fines Nursing Home for Violating DNR Order

Tampa Bay Times reports that the Florida Agency for Health Care Administration has fined Jacaranda Manor nursing home $16,000 after workers performed CPR and used a defibrillator on a 75-year-old man who had a "do not resuscitate'' order on file. I posted a copy of the order here.



As a result of the investigation, the St. Petersburg facility has retrained its staff, state records say. Records don't make clear what happened to the resident, who was placed in intensive care and had chest tubes inserted in his lungs. He suffered from nearly 20 medical conditions, including chronic airway obstruction, a kidney disorder and dementia.



This Florida action is not uncommon.  As I recently explained in a lengthy review, public and private parties have been increasingly enforcing the honoring of advance directives.

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Revitalizing Informed Consent Law

My latest post "Revitalizing Informed Consent Law" is now up over at the AJOB blog, bioethics.net.

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Medicare to FINALLY Cover Advance Care Planning?

The federal government may finally better reimburse doctors for talking to Medicare patients and their families about “advance care planning.  (I have carefully reviewed the history of expanded Medicare coverage here.)



The proposal is headed toward reconsideration.   The American Medical Association soon will issue recommendations on what doctors should be paid for advance care planning. Every year, the AMA makes reimbursement recommendations on a broad range of procedures and services to CMS. While CMS and private insurers don’t have to follow AMA’s recommendations, they typically do.

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