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 day to day decision-making dilemmas faces by front-line clinicians."

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 retrieve a person’s advance directives when we have need to employ and use them? Well, a handful of states have come up with a solution. Nevada, Washington, and Vermont now have legislation in place that allows citizen’s of those states to digitally or electronically store their advance directives on the Internet, in a digital or electronic lockbox or portal of sorts. These states have addressed a critical need of their citizens: the need to have their advance directives accessible and readily available to health care providers so that their intent and wishes will be honored. 

This Article advocates that other states follow the lead of Nevada, Washington, and Vermont by adopting similar legislation and embracing digital or electronic technology by creating Internet “lockboxes” or registries, or portals where citizens can store their advance directives, and health care providers can access these advance directives in the most pressing and critical situations. 

Part One of this Article examines the rationale and need driving the creation of digital or electronic registries. Part Two of this Article lays out a model for the movement toward an advance directive for health care registry. Specifically, Part Two examines some of the pitfalls and shortcomings in existing legislation in Nevada, Washington, and Vermont. Additionally, Part Two sets forth model legislation that could be adopted by states wishing to legislatively create an advance directive for health care registry. Part Three explores who could administratively administer an advance directive for health care registry in the various states that decide to adopt the model legislation. Part Four addresses mechanisms and means to create the website or portal. Part Five explores the cost and expenses involved in building and maintaining the website or portal. Part Six explores demographic issues, namely who will use and benefit from an advance directive for health care registry. 

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 it is hardly clear that patients have that right under New York law.  

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 for 30 minutes was resuscitated after a further 25 minutes efforts. The child now suffers from serious disabilities. The jurisprudence: the maternal medical management was not found guilty. However, the judge considered the hospital was guilty of unreasonable obstinacy in saving the life of this child because the medical team could not be unaware of the serious neurological consequences of a long intrauterine hypoxia and because of the excessive duration of the resuscitation efforts. Comment: we will focus the discussion of this jurisprudence from a medico-legal and ethical point of view on four topics: the resuscitation efforts considered as excessively long whereas the starting of the resuscitation efforts was well-justified; inappropriately informing the parents of the death of their child, for which the judge found not guilty; the damages that will be paid to both parents and child, that is to say the indemnification of a disabled child for being in life, as in the Perruche affair in 2000; the difficulties of distinguishing between damage due to the unreasonable obstinacy to save his life, and the consequences due to his prior medical condition.  In conclusion, as a consequence of this jurisprudence, neonatologists may prefer not to resuscitate a child who has suffered from intrauterine hypoxia, in order not to be found responsible for any possible resulting disability, but with the risk of being charged of failure to render assistance to a person in danger. 

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 much, much, much, much less for actually communicating."  Dr. David Goodman similarly explained:  "Money is an unconscious influence that we as professionals can't pretend doesn't exist. . . .  It's like being in a slow-moving but powerful river, where the current is hard to overcome. You might not even be aware of it, but you can't deny that it's there."  

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 that you may face, assist you to record your decisions and do our best to ensure that your wishes are fulfilled, wherever possible, by all those who offer you care and support.
• Talk with you and the people who are important to you about your future needs. We will do this as often as you feel the need, so that you can all understand and prepare for everything that is likely to happen.
• Endeavor to ensure clear written communication of your needs and wishes to those who offer you care and support both within and outside of our surgery hours.
• Do our utmost to ensure that your remaining days and nights are as comfortable as possible, and that you receive all the particular specialist care and emotional and spiritual support that you need.
• Do all we can to help you preserve your independence, dignity and sense of personal control throughout the course of your illness.
• Support the people who are important to you, both as you approach the end of your life and during their bereavement.