New Case - Arthur Johnson III v. Charlotte Regional Medical Center

On Thursday, 19-year old Florida resident Arthur Johnson III was shot in the head.  He was declared dead and Charlotte Regional Medical Center prepared to harvest his organs consistent with his prior consent.  (Herald Tribune)  But Arthur's parents protested.  They wanted a "second opinion on whether he was actually brain-dead or if he could have recovered."  But the parents were unable to obtain a second opinion and, this afternoon, consented to stopping life support.  Arthur’s parents also objected to the organ procurement.   As if the case were not sad enough, the Herald-Tribune reports that "Lifelink,...

Autonomy at the End of Life - Classic Quote

"Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny."          --  Ronald Dworkin, Life’s Domin...

Addressing Inappropriate Care Provision at the End-of-Life: A Policy Proposal for Hospitals

Carolyn Standley and Brian Liang at California Western School of Law have published "ADDRESSING INAPPROPRIATE CARE PROVISION AT THE END-OF-LIFE: A POLICY PROPOSAL FOR HOSPITALS" in the Michigan State University Journal of Law and Medicine 15 (2010): 137-176.  This article reviews many of the open issues, though it has two limitations.  First, it appears the article was written over a year ago, making its March 2011 publication a little dated.  Second, it does not grapple with the open issues in a sufficiently detailed manner.  For example, the end of the article offers a model institutional futility policy.  But the final step recommends that "if the disagreement persists after the ethics committee meeting" then the patient should be transferred....

Winnipeg Health Region Issues Reports on End-of-LIfe Conflict

Yesterday, the Winnipeg Health Region released two reports that examine how achieving consensus between patients (their families and representatives) and health care providers over end-of-life issues can be better supported.  Both reports are available here. "End-of-life decisions are personal and difficult," Dr. Brock Wright, WRHA Senior Vice President and Chair of the Regional Working Group, said. "But the vast majority are resolved through consensus. What we're trying to do here is put in place the necessary supports so that everything possible is done to facilitate agreement between families and care providers in the very small number of more complex and contentious situations."The report produced by the Working Group chaired by Dr. Wright recognizes the College of Physicians...

Rasouli v. Sunnybrook - Ontario Physicians Must Use CCB to Resolve Futility Disputes

A couple of weeks ago, the Ontario Court of Justice issued its opinion in Rasouli v. Sunnybrook Health Sciences.  I posted a copy of the opinion here.  Some earlier Canadian cases (outside Ontario) held that physicians need not seek patient or surrogate consent to refuse life-sustaining treatment that they deem inappropriate.  The Ontario court rejected this proposition.  Instead, it ruled that Ontario physicians must use the CCB to resolve medical futility disputes. &nb...

Advance Care Planning - Free Video

Loving Conversations: One Family's Story About the Importance of Advance Healthcare Planning The American Health Lawyers Association's Loving Conversations video follows a fictional family through the difficult process of making healthcare decisions for a loved one who did not execute an advance directive. Each dramatization is followed by a didactic session where health lawyers answer some of the questions raised in the video. This video will be helpful in facilitating conversations between you and your client or the healthcare provider and her patie...

National Healthcare Decisions Day in Delaware (April 15, 2011)

Designed for healthcare professionals.  (Public program is on April 16...

National Healthcare Decisions Day in Delaware (April 16, 2011)

Designed for and open to the publ...

Peter Singer on Joseph Maraachli - Which Lives to Save

Peter Singer argues that what has happened to Joseph Maraachli should teach us what to do - and what not to do - if we are really serious about saving human lives.If Priests for Life were really serious about saving lives, instead of "rescuing" Joseph so he can live another few months lying in bed, unable to experience the normal joys of childhood, let alone become an adult, they could have used the money they have raised to save 150 lives - most of them children who would have gone on to live healthy, happy lives for 50 years or more. . . .  We can obsess over Joseph and Terri - or we can make an honest effort...

CCB Rules for Surrogate in Desmond Watson Case

Normal 0 MicrosoftInternetExplorer4 st1\:*{behavior:url(#ieooui) } /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman";} After 14 months of treating him for dementia, pneumonia, bed sores and other ailments, Desmond Watson’s medical team at Oakville Trafalgar Memorial Hospital determined that he had noncommunicative and irreversible dementia and that no improvement can be expected.  (Toronto Star)  The medical team sought permission from Desmond's wife Maria...

Pediatric Futility Controversies: Ethical and Legal Considerations

In May 2011, at the Pediatric Academic Societies meeting in Denver:  “Futility Controversies: Ethical and Legal Considerations”  Here is the program description: In pediatric clinical ethics today, the most common and intractable controversy is about medically futile therapy. Doctors and nurses get frustrated when they believe that further medical treatment is futile, but family members insist that treatment be continued. For professionals, such demands create a clash between their own personal moral beliefs and perceived legal or institutional constraints that force them to act in ways that violate those beliefs. Bioethicists are divided about the appropriate response to such dilemmas. Many professional societies, some hospitals, and some states...

