At Any Cost? A New Play About Prolonging Life Support

Starting next week, and coinciding with a major medical futility conference in Australia, is At Any Cost at the Ensemble Theatre.  A 2-minute video about the play is embedded below.  Here is the synposis:  "Des loves his wife Faith dearly, but she is gravely ill. The family must decide whether her intensive care treatment should be prolonged.  Des can’t bear to have any part in ending her life, but her three children vary sharply in their attitudes.  The power of modern medicine can prolong life but is there any point if the life prolonged is poor? The family conflict becomes intense, generating both dark humour and shock as devastating family secrets are inevitably revealed."A press write-up about the play quotes the surgeon co-writer:  "three-quarters of...

Decision in Rasouli - Ontario Doctors Must Use CCB

The Court of Appeal for Ontario has released its opinion in Rasouli v. Sunnybrook Health Sciences Center.The appeals court has affirmed the March 2011 ruling of the Ontario Court of Justice.  That court held that Ontario providers must use the CCB to resolve intractable medical futility disputes.  Providers appealed that decision in hopes that they could unilaterally refuse inappropriate interventions without the consent of the patient, the surrogate, or through the C...

Covert Denials of Non-Beneficial Treatment in Sweden

The Swedish newspaper Expressen reports that physicians there often decide to withhold or withdraw life-sustaining treatment without consulting either the patient or surrogate.  Prevailing laws and regulations require consultation with the family.  But this fails to occur up to 50% of the time.  (HT: Stockholm News)  While this happens in the United States too, there is legal risk in doing so.  There has been one consistent source of liability for unilateral refusals of life-sustaining treatment:  claims for intentional infliction of emotional distress when the refusal was done secretively or insensitively. &nb...

Raising Medicare Eligibility from 65 to 67

U.S. Senators Lieberman and Coburn recently proposed raising the Medicare eligibility age from 65 to 67.  This would help save hundreds of millions of dollars.  While this is obviously incredibly politically controversial, it is probably easier to cut eligibility than it is to cut benefits.  Richard Lamm recently wrote that "seniors have long expected Cadillac care for a moped premium."  Perhaps the Cadillac care will continue.  But fewer will get it.  And they will have to pay at least Subaru premiu...

Richard Lamm on End-of-Life Rationing

Writing in Sunday's Denver Post, former Colorado Governor Richard Lamm writes that "[r]ationing is the price an aging society must pay to prevent health care from crowding out all other public needs."  We should, Lamm argues, "shift our emphasis from quantity of life to the quality of life.  If we put death in perspective and use fewer desperate measures to extend life, we would free up money to spend on improving the quality of our lives."  Lamm argues, among other things:No nation can escape weighing costs and benefits and setting limits on marginal care.No citizen can expect, in this time of technological marvels, public programs or insurance companies to pay for all the health care that modern medicine can provide."We can't allow everyone to attempt to...

Can rationing possibly be rational?

Lauren Vogel has just published the 17th in a series on end-of-life care in the Canadian Medical Association Journal.  This is a nice review of the growing professional and public conversation about health care rationing, especially of intensive care. &nb...

Hospital Policy on Medical Futility — Does it Help in Conflict Resolution and Ensuring Good End-of-Life Care?

Singaporean neonatologist Roy Joseph has published a nice literature review in the January 2011 Annals Academy of Medicine Singapore.  The full text is freely available here.  Here is the abstract:Introduction: This paper aimed to ascertain if hospital policy on medical futility helps in conflict resolution, and in ensuring good end-of-life care. Materials and Methods: Literature on the subject published in the last 5 years was identified through Pubmed, and those with empirical data pertaining to the outcomes of interest were examined. A systematic analysis was not possible as papers varied greatly in aims, designs, outcomes and their measures. Instead, the outcomes of representative papers were described and discussed. Results: There is a widespread use of policies and guidelines...

Modernizing the Code of Medical Ethics

Last Monday, the delegates AMA Annual Meeting attended an open forum by the Council on Ethical and Judicial Affairs.  The topic of discussion was "At what point should physicians say “no” to their patients?"  The delegates also discussed CEJA's project to modernize the AMA’s Code of Medical Ethics. “The Code needs to be user-friendly and organized in a way that you can put your finger on what you need, when you need it,” said Sharon Douglas, MD, who moderated the for...

