Resolving Intractable Medical Futility Disputes in Virginia

Over six years ago, I analyzed how an intractable futility dispute might be resolved under Virginia law. Earlier this month, I explained that Virginia is considering legislation to strengthen the governing law.

Today, the bill's author explains his objective.  "Del. Chris Stolle, a Virginia Beach Republican who is a doctor, was approached by other doctors to clarify state law to say a physician has the right to stop care that's medically and ethically inappropriate over the objections of the patient, family or advocate after a 14-day period of trying to transfer the patient to a doctor or hospital who will provide such care."

"Currently, the law says a doctor must try to find other care during that period but leaves hanging what can be done once the time comes to a close."  Stolle explained: "There needs to be some closing of the loophole."

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Bad Healthcare Surrogates Kill Patient for the Money - Victorino Noval

Three years ago, I blogged about the Victorino Noval case.  The case (actually multiple cases) are still being litigated.  An appellate decision issued a few days ago summarizes the key alleged facts.  



Three siblings, Lourdes, Tania, and Victor, allegedly directed a hospital to take their father, Victorino Noval, off life support and administer fatal doses of morphine, without the consent of their brother, Hector Noval (Hector), whose permission was required under a durable power of attorney for healthcare. Lourdes, Tania, and Victor also allegedly absconded with cash and other personal property of Victorino while he was hospitalized.


"Decedent was a fully functioning 78-year-old with about $60 million in assets and $3 million in annual income. On April 28, 2010, decedent was admitted to the hospital with pneumonia. He was intubated and, when sedated, became temporarily incapable of making his own medical decisions. By the end of the 10-day hospitalization, decedent had overcome the pneumonia, had had his intubation removed, had become distress free, and could make 'eye contact for more than 10 seconds.'"


"Nonetheless, Lourdes, Tania, and Victor ordered hospital staff to terminate decedent’s treatment and administer fatal doses of morphine on May 7, 2010, causing his death that day. The only reason the threesome so directed hospital staff was to hasten decedent’s death and collect their inheritances."



"According to Hector, decedent had a durable power of attorney for health care (health care power) that named Hector and Lourdes as joint attorneys-in-fact, such that the unanimous consent of the two of them was required for action to be taken. However, Lourdes, Tania and Victor falsely represented to hospital staff that Hector concurred in their decision to end decedent’s life, and concealed the existence of the health care power from Hector himself. Furthermore, at the same time that they directed hospital staff to withdraw decedent’s treatment and end his life, they misrepresented to Hector that decedent’s treatment would be continued indefinitely."


"Lourdes, Tania and Victor met with hospital staff on May 4 and 5, 2010 and represented that the whole family, Hector included, 'desired terminal extubation for decedent.' They also represented to hospital staff, on May 5 and 6, 2010, that Hector 'was a violent person, a drug addict, someone with paranoid personality,' who had 'threatened violence’ against them . . . and that they were afraid of him.' Hector further alleged that his siblings had represented to hospital staff that he had ulterior motives and was unfit to make health care decisions for decedent."


"Lourdes, Tania and Victor met with hospital staff on May 7, 2010 for 'the planned withdrawal of decedent’s treatment and fatal injections or morphine[.]' Even though they were informed that decedent was improving, they declined 'the opportunity to . . . cancel decedent’s planned death[.]'  Moreover, they again falsely informed hospital staff that Hector was in favor of the plan, and said he simply elected not to be present. To the contrary, Hector was not even aware of the plan. Hospital staff removed the ventilator, withdrew oxygen support, removed the nutritional tubes, and administered fatal doses of morphine. According to Hector, decedent would have lived absent these acts."

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Oklahoma Medical Treatment Laws Information Act - The Disclosures

Last year, I blogged about the 2014 Oklahoma  Medical Treatment Laws Information Act.  



This law was enacted to educate clinicians about their duties, and patients about their rights, under the 2013 Oklahoma Nondiscrimination in Treatment Act.



The law went into effect on January 1, 2015.  Accordingly, the state Medical Board has posted disclosures (for clinicians and for patients) that hospitals must provide to the same extent they must make disclosures under the Patient Self Determination Act.  