Non-Medical Goals of Treatment

Surgeon Richard Thompson has a brief article in the February 2011 British Journal of Hospital Medicine titled "Medical Futility: A Commonly Used and Potentially Abused Idea in Medical Ethics."  It is an elementary overview of the concept using a narrow range of dated sources.  But Thompson does helpfully remind us that patients have treatment goals other than the "obvious biological goals of most treatments."  These include:Aesthetic (e.g. cosmetic surgery)Hedonic (e.g. analgesia)Personal (e.g. birth control)Psychological (e.g. antidepressants)SpiritualIf the treatment can achieve any one or more of these goals for the patient, is it futile?...

Wilkinson & Savulescu on Medical Futility

Last month, I blogged about the early publication of "Knowing When to Stop: Futility in the ICU" by Dominic Wilkinson and Julian Savulescu.  The final article has been published and is (apparently because of its funding source) freely available on the Journal site.  This is primarily a review article.  As such, it is first-rate.  It succinctly summarizes the history and core issues surrounding medical futility (as well as citing several articles by Professor Pope).  Still, I have one concern.  The authors write that there are two basic justifications for unilateral refusal:  (1) when further treatment is...

Surrogates Replaced with Guardians Fight Back

In the United States as in Canada, surrogate decision makers who demand treatment that healthcare providers judge medically inappropriate are sometimes replaced with court-appointed guardians.  Interestingly, in the past weeks, some of those displaced surrogates have been turning around to challenge the decisions of the guardians, just as their own decisions were earlier challenged.  One case is the long-running Gary Harvey case in New York.  Another is the Rachel Nyirahabiyambere case outside Washington, ...

New Case - Oakville Trafalgar Memorial Hospital v. Desmond Watson

The Toronto Star reports that "over the past two weeks, a provincial panel has been adjudicating an agonizing dispute over the life of 87-year-old Desmond Watson.  Doctors at Oakville Trafalgar Memorial Hospital, where Watson has been for more than year, have asked to cease aggressive, life-saving medical intervention."  But Maria, his wife of 69 years, has steadfastly insisted he be given every chance at life. “How could I accept what they want to do?” she says. “I can’t. It’s against my religion and against his wishes. I would be murdering my own husban...

New Report from Massachusetts Expert Panel On End-Of-Life Care

This week, the blue ribbon Massachusetts Expert Panel on End-Of-Life Care issued its report.  It found three core principles on which there is consensus:From the time of diagnosis, as early as possible, every patient with a serious illness that may be fatal should be fully informed of the range of ways they might be taken care of. If the patient has preferences among that range, either for efforts to prolong life or for, say, as much time at home as possible, whatever those preferences are should be known, documented, and always available when decisions are going to be made.Those preferences should always be respected when a person receives care.To achieve these ends, the Panel makes several specific proposals which would be equally beneficial in any other state too:A public awareness...

Congress Investigating Agency Advance Care Planning Coverage Circumvention

This week, the House Energy and Commerce Committee sent this letter to HHS Secretary Sebelius questioning her short-lived attempt to expand now-available Medicare coverage for advance care planning.   The Committee charges that "the secrecy surrounding their inclusion in the final rule indicates that this was a political maneuver designed to avoid public scrutiny and comment."  The committee further charges that "if a regulation based on a proposal that could not be enacted through the legislative process can be inserted into a final rule without a chance for any public comment, then there appear to be...

Ethical Choices: When Medicine Can't Save Your Life

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Texas Treat Til Transfer Bill -- Patient and Family Treatment Choice Rights Act of 2011

Texas Representative Bryan Hughes has introduced H.B. 3520 which would materially amend the medical futility provisions in the Texas Advance Directives Act.  The purpose of the Patient and Family Treatment Choice Rights Act of 2011 is “to protect the right of patients and their families to decide whether and under what circumstances to choose or reject life-sustaining treatment.”  The amendments proposed in the bill are aimed at ensuring that “when an attending physician is unwilling to respect a patient's advance directive or a patient's or family's decision to choose the treatment necessary to prevent the patient's...

National Healthcare Decisions Day in Delaware

Here is the schedule for an event open to the public on Saturday, April 16th, for National Healthcare Decisions Day.  Registration 9:00 – 9:30 AMAdvance Directive Basics – Legal perspectiveTimothy J. Snyder, Esq. Estate Planning Attorney Young Conaway Stargatt & Taylor, LLP9:30 – 10:15 AMAdvance Directive Basics – Medical perspectiveJohn Goodill, MD, Director; Jo Melson, RN, NP Pain & Palliative Care Service Christiana Care Health System10:15-11:00 AMBreak 11:00-11:15 AM   Community ResourcesChris Johnson, Social Worker Christiana Care Health System11:15-12 noonLunchSponsor & Info Tables staffed12:00 – 1:00 PMDelaware Next of KinThaddeus Mason Pope, J.D., Ph.D. Law Professor Widener University1:00-1:45 PM5...

