Not really news anymore, but yet another new poll suggests Americans are in denial about death. Only 40% have a will (for property). &nb...
Live Faster, Die Younger
Social Security Reform Bill Encourages Americans To Live Faster, Die Youn...
Four Big Obstacles to Rational Health Policy
A few weeks ago, the Institute of Medicine released For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges. In this second of three commissioned reports, the IOM reviews how statutes and regulations prevent injury and disease, save lives, and improve the health of the population. The IOM examines the legal and regulatory authority for public health activities, identifies past efforts to develop model public health legislation, and describes the implications of the changing social and policy context for public health laws and regulations.In Chapter One, the IOM notes four obstacles to more rational health policy. These are readily adaptable to clinical medicine and to end-of-life bioethics in particular.The rescue imperative (or the rule of rescue)....
When is postponing removal of the ventilator after the diagnosis of brain death justifiable?
The "Ask the Ethicist" column in the latest Lahey Clinic Medical Ethics Journal argues that postponing removal of the ventilator after the diagnosis of brain death is often justifiable. As I argued a few years ago, this seems to be a common positi...
The Prospects of Immortality
Robert Ettinger, the father of the cryonics movement, died on Saturday. Adherents of cryonics believe that future developments in medical technology will allow their frozen bodies to be brought back to life. (Daily Maverick; Telegraph). The idea is that the dead might be "cured" by the doctors of the future. The Cryonics Institute promises it is "Your Last Best Chance For Life--and Your Family's." It has nearly 1000 members, 103 now in cryostasis + 78 pe...
When Are You Ready to Pull the Plug against the Wishes of the Family?
On his blog, End of Life - Thoughts from an MD, Dr. Jim deMaine describes a recent case in which a conflicted family could not reach a treatment decision. So, the patient with metastatic cancer spent three weeks in the ICU. Her heart then stopped "and the nurses, much against their wishes, had to perform fruitless CPR. Mary thus died in a traumatic way, ribs broken from chest compressions, suffering the kind of technological imperative that's sarcastically referred to by the staff as 'medical last rites.'" Dr. deMaine also asks how the case might have reached a better resolution, for example, through unilateral withdraw...
More Concern about Catholic Hospital Mergers
As with other mergers in other parts of the country, the Louisville Courier-Journal reports significant concern that that Catholic doctrine could override patients' end-of-life wishes under a pending merger of three Kentucky hospitals (University Hospital, Jewish Hospital & St. Mary's HealthCare, and St. Joseph Health System). Catholic Health Initiatives would own 70% of the combined operations, and the merged hospitals will follow Catholic health care directiv...
Wise on Rasouli v. Sunnybrook
Ontario attorney Gary Wise blogged about Rasouli v. Sunnybrook here. He describes the decision as "a good example of the Court of Appeal taking pains to not rule on a contentious and divisive issue they would prefer to leave to the Legislature." That reminds me of Betancourt v. Trinitas Hospit...
Legal Commentary on Rasouli v. Sunnybrook
Rahool Agarwal, an attorney in the Toronto office of the global law firm Norton Rose, has posted a brief commentary on the recent Ontario Court of Appeal decision in Rasouli v Sunnybrook Health Sciences Centre. He notes several issues that remain open and unsettled:"[P]hysicians may be left guessing as to whether their treatment proposal is closer to the chemotherapy example, where consent would not be required, or the situation in Rasouli.""[A]bsent from the court’s decision is any acknowledgment that applying to the Consent and Capacity Board is not always desirable.""[B]ecause the court viewed the Act as providing...
ICU Head Faces Criminal Charges for Hastening Death
Dr. EE, the head of the intensive care unit at Rashid Hospital in Dubai and another physician are accused of murdering their patient Ghulam Mohammed.Mr. Mohammed, a quadriplegic, was in a critical condition and needed continuous monitoring because of chronic heart complications. Prosecutors say that two days before Mr. Mohammed died, Dr. EE issued orders that he was not be resuscitated if he suffered a heart attack. Dr. EE also allegedly removed an oxygen monitor and other life support apparatus. And he ordered an increase in the dosage of morphine and a decrease in the quantity of...
Lawsuit for Disregarding DNR Order
The Denver Post reports on a lawsuit by Daniel Self against a number of individual and institutional healthcare providers. According to his Complaint, filed in U.S. District Court for the District of Colorado, Mr. Self completed a "CPR Directive" in January 2009. In April 2009, correctional officers and EMTs resuscitated Mr. Self in contravention of this directive. While Mr. Self's lead claims are constitutional, he also alleges claims for negligent supervision and battery. While this case is special given its prison context, expect to see more lawsuits for wrongful resuscitation. &nb...