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Texas Advance Directives Act - 2015 Legislative Session

The 2015 legislative session (the 84th) in Texas has just begun and some are getting ready to again tackle the Advance Directives Act.



TADA was last amended in 2003.  Multiple bills were advanced in 2007, 2009, 2011, and 2013.  But none were enacted.  Get ready for round five.    



In the January 2015 issue of TEXAS MEDICINE:  "In anticipation of another round of debates over end-of-life care, TMA's workgroup dedicated to the issue will work to protect physicians' ability to do what's best for patients in their final days."



Defending TADA is part of the Texas Medical Association's strategic roadmap for state advocacy initiatives, Healthy Vision 2020 (2d ed.).

"Legislation has been introduced over the past four legislative sessions that would instead require indefinite treatment with no provision for the physician exercising ethics or moral judgment. TMA has opposed these proposals because they would prolong unnecessary — and often painful or even torturous — care that cannot prevent but can only prolong death. They would also require physicians, nurses, and other health care professionals to provide medically inappropriate care, even if that care violates medical ethics or the standard of care. They also would set a dangerous precedent for the legislature to mandate the provision of physician services and treatments that may be medically inappropriate, outside the standard of care, or unethical."

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Medical Benefit Is ALWAYS Patient Determined

The value or benefit of any medical intervention can be assessed on two dimensions.  First, the intervention can be assessed physiologically (e.g. does it restore function to an organ).  Second, the intervention can be assessed subjectively from the patient's values and preferences.



Established legal and ethical principles hold that the patient's subjective assessment controls.  For example, while a blood transfusion may provide a physiological benefit, it is not a benefit (but actually a harm) to a patient who refuses it for religious reasons.  



But this principle is far more controversial when applied in the opposite situation in which there is no physiological benefit but there is subjective value.  Can we really say that continued physiological support after the determination of death by neurological criteria provides no benefit.  It may provide no physiological benefit.  But if subjective assessment of value and benefit controls, then continued physiological support does confer a benefit.

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New Mexico Court of Appeals to Hear Aid in Dying Case

In January 2014, a New Mexico trial court  ruled that patients have a fundamental right to aid in dying under the state constitution.



This afternoon, the New Mexico Court of Appeals will hear oral arguments in the case, captioned as

KATHERINE MORRIS, M.D., AROOP MANGALIK, M.D., and AJA RIGGS, Plaintiffs-Appellees

vs.

KARI BRANDENBURG, in her official capacity as District Attorney for Bernalillo County, New Mexico, and GARY KING, in his official capacity as Attorney General of the State of New Mexico, Defendants-Appellants

A number of amici are also involved:

• Attorneys for Disability Rights


• ALS Association NM Chapter


• NM Psychological Association


• American Medical Women’s Association


• American Medical Students Association


• NM Public Health Association

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5th International Conference on Advance Care Planning and End-of-Life Care (ACPEL)

The 5th International Conference on Advance Care Planning and End-of-Life Care (ACPEL) will be held from 9 to 12 September 2015 in Munich, Germany.  The Call for Abstracts is open until 15 Feb 2015.



Already booked sessions include:

• Does the plan actually represent what the patient wanted? - Susan Hickman, Respecting Choices


• ACP in Palliative Care Evaluation of implementation - Rebecca Sudore, UCSF School of Medicine, San Francisco


• Setting the agenda for the next two years - Sara Davison, Dpt of Nephrology, University of Alberta


• What do we know about the economic case? - Josie Dixon, LSE London, GB


• Nationwide adoption of an ACP program by a large U.S. health provider (HMO) - Daniel Johnson, Kaiser Permanente


• Facilitator Training and (Re-)Certification - Bud Hammes, Respecting Choices, La Crosse

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Death Test: Criteria for Screening and Triaging to Appropriate ALternative Care (CRISTAL)

Australian critical care physician Ken Hillman and health services researcher Magnolia Cardona-Morrell have just published a new checklist in BMJ Supportive and Palliative Care:  "Development of a Tool for Defining and Identifying the Dying Patient in Hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL)."



The goal is to develop an evidence-based screening tool to identify elderly patients at the end of life and quantify the risk of death in hospital or soon after discharge.  The Telegraph calls it a "death test."