Do Courts Favor Families in Futility Disputes?

A hospital ethicist sent me this quote by Rebecca Dresser in a story on the Joseph Maraachli case.  She asked: Do you know if this statement is based on actual "legal cases"?Rebecca Dresser, a professor of law and medical ethics at Washington University in St. Louis, said U.S. courts generally side with families in such cases that want to continue treatment for loved ones even in seemingly hopeless medical cases.This was the heart of my response:  I think that is true in only a very limited sense.  Courts will order TEMPORARY injunctions to continue care until there can be a fuller development of the facts and experts.  Often the patient dies in the meantime, so the TEMPORARY injunction often ends up being dispositive.  But on the merits, courts have not...

End-of-Life Disputes Go To Court

The Philadelphia NPR station ran this story, yesterday, titled "End-of-Life Disputes Go To Court."  It uses the Betancourt case as a vehicle to explore some of the public policy issues concerning conflict over end-of-life treatment.  The reporter effectively uses clips from interviews with physicians and with several lawyers involved in the Betancourt case, including myse...

Joseph Maraachli Transferred to St. Louis

Surrogate decision makers are almost never able to find a transfer facility in intractable futility disputes.  But the parents of Joseph Maraachli have.  (Toronto Sun)  Against the "strongest possible medical advice" from experts in Canada, the U.S. and Europe, London Health Sciences Centre said, Baby Joseph's parents accepted an offer to transport him by air to the faith-based Cardinal Glennon Children's Hospital in St. Louis, Missouri.  Thirteen-month-old Joseph was flown out of London, Ontario at 10:20 p.m. Sunday on a private plane.  For pictures of the transfer see the Priests...

Guardian Replaces Surrogate. Will Guardian-2 Replace Guardian?

The New York Times reports that the the children of Rachel Nyirahabiyambere have challenged the decision of a court-appointed guardian to remove their mother's feeding tube.  An Alexandria, Virginia Circuit Court ordered her feeding tube reinstated while the legal issues were weighed.  It does not look like this latest court action is a direct attack on Georgetown University Hospital's November 2010 decision to remove the family as decision maker.  Rather, the inquiry will probably focus on the articulated rationale of the appointed guardian.  It seems that she did not act, as required, as a fiduciary to the patient....

Palliative Medicine: Care versus Cure? (Diane Meier video)

While it was taped last September and just aired a couple weeks ago, this 28-minute interview with Diane Meier is, as one would expect, an excellent primer and overview of what is going on in palliative care. Watch the full episode. See more The Open Mi...

Maraachli to Appeal Once Again

The Maraachlis lost before the Consent and Capacity Board in January 2011.  They appealed that ruling to the Ontario Superior Court of Justice.  In March 2011, that court affirmed the ruling of the CCB.  Now, with their new attorney Claudio Martini, the Maraachlis plan to appeal the Superior Court ruling to Court of Appeal for Ontario. (Toronto Sun)  Even if the appeal fails, a stay would mean the parents get several more mont...

Defying the Odds: Kimberly McNeill

In December 2010,   New Zealand teenager Kimberly McNeill was in a very serious car accident on her way to a music festival.  Physicians determined that she would never recover.  After 15 days, they withdrew life support against her family's wishes.  But, defying the odds, Kimberly pulled through and was transferred to a regional hospital and then, this week, to her parents' home.  (Hawkes Bay Today)There really are limits to prognostication.  That fact and cases like this will continue to prevent some surrogates from accepting recommendations to move to comfort care only.  There is often a remote...

Off Sick project

Posted on behalf of Dr Richard Marsden:Scholars from the universities of Glamorgan and Cardiff are currently breaking new ground in the Medical Humanities with the Off Sick project. This research initiative, led by Dr Martin Willis and Dr Keir Waddington, puts a new twist on the well-known concept of the ‘illness narrative’. It focuses not on the people who actually suffer from illness, but instead on those who support and care for them. In this vein the project team is currently gathering stories from carers across the South Wales area.This is very much an interdisciplinary project, which aims to explore not only how carers construct and define their experiences through stories in the present day, but also how they did so in previous decades and centuries. Moreover, Off Sick also brings in...

Not so Black and White

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John Stezaker and the Medical Profession

British artist John Stezaker takes portraits and various landscapes and questions conventional understanding of lines and flow. He creates collages of seemingly contrasting pictures into curious, coherent and captivating images, in this exhibition of various collections of his artwork. A few of us from the medical humanities course attended his exhibition held at Whitechapel Gallery (on till 18Mar11). This blog posting is an analysis of some of the images and their possible interpretations applicable to the medical profession.Stezaker is perhaps best known for his Mask series which fuses celebrity portraits with landscapes and makes the stones...