Patients over 80 Do Not Benefit from ICU

French researchers have found, in an observational prospective cohort study, that there was no benefit of ICU admission for very old patients (over 80 years old).  Researchers focused on long-term survival, than hospital survival, to investigate potential ICU benefit.  (Archives of Internal Medicine 171(12):1116-11...

End-of-Life Decision Making and Care of the Dying Patient

Every two weeks, the American College of Chest Physicians issues a PCCSU (Pulmonary Critical Care Sleep Update).  Each one features timely, concise, diagnostic information on current pulmonary, critical care, and sleep medicine issues.  The second PCCSU in June 2011 is by Yale University Medical Critical Care Director Mark Siegel.  It is titled “End-of-Life Decision Making and Care of the Dying Patient."The objective of his brief review is to highlight effective approaches to end-of-life decision making and palliative care in the ICU.  Here are his objectives:Explore the key ethical principles that underlie...

NICE - New Quality Standard on End-of-Life Care

NICE has posted a 70-page draft quality standard on end-of-life care.  It will remain open for consultation through next mon...

The Best Interest Standard: Keep or Abandon?

In the just-published Summer 2011 edition of The Journal of Clinical Ethics, Douglas Diekema wrote "Revisiting the Best Interest Standard: Uses and Misuses."  I wrote a response titled "The Best Interest Standard: Both Guide and Limit to Medical Decision Making on Behalf of Incapacitated Patients."  I have copied both abstracts below.Diekema:  The best interest standard is the threshold most frequently employed by physicians and ethics consultants in challenging a parent’s refusal to provide consent for a child’s medical care. In this article, I will argue that the best interest standard has evolved to serve two different functions, and that these functions differ sufficiently that they require separate standards. While the best interest standard is appropriate for choosing...

Voluntarily Stopping Eating and Drinking

My article with Lindsey Anderson, "Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life," which I blogged about in October, was just published by the Widener Law Review: 17 Widener L. Rev. 363-428 (201...

Streamlining the Process for Removing Life Support from Vegetative Patients

It is difficult to find precise figures, but experts believe there could be as many as 5,000 people in the UK living in a vegetative state, enduring what has been described as a "living death."  And because of advances in medical science, the figures are set to continue to grow.  Unfortunately, there is evidence families are not routinely being told of all the options open to them.  And even when families have made an informed decision to withdraw treatment and allow their loved-one to die, the court process involved can be beset with lengthy delays.  (BBC News)Professor Lynn Turner-Stokes is chair of a Royal College of Physicians working party which has been set up to review the issues around the diagnosis and care of vegetative patients.  The...

Betancourt to be Codified? No Futility Law in New Jersey

In last year's Betancourt v. Trinitas Hospital case, leading New Jersey medical associations asked the Appellate Division for permission to unilaterally withdraw life-sustaining treatment that providers deemed medically inappropriate.  The court refused to grant that permission, suggesting that such permission should instead be sought from the Legislature. The Court wrote:  "The issues presented are profound and universal in application.  They warrant thoughtful study and debate not in the context of overheated rhetoric in the battlefield of active litigation . . . but in thoughtful consideration by the Legislature . . . ."  It does not look like the New Jersey Legislature will be granting any Texas-type safe harbors for unilaterally refusing non-beneficial treatment. ...

Offensive Medicine: Animated Video Cariacature of End-of-Life Medicine

A great deal of discussion of medical futility focuses on surrogates and on therapy given as a result of defensive medicine.  But the amount of non-beneficial treatment demanded by surrogates pales in comparison to the amount of unwanted interventions foisted onto patients by physicians.  In other words, there is far more offensive medicine than defensive medicine.  This is colorfully illustrated in this seven-minute Xtranormal video.  [Hat Tip: Pallimed and Happy Hospitali...

American Bar Association Resolution againt Overly Aggressive Treatment

Three years ago (here too), I proposed deterring overly aggressive end-of-life treatment through the increasingly-wielded False Claims Act.  I just noticed that, a few weeks ago, the ABA will be considering a similar Resolution at its August 2011 annual meeting in Toronto.  The Resolution, earlier approved by the Commission on Law and Aging observes that "the threat of lawsuit does not adequately deter unwanted treatment."  The Resolution: calls on the Centers for Medicare and Medicaid Services (CMS) to take preventive and corrective action in response to evidence that some institutional and individual health care providers are violating their obligations under the Medicare and Medicaid Conditions of Participation(CoPs), thwarting the treatment wishes expressed by terminally...