This should minimize prognostic uncertainty and avoid potentially harmful and futile treatments.  After all, an unambiguous checklist may assist clinicians in reducing uncertainty patients who are likely to die within the next 3 months and help initiate transparent conversations with families and patients about end-of-life care. 

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A Better Death: End of Life Care: Doctors, Machines and Technology Can Keep Us Alive, but Why?

The Vancouver Sun has just published the first of a significant 3-part series on "A Better Death": "End of Life Care: Doctors, Machines and Technology Can Keep Us Alive, but Why?"

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Managing Conscientious Objections in Intensive Care Medicine

I was delighted to be a part of this ad hoc subcommittee of this American Thoracic Society Ethics and Conflict of Interest Committee that developed An Official Policy Statement: "Managing Conscientious Objections in Intensive Care Medicine."  It was just published in the American Journal of Respiratory and Critical Care Medicine 191(2): 219–227.

"Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs."



"The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients."



"The committee recommends that: 

1. COs in ICUs be managed through institutional mechanisms


2. Institutions accommodate COs,  provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution


3. A clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate


4. Institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting."

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VSED & Complexities of Choosing an End Game for Dementia

On the front page of today's Science section of the New York Times, Paula Span has an important story, " Complexities of Choosing an End Game for Dementia."



Can you specify in advance of severe dementia, "triggering conditions" to ensure that nobody tries to keep you alive by spoon feeding or offering liquids?



Can people who develop dementia use VSED (“voluntarily stopping eating and drinking”) to end their lives by including such instructions in an advance directive?

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Involvement of ICU Families in Decisions: Fine-tuning the Partnership

Elie Azoulay and colleagues in Paris has just published "Involvement of ICU Families in Decisions: Fine-tuning the Partnership" in the Annals of Intensive Care.

I have written a lot about the resolution of intractable end-of-life conflicts.  If the lessons and strategies in this article were followed, there would be far fewer such conflicts.



Here is the abstract:



"Families of patients are not simple visitors to the ICU. They have just been separated from a loved one, often someone they live with, either abruptly or, in nearly half the cases, because a chronic condition has suddenly worsened. They must cope with a serious illness of a loved one, while having to adapt to the unfamiliar and intimidating ICU environment. In many cases, the outcome of the critical illness is uncertain, a situation that causes considerable distress to the relatives. 



"As shown by our research group and others, families exhibit symptoms of anxiety (70%) and depression (35%) in the first few days after admission, as well as symptoms of stress (33%) and difficulty understanding the information delivered by the healthcare staff (50%). Furthermore, relatives of patients who die in the ICU are at risk for psychiatric syndromes such as generalized anxiety, panic attacks, depression, and posttraumatic stress syndrome. In this setting of psychological distress, families are asked to consider sharing in healthcare decisions about their loved one in the ICU."



"This article aims to foster the debate about the shared decision-making process. We have three objectives: to transcend the overly simplistic position that opposes paternalism and autonomy, to build a view founded only on an evaluation of actual practice and experience in the field, and to keep the focus squarely on the patient. Families want information and communication time from the staff. Nurses and physicians need to understand that families can share in decisions only if the entire ICU staff actively promotes family involvement and, of course, if the family wants to participate in all or part of the decision-making process."

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"Being Mortal" - Atul Gawande on FRONTLINE

On February 10, FRONTLINE follows renowned New Yorker writer and Boston surgeon Atul Gawande as he explores the relationships doctors have with patients who are nearing the end of life. 



In conjunction with Gawande's new book, Being Mortal, the film investigates the practice of caring for the dying, and shows how doctors -- himself included -- are often remarkably untrained, ill-suited and uncomfortable talking about chronic illness and death with their patients.

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Virginia to Strengthen Futile Care Law

This week, Virginia introduced a new bill (H.B. 2153) that would strengthen and clarify that state's long-standing futile care law.


CURRENT VIRGINIA LAW

Current law provides that "Nothing in this article shall be construed to require a physician to prescribe or render health care to a patient that the physician determines to be medically or ethically inappropriate. . . .  If the conflict remains unresolved, the physician shall make a reasonable effort to transfer the patient to another physician who is willing to comply with the request . . . .  The physician shall provide . . . a reasonable time of not less than fourteen 14 days to effect such 27 transfer. During this period, the physician shall continue to provide any life-sustaining care . . . ." 