DNAR Orders: Problems, Causes, Solutions
In the Journal of General Internal Medicine, Jacqueline Yuen and colleagues review the problems with DNAR orders, the causes of those problems, and some solutions.The problems:DNAR discussions occur too infrequently. DNAR discussions occur too late.DNAR discussions fails to satisfy criteria for informed consent.Healthcare professions inappropriately extrapolate DNAR orders to other treatment decisions.The causes of the problems:Medical culture that values the technological imperative.Inadequate hospital policies on DNAR discussion standards.Insufficient training of physicians in communication skills.Payment system that rewards volume and intensity of ca...
Nursing Home: Sanctions for Over-treatment and Under-treatment
In the latest Archives of Internal Medicine, Phillip Bale describes his 99-year-old nursing home patient with sever dementia in whose feet he noticed some gangrenous changes. Recognizing that the patient had "enjoyed almost no quality of life for many years," the patient's POAs agreed that "only supportive comfort measures should be implemented." But when Dr. Bale later went on vacation, the nursing home, recently-sanctioned for the death of another patient, started sending Dr. Bale's patient to the local hospital for wound care treatment. The administrators "felt they could not risk another investigation claiming that they could have done more for the patient." Apparently, though, the administrators felt they could risk a battery claim, False Claims...
New Jersey End-of-Life CLE
On Thursday, September 8, a half-day CLE on end-of-life will be offered at the New Jersey Law Center in New Brunswick. Tentative Program Agenda: 9:10 Introduction - Margaret J. Davino, Esq.- Role of lawyers in helping to prevent problems- Problems with end of life decision-making 9:40 Overview of end of life decision-making and problems involved, including Dartmouth Atlas Study and New Jersey's role in use of resources, plus medical futility and its role as a public health problem - Dr. Gregory Rokosz 10:40 Need for change in the law: the Betancourt case - William P. Isele, Esq. 11:10 Break 11:25 Overview of the case law regarding EOL decision-making: Conroy, Jobes, Quinlan...
Miracle survivor Kimberly McNeill
In March, I blogged about Kimberly McNeill. She was in a serious car crash in late December. Fifteen days later, providers at Auckland City Hospital turned off her life support. She survived and is now scheduled to enroll full-time at Auckland University. (Stu...
Public Health Professionals More Focused on Justice than Physicians
Joshua Greene and colleagues recruited 84 medical doctors and 69 public health professionals for some interesting morality experiments. One hypothetical was “To save the lives of several patients who need brief access to life support, you need to pull the plug on a more gravely ill patient and redistribute the limited supply of machines in a hospital.” (ScienceNOW)There was a wide gap between physicians and administrators. Nearly half of public health professionals were willing to pull the plug on a patient's life support to save others, compared with less than a third of doctors. Not terribly surprising results. Public health professionals, after all, are focused on the good of the community. Physicians, in contrast, are focused on the...
Medicare and End-of-Life Costs
Dudley Clendinen has a great essay in last Sunday's New York Times about living with ALS. He continues to have a valuable life. But, as his condition deteriorates, Clendinen does not plan to use all available medical technology to prolong his biological life as long as possible. He explains that would just leave him "a conscious but motionless, mute, withered, incontinent mummy of my former self." Instead, Clendinen explains that "when I can’t tie my bow tie, tell a funny story, walk my dog, talk with Whitney, kiss someone special, or tap out lines like this — I’ll know that Life is over. It’s time to be gone.”Yesterday, David Brooks commended Clendinen for the way he defines what life is: "Life is not just breathing and...
History of the Growth of Patient Power
Michael Millenson has a new article in the Journal of Participatory Medicine, titled “Spock, Feminists, and the Fight for Participatory Medicine: a History.” It is, as Richard Smith at the BMJ Blog observes, "a fascinating and very readable account of how patient power has steadily increased in the United State...
The Science of Compassion: Future Directions in End-of-Life and Palliative Care
On August 10 - 12, 2011, the National Institute of Nursing Research presents The Science of Compassion: Future Directions in End-of-Life and Palliative Care, at the Hyatt Regency in Bethesda, Maryland. The entire program is free and open to the public. Overall Summit objectives include:Examine the current status of end-of-life and palliative care research, practice and policyPropose strategies to overcome barriers and ensure scientific and methodological rigor in researchDelineate new action items that galvanize progress in this vital area of scienceEnvision and map pathways to ensure a future rich with scientific endeavor and achievementsHere is the agendaAugust 10, 20117:00 PM - 9:00 PM The Ethics of Science at the End of Life: A Town Hall...
Health Law and Bioethics Conference (July 2012)
While I have been blogging a bit about some of the substantive issues discussed at the recent AABHL conference, I should take a moment to discuss the conference itself. The Australasian Association of Bioethics and Health Law runs a good conference. At first, I thought it would be the analog to the ASLME Health Law Professors Conference. Instead, it is probably closer to the ASBH. There were quite a few physician attendees as well as law professors, lawyers, nurses, anthropologists, ethicists, and others. But unlike the ASBH, the conference is cozy enough to really meaningfully interact with fellow attendees. Next...
