Thứ Tư, 30 tháng 5, 2012

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

MedSmart has released a new free report, Death-by-ICU: End-of-Life Care in America.




MedSmart generally advocates for greater caution in assessing your medical interventions generally. The reason is that our medical interventions – not just invasive procedures, but medications as well – can often cause more harm than benefit.  Many consumers have too much fear of death and disease and too little fear of the injury possible with medical interventions that may hasten their death with treatment-induced disease.  And if aggressive medical interventions pose a greater-than-appreciated risk for the average patient, don’t you think the risk is even greater for vulnerable patients at death’s door?


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

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

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

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


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




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




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


Thứ Ba, 29 tháng 5, 2012

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



The modern healthcare system has become proficient at staving off death with aggressive interventions.  And yet, eventually everyone dies--and although most Americans say they would prefer to die peacefully at home, more than half of all deaths take place in hospitals or health care facilities. 




A new book, At the End of Life: True Stories About How We Die, tackles this conundrum head on.  These twenty-two compelling personal-medical narratives explore death, dying and palliative care, and reveal the inner workings of a system in which doctors, patients and their loved ones battle to hang on--and to let go. 





Video of Rasouli Hearing

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


Thứ Bảy, 26 tháng 5, 2012

Finally - Measuring Use of Texas Futility Law

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


Thứ Sáu, 25 tháng 5, 2012

Combining Scholarship and Service




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

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







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





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



Thứ Năm, 24 tháng 5, 2012

Defending the Slow Code

At the end of 2011, Lantos and Meadow published “Should the ‘Slow Code’
Be Resuscitated?” in AJOB.  (Lantos also discusses the article in this Bioethics
Channel podcast
.)  I applaud Lantos
and Meadow for defending the slow code (or at least the short code).  As John Stuart Mill said in defending freedom of
expression:




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

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

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

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











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







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




  •          Conversational – try to convince the surrogate

  •          Deferential – accede to the surrogate’s wishes

  •          Confrontational – refuse and override the
    surrogate









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





Massachusetts to Require End-of-Life Counseing



Massachusetts may soon join California and New York in statutorily requiring end-of-life counseling.  Here is the relevant text of amendment to Senate No. 2260:



(b) The commissioner shall adopt regulations requiring each licensed hospital, skilled nursing facility, health center or assisted living facility to distribute to appropriate patients in its care information regarding the availability of palliative care and end-of-life options.



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



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



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