Recommendations for Appropriate Use of Critical Care Services

Three Ontario critical care specialists have published "Multi-Professional Recommendations for Access and Utilization of Critical Care Services: Towards Consistency in Practice and Ethical Decision-Making Processes" in the latest issue of the Journal of Law, Medicine, and Ethics (also here).  The brief abstract states:  "Multi-professional guidelines for fair access to and use of adult critical care services are desperately needed to define a consistent transparent standard of care: when such therapies have the potential to benefit and help a patient as they journey with illness and when they cannot."  The authors claim that their recommendations for appropriate use of critical care services "are the first of their kind in that they seek to respond to the challenging...

Advance Directive Registries

A recent DHHS study reported that "between 65% and 76% of physicians whose patients had an AD were unaware of its existence."  This lack of availability exacerbates the already too-low completion rate.  One way to address the availability issue is through AD registries.  In a forthcoming article titled “The Advance Directive Registry or Lockbox: A Model Proposal and Call to Legislative Action.”in the JOURNAL OF LEGISLATION, Capital Law School Professor Joseph Karl Grant reviews and evaluates registry legislation.  Here is the abstract: In times of need, what portal or place could we go to easily...

A Prerogative to Take Advantage of Everything in the Medical Armamentarium?

In yesterday's New York Times, Jane Brody writes about the New York Palliative Care Information Act.  This is basically a specialized informed consent obligation like that earlier enacted in California and more recently considered in Maryland and Arizona.  Unfortunately, such laws seem to be necessary.  What caught my eye in the article was this statement:  "Even knowing these facts [about palliative options], some patients are likely to choose to take advantage of anything and everything in the medical armamentarium that could conceivably grant them extra days, weeks or months of life.  And such a choice is the prerogative of every terminally ill patient; the new law does not in any way deny that choice."  Well, the PCIA does not deny that choice.  But...

Hospital Ordered to Pay Damages for Providing Futile Medical Treatment

The Andalusian La Ley de Derechos y Garantías de la Dignidad de las Personas en el Proceso de la Muerte, since copied both by other provinces and currently by the Spanish federal government, provides penalties for engaging in "therapeutic obstinacy."  But I had not yet seen an example of sanctions for providing "futile" treatment.  Now I have one.  A forthcoming article in La Revue de Médecine Légale describes a case in which a French hospital was ordered to pay damages for providing overly aggressive futile (obstinate) treatment to a hypoxic newborn.  Here is the abstract:  On 2nd June 2009, Nîmes administrative court ordered Orange town hospital to pay damages for futile treatment. An apparently stillborn infant, who had suffered fromintrauterine hypoxia...

Money Drives Aggressive End-of-Life Treatment

On my summer reading list is Mark Rodwin's Conflicts of Interest and the Future of Medicine.  One specific manifestation of the broader problem is illustrated in an article in today's Pittsburgh Tribune-Review that discusses the role of money on end-of-life treatment.  "Hospitals and doctors make more money by aggressively treating terminal patients than by keeping them free of pain and letting them die with dignity."     Dr. Gail Gazelle explained:  "It's impossible to remove money from the discussion because doctors are paid more to treat — not talk. . . .  "Physicians are reimbursed...

Videos Help Advance Care Planning

I espoused using video and interactive CD-ROM for advance care planning in this 1999 Health Matrix article.  This CBS Evening New story reports on their use and success. ...

Launched June 1: End of Life Care Patient Charter

Today, the Royal College of General Practitioners (RCGP) launched a "Patient Charter" for the care of people nearing the end of their life.  The Charter represents an ideal of best practice that all patients should be able to expect from their GP and Primary Health Care Team.  Here are the promises in the Charter:We want to offer people who are nearing the end of their life the highest quality of care and support. We wish to help you live as well as you can, for as long as you can. Therefore, if and when you want us to, we will:• Listen to your wishes about the remainder of your life, including your final days and hours, answer as best we can any questions that you have and provide you with the information that you feel you need.• Help you think ahead so as to identify the choices...