New Case - Lee Ah Cheo
Not terribly far from the futility conference in Brisbane and the Gold Coast, a futility dispute was playing out in Singapore. The family of Lee Ah Cheo, 64, called the police after, they claimed, the hospital did not follow their wishes to keep her on assisted ventilation. (AsiaOne)&nb...
Improving End-of-Life Care in New Jersey
New Jersey has long been known as having, on some measures, the worst end-of-life care in the country. But two bills have been voted out of the state legislature and have been sent to the Governor. One would authorize POLST. The other would create an End-of-Life Advisory Commissi...
More Problems with Surrogates at the End of Life
Much of the overly-aggressive medicine and many of the conflicts at the end-of-life are due to the fact that a surrogate, rather than the patient herself, makes the treatment decision. A plethora of evidence already supports this point. Now, in the July 2011 Journal of the American Geriatrics Society Alexia Torke and colleagues have published "Timing of Do-Not-Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision-Maker." They conclude: "For patients who have a DNR order entered during their hospital stay, order entry occurs later when a surrogate is involved. Surrogate decision-making may take longer because of the greater ethical, emotional, or communication complexity of making decisions with surrogates than with patient...
POLST in Australia
I was pleasantly surprised to learn about Queensland's "Acute Resuscitation Plan." While the organizers explained that it was developed independently from POLST, it is remarkably similar. Still, there is at least one key difference. Failure to complete a section on a POLST triggers the default choice: the treatment will be provided. In contrast, failure to object on an ARP means, when determined not medically indicated, CPR will not be provided. This is, in essence, a reversal of the long-criticized CPR presumption in those cases in which the presumption is inappropria...
Dying Prohibited
A presenter from Queensland Health used this cartoon in a PowerPoint deck the other day. While futility disputes are one problem, this nicely illustrates the far bigger probl...
Medical Futility - Conflict and Illusory Consensus
Wesley Smith, a well-known opponent to medical futility policies and laws, clarified his position in commenting on a new study in the Archives of Pediatrics and Adolescent Medicine. He writes: "My opposition to what I call Futile Care Theory has never been about withdrawing treatment that sustains life but does not provide cure or improvement, but about medical personnel and/or ethics committees forcing an end to treatment over the objections of those who want non elective treatment continued." It strikes me that depending on how the term "coercion" is used, I could almost agree with Wesley here. It seems rare that providers literally coerce surrogates into stopping what the provider thinks is non-beneficial treatment. Providers typically...
Texas Advance Directives Act - Brief Update
The Dallas Observer has a very brief update on the status of the Texas Advance Directives Act, "How Long Should Texas Docs Treat Untreatable Patients? The Debate That Won't Go Away." In short, no bills to amend and/or repeal the unilateral refusal provisions succeeded in the 2011 legislative session. The issue is to be studied. And we will see bills to amend and/or repeal introduced again in 20...
Rule of rescue or the good of the many? An analysis of physicians’ and nurses’ preferences for allocating ICU beds
A new study from the University of Pennsylvania published in the July 2011 Intensive Care Medicine indicates that the so-called “rule of rescue” – whereby clinicians are prone to try to save their own patients as opposed to opening up a bed for a new patient – often prevails even in the face of substantial social benefit in terms of cost containment and procurement of organ donations.The researchers analyzed mixed methods questionnaires from 1,122 ICU clinicians in the U.S., 648 physicians and 438 nurses. The questionnaires addressed the clinicians’ preferences for allocating their last bed in the ICU to a gravely ill patient already being treated, but with little chance to survive, versus an incoming deceased or dying patient for whom aggressive management could help others...
The Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School Seeks Distinguished Candidates for the 2012-2014 Academic Fellowship Program
The Petrie-Flom Center for Health Law, Bioethics, and Biotechnology at Harvard Law School will be accepting applications for the 2011-13 Academic Fellowship Program on a rolling basis from September 1, 2011through November 14, 2011.The fellowship is designed for applicants who have the intellectual focus to make top-rate academics in health law policy, bioethics or biotechnology, and who would benefit from time to develop their ideas and writing before they enter the academic job market. Our prior fellows have found homes on the law faculties at Harvard, Berkeley, BU, UCLA, Cornell and the University of Arizona. The fellowships include stipends of $60,000/yr for two years, a research budget and access to the full range of the Center's and Harvard's facilities and research resources....
Jocelyn Downie on Medical Futility at the AABHL
The AABHL conference on medical futility kicked off last night with a lecture by Jocelyn Downie titled "Cutting the Gordian Knot of Futility: Responding to the Unilateral Withholding and Withdrawing of Potentially Life-Sustaining Treatment." After reviewing relevant court decisions from New Zealand and Australia, Professor Downie outlined the standard problems with having end-of-life policy developed through the judiciary (e.g. insufficient time, complex issues). More importantly, she argued that there are a number of concerns with the current status quo in New Zealand and Australia which generally permits physicians...