PROPOSED AMENDMENT

The bill would add the following language.  "If, at the end of the 14-day period, the physician has been unable to transfer the patient to another physician who is willing to comply with the request of the patient, the terms of the advance directive, the decision of the agent or person authorized to make decisions pursuant to § 54.1-2986, or the Durable Do Not Resuscitate Order despite reasonable efforts, the physician may cease to provide care that he has determined to be medically or ethically inappropriate."

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Australian Medical Association Calls for Cuts to ‘Futile Care’ to Make Medicare Sustainable

Australian Medical Association President Patricia Montanaro said that needed healthcare savings could be found by cutting out “futile care” - where people were given ­expensive (and often risky) treatments with no hope of lengthening life or improving quality of life.



"We’re continuing to push treatments that may not be what – if you could explain them to the patient and had other options for them – what they would choose."

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Futility Conflicts Turn Violent

Sometimes, ICU physicians worry about getting sued by a family member unhappy or dissatisfied with the dim prospects of the patient.  But they do certainly get death threats too.



One recent clinician-family interaction turned ugly this past weekend.  George Pickering, 59, has been charged with aggravated assault. According to court documents, he went to Houston's Tomball Regional Hospital Saturday night, where his son was in the intensive care unit.



When he was told his son had been placed on life support and would soon be taken off, investigators say that Pickering pulled a gun from his waistband and pointed it at a nurse who was in the room with other family members.  (Houston Chronicle)

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But the Donor Is Not Dead: Organ Procurement Halted

Surgeons in the Bremen area of Germany were forced to stop operating on a 'deceased' patient after discovering he was not brain dead.  (Daily Mail)

The team were due to harvest the man's organs for donation. But the operation was stopped as soon as the surgeons discovered their patient was still alive according to medical regulations.

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New York May Expand Medical Facility Duty to Respect Patient's Religious Beliefs at End of Life

N.Y. Public Health Law 2803-c requires healthcare facilities to publicly adopt and to comply with a statement of patient rights.  Senator Kemp Hannon has introduced a bill that would amend the statement of patient rights.  The capitalized words are new.

"Every patient's civil and religious liberties, including the right to independent personal decisions and knowledge  of  available  choices, shall not be infringed and the facility shall [encourage] FACILITATE and assist  in  the  fullest  possible  exercise  of  these  rights.   EVERY PATIENT'S RELIGIOUS BELIEFS SHALL BE RESPECTED WITH REGARD TO WITHHOLDING OR  WITHDRAWING  LIFE  SUSTAINING  TREATMENTS,  OR DISCHARGE FROM A FACILITY. IF SUCH PATIENT IS INCAPACITATED, SUCH DETERMINATION SHALL  BE MADE BY THEIR AGENT OR SURROGATE AS APPLICABLE BY LAW."

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My Life, My Death, My Choice - Assisted Suicide (Scotland) Bill

The My Life, My Death, My Choice campaign has published a new video to provide the facts about the proposed Assisted Suicide (Scotland) Bill currently being considered by the Scottish Parliament.

The video tackles some of the misconceptions and misunderstandings about the draft legislation.  Importantly, it is limited to those with terminal or life shortening condition.  Only those who choose to opt-in will be eligible.  And safeguards will protect vulnerable groups.

The video also clearly demonstrates the breadth of support in Scottish society, with politicians, religious figures, legal figures, secular groups and members of the public all voicing their support for the Bill.

The Assisted Suicide (Scotland) Bill is currently being considered by the Health & Sport Committee of the Scottish Parliament.  Oral evidence sessions are expected to take place in January / February 2015.

The summary of evidence submitted to the Committee indicated “Overall, 73% of respondents expressed support for the Bill…”  The full report can is available here.  According to a poll conducted in January 2014, 69% of the Scottish electorate supported the Bill. 

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Parent in Brain Death Dispute Indicted for Murder

Juan Alejandro Lopez Rosales had been in jail for six months on abuse charges, awaiting an autopsy for his 2-month-old baby, Issac Lopez, declared dead on July 2, 2014. (Courier-Journal)  Yesterday, Louisville, Kentucky prosecutors indicted Rosales on a murder charge.



