Medical Futility and Maryland Law II

I am on the way back home from spending the day in Baltimore with some 200 healthcare professionals, hospital lawyers, and risk managers, talking about whether there should be changes to the unilateral refusal provisions in the Maryland Health Care Decisions Act.  The general consensus was that changes are needed.  Among other things:

• Maryland is a treat until transfer state.  Even if the hospital determines inappropriateness, it must continue to provide the disputed treatment until the patient is transferred.  


• The definition of "medically ineffective" is extremely narrow, effectively encompassing only physiological futility.  

MY attention was drawn to a few things I had not sufficiently grasped before.  For example, Charlie Sabatino pointed out that once a medical inappropriateness determination is made, the transfer could be impaired because that determination could itself affect reimbursement at the potential transferee facility.  In other words, the refusal of transfer may not be due to an agreement of medical inappropriateness but to a concern about taking an expensive patient.  While the patient may be insured at the time of the transfer, she may be imminently uninsured either because of inpatient days, total cap, or because of the dispute resolution process itself.

Medical Futility and Maryland Law

On Monday, Baltimore radio station, WYPR, ran this show about medical futility and Maryland law.  This was a warm-up for next Tuesday's all-day conference on the topic.

Ira Byock and Elliott Fisher on Better End-of-Life Care

We're all going to die someday, but imagine for a moment that you have a terminal illness and will die in two months. Where would you choose to be as you approach the end of your life? Most people would say they'd like to be at home, but in reality, 75% of all people at the end stages of life die either in a hospital or nursing home. New Hampshire Public Television hosts a provocative discussion about end of life care with Dr. Ira Byock and Dr. Elliott Fisher. Dr. Byock is the Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center. He is the author of Dying Well and The Four Things that Matter Most as well as the co-author of several other books. Dr. Fisher is Director, Center for Population Health at The Dartmouth Institute for Health Policy and Clinical Practice.

Engage with Grace

Bioethics and Disability: Toward a Disability-Conscious Bioethics

One thing I that forgot to blog about when I was in Albany a few days ago is that my colleague Alicia Ouellette (at Albany Law School) has just finished Bioethics and Disability: Toward a Disability-Conscious Bioethics (Cambridge University Press 2011) ((ISBN-13: 9780521110303).  Here is the table of contents:

1. The struggle: disability rights versus bioethics

2. Clashing perspectives and a call for reconciliation

3. Infancy

4. Childhood

5. The reproductive years

6. Adulthood

7. The end of life

8. Toward a disability-conscious bioethics

Canine Medical Futility

Today, on NPR's Fresh Air: “Helping Your 'Good Old Dog' Navigate Aging.”  As dogs age, taking care of them becomes more difficult. Owners of aging dogs often struggle with their pets' dementia and incontinence — as well as navigating through the maze of end-of-life care decisions.   Among other things, this show covers “what to do when [a] pet gets a terminal disease.”   

Veterinarian Nicholas Dodman explains that some owners treat a dog’s cancer aggressively “just to drag out an existence.”  He says “Some people, I have known in the past ... have done that. Owners, with cooperating vets, have just gone step after step after step, when really, you're on a highway to nowhere. If the dog is in chronic pain and doesn't have long to go, sometimes I question the wisdom of that approach."

Expectations, Hope, and Futility (July 7-10, 2011)

The Australian Association of Bioethics and Health Law (AABHL) 2011 conference is titled "Expectations, Hope, and Futility: Law and Bioethics in Contemporary Healthcare."  It will be held July 7-10, 2011 on the Gold Coast.

Getting the DNR vs. Reaching Consensus

Wynne Ellen Morrison at The Children's Hospital of Philadelphia has a brief "personal reflection" piece in the Journal of Palliative Medicine titled "Is that All You Got?"  A young child is imminently dying from leukemia related complications such as overwhelming sepsis.  The ICU team is constantly pushing medications, fluids, and blood products.  The boy is on a ventilator.  Morrison then talks to the family and they all agree to make the patient DNR.  The fellow back in the ICU asks "is that all you got?"  





In her article, Morrison talks about framing the discussion as goal-oriented, as "getting the DNR."  She supports an "informed nondissent position" in which she makes her recommendation clear but allows the surrogates to raise objections.  Still, her overall purpose is not to "convince them they had to stop but to come to an agreement with them about mutually acceptable and achievable goals."  (HT: Art Caplan)