Back in July, a court denied the request from Issac's parents asking the court to order the children's hospital to continue physiological support after Issac was declared dead by neurological criteria.  I review this case in "Legal Briefing: Brain Death and Total Brain Failure," The Journal of Clinical Ethics 25, no. 3 (Fall 2014): 245-57.



The Issac Lopez case is not unique.  A significant subset of litigated brain death disputes concern parents who were accused of child abuse that caused the child's death.  For example, in the New York "Long Island Jewish"case anesthesiologist Malcolm Scoon was convicted.   In the California "Dority" case "both parents were arrested and charged with felony child neglect or child abuse."

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How should a Catholic hospice respond to patients who choose to voluntarily stop eating and drinking in order to hasten death?

The Linacre Quarterly is the official publication of the Catholic Medical Association (distinct from the larger Catholic Health Association).



In a recent issue, Maureen Cavanagh published "How should a Catholic hospice respond to patients who choose to voluntarily stop eating and drinking in order to hasten death?"  Cavanagh is Manager of Ethics Services for St. Peter's Health Partners in Albany, New York.



This is her abstract:  "The practice if voluntarily stopping eating and drinking (VSED) in order to hasten death poses a unique problem for the Catholic hospice. Hospice staff may be confronted with patients already on their service who decide to pursue this option for ending their lives. Patients not on hospice service who are contemplating VSED are often advised to contact hospice for symptom palliation associated with the process if VSED."



"Intentionally hastening death not only violates the sanctity if human lift and the Ethical and Religious Directives the Catholic hospice is bound to uphold. but it also runs counter to the general philosophy that hospice neither hastens nor postpones death. At the same time, hospice programs have a strong philosophy of non-abandonment of patients. This article will analyze the ethical issues from the perspective of the Catholic tradition and suggest strategies for the Catholic hospice to respond to this group if patients."



Stanley Terman shared his response to Cavanagh's article:  "The author's position is clear: Life always has value and the intent to die is always wrong. Voluntarily stopping eating and drinking to hasten dying thus violates Catholic principles. It also violates the stated philosophy of hospice—to neither hasten nor postpone death."



"She recommends even secular health care professionals on staff at hospices refuse to provide palliative care if the cause of suffering is solely due to VSED (which it rarely is). Ideally, hospice staff would inform prospective patients about their position ahead of time, but for patients who decide after admission they prefer to die by Voluntarily Stopping Eating and Drinking, hospice staff should not abandon them but instead 'present a life giving alternative… and reassure patients that pain and other uncomfortable symptoms are manageable.' She admits, 'No patient can be forced to take food or fluids,' and 'No patient should be urged to eat if eating causes distress,' but if hospice staff remain involved, they can 'offer food and fluid if requested and tolerated by the patient.'"



"Major disagreement: The publication of one article by Ivanovic et al. does not eliminate the possibility that some hospice patients will be motivated to request Voluntarily Stopping Eating and Drinking for any reason they consider compelling, including intractable pain and suffering."



"I can appreciate that human beings have a responsibility to honor the gift of life and therefore may not end life to end suffering. However when this mandate is combined with an undeservedly extremely negative view of the ultimate method to relieve pain and suffering—Palliative Sedation to Unconsciousness[1]—patients might find themselves in an environment where they are forced to endure unbearable end-of-life suffering."



[1] She quotes Rady et al., who wrote it "may represent a cruel and inhumane method of terminating life." Rady,  M,   and J.  Verheijde. 2012.  Distress from voluntary refusal of food and fluids to hasten death: What  is the role of continuous deep sedation. Journal if Medical Ethics 38: 510-2. Palliative Sedation is similar to general anesthesia so palliative care clinicians do not need "empirical evidence for its efficacy...in managing distress." The American Medical Association’s Opinion 2.201 states that “physicians may consider Palliative Sedation to Unconsciousness for those terminally ill patients whose clinical symptoms have been unresponsive to aggressive symptoms-specific treatments.” My clinical experience with patients and my personal experience with my own fasting led me to conclude that patient's discomfort solely due to VSED is mild, can be treated easily, and will therefore rarely, if ever, require palliative sedation solely for VSED. 

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European Court of Human Rights - Lambert v. France

This morning, the European Court of Human Rights held a Grand Chamber hearing in the case of Lambert and Others v. France (application no. 46043/14).  A video is available here with English translation.



The case concerns execution of the judgment delivered on 24 June 2014 by the Conseil d’État (the French Supreme Administrative Court) authorizing the withdrawal of the artificial nutrition and hydration of Vincent Lambert.

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Suicide Certificates & Suicide Kits

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.  He recently proposed a "suicide certificate" as a way to remove doctors "from the direct ordering of death" yet still "empower those who believe in suicide a legal outlet, as well as the tools to act."



Salwitz explains:  "The suicide certificate would be a kind of application. A legal checklist, which once complete would allow the individual to die by their own hand, but in a controlled and definite manner."



"Once the form was complete, itemized and notarized, the patient would take it to a suicide assistance registered pharmacy or perhaps a specialty funeral home, which would exchange this ultimate document for death inducing drugs.  The sealed suicide kit would come with a final instructional booklet, including safety warnings."

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ASBH - 2015 Call for Proposals

The ASBH 2015 Call for Proposals is now open.



This year's theme is "Ethics and Creative Expression." ASBH represents the intersection of bioethics and humanities. It is a crossroads where we celebrate multiple disciplines and practices and professions. It is a place characterized by creative expression of every dimension of the human experience, including both suffering and healing. 



This meeting offers an opportunity to explore this space in the spirit of collegiality and inclusion, and ASBH welcomes proposals on the theme of "ethics and creative expression" and others in every submission category.

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Debbie Purdy Denied VSED

In her final article calling for legalization of aid in dying, Debbie Purdy notes that while at "the Marie Curie Hospice, the staff have been brilliant, they would not help me to refuse food or drink."

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More Unwanted Treatment - Cassandra C - Mature Minor Doctrine

Cassandra C. was diagnosed with "stage 3/4" Hodgkin's lymphoma.  She is 17 years old.  She will die without treatment.



But Cassandra refused treatment.  Pursuant to their reporting duties, Cassandra's treating clinicians notified Connecticut DCF.  For the past four weeks, Cassandra has been undergoing chemotherapy treatment at Connecticut Children's Medical Center in Hartford.  Cassandra's mother, Jackie Fortin, explains on NBC.  



Does Cassandra have the right to refuse treatment?  The case has been briefed to the Connecticut Supreme Court.  Oral arguments are Thursday at noon.

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Medicine's Alarming Ethic of Preserving Life at All Costs

An anonymous article in the January 1957 Atlantic Monthly captures then emerging alarm over medicine's ethic of preserving life at all costs.



"There is a new way of dying today.  It is the slow passage via modern medicine.  if you are very will modern medicine can save you.  If you are going to die, it can prevent you from doing so for a very long time."



A 1957 editorial in the New England of Medicine said this article should be "required reading for physicians."  It warned of "an approaching specter that looks almost as ghoulish and quite as menacing as euthanasia itself." 256(16):760.

(Hat Tip:  Gary Belkin, Death Before Dying)

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Moral Distress from "Forced Futile Care"

Ontario is what I refer to as a "red light" jurisdiction.  Clinicians always need consent to stop life-sustaining treatment, even if they are confident it is medically and ethically inappropriate and outside the standard of care.



One Canadian physician blogger provides a first person perspective for why this is a problem for her professionally and personally.

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More Lawsuits for Unwanted Resuscitation

Last year, I blogged about a number of cases in which families sued, or regulators fined, healthcare facilities for resuscitating patient and residents who did NOT WANT to be resuscitated.  These cases continue.



A recently filed federal complaint on behalf of 93-year-old Flora Mae Daniels alleges:  "Daniels was in respiratory failure and despite the fact that her wishes were not to be resuscitated, Golden Living Trussville negligently and wantonly ignored her wishes and the DNR and sent her back to the hospital."



The complaint asserts claims for 

• Negligence


• Wantonness


• Negligent Training & Supervision


• Medical Malpractice


• Breach of Contract


• Wanton Supervision & Training


• Independence & Dignity at End of Life


• 1983 Deprivation of Rights


• Denial of Due Process


• Outrage

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