The legal consensus about foregoing life-sustaining treatment: its status and its prospects

Organ Donation by the Imminently Dead: Addressing the Organ Shortage and the Dead Donor Rule

The dead donor rule (DDR) has facilitated the saving of hundreds of thousands of lives. Recent advances in heart donation, however, have exposed how DDR has limited donation of all organs. We propose advancing the moment in the dying process at which death can be determined to increase substantially the supply of organs for transplantation. We justify this approach by identifying certain flaws in the Uniform Determination of Death Act and proposing a modification of that law that permits earlier procurement of healthier organs in greater numbers.

Futility and Shared Decision-Making

Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.

The Ethics of Surgery at End of Life

The role of the anesthesiologist cannot be understated when it comes to ethical decision making, especially at end of life. To best serve patients within the limits of the law, anesthesiologists must arm themselves with an understanding of how the laws surrounding ethical decision-making impact daily practices. It is also important to know what rights and duties a patient or surrogate has in the decision-making process. With proper understanding of their responsibilities and the available tools, anesthesiologists can fulfill their roles as leaders and advocates for their patients as approaches to ethical decision-making at the end of life evolve.

The stigma of "mental" illness: end stage anorexia and treatment refusal

OBJECTIVE

To answer the questions of whether psychiatric patients should ever be allowed to refuse life-sustaining treatment in favor of comfort care for a condition that is caused by a psychiatric disorder, and if so, under what conditions.

METHOD

Case discussion and normative ethical and legal analysis.

RESULTS

We argue that psychiatric patients should sometimes be allowed to refuse life-sustaining treatment in favor of comfort care for a condition that is caused by that psychiatric disorder and articulate the core considerations that should be taken into account when such a case arises.

DISCUSSION

We also suggest that unwillingness among many, especially mental health professionals, to consider seriously both of these questions risks perpetuating stigmatization of persons with psychiatric disorders, i.e., that the "mentally" ill should not be allowed to make significant decisions for themselves-a-a stigmatization that can result in persons with mental disorders both being prevented from exercising autonomous choice even when they are capable of it, and being denied good comfort care at the end of life--care which would be offered to patients with similarly life-threatening conditions that were not deemed to be the result of "mental" illness.

Clinical report--Forgoing medically provided nutrition and hydration in children

There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.

Separating medical and ethical: helping families determine the best interests of loved ones

Critical care nurses are often confronted with situations where the wishes of an incompetent patient on life support are undocumented and the family is struggling with the decision to either continue or withdraw life support. It is important that critical care nurses are able to identify their values in this and similar situations. With a better understanding of personal values, nurses are better able to provide medical information families need to make decisions about life support, without their ethical opinions being confused with medical knowledge. This article presents a framework using 2 values that are essential to decisions about life support, the sanctity of life, and quality of life to assist critical care nurses to identify values.

Ethics and the law in emergency medicine

When ethical issues arise in emergency medical practice, many emergency physicians turn to the law for answers. Although knowing when and how the law applies to emergency medicine is important, the law is only one factor to consider among many factors. Additionally, the law may not be applicable or may not be clear, or the ethical considerations may seem to conflict with legal aspects of emergency medical treatment. Situations where ethics and the law may seem to be in conflict in emergency medicine are described and analyzed in this article, and recommendations are offered. In general, when facing ethical dilemmas in emergency medical practice, the emergency physician should take into account the ethical considerations before turning to the legal considerations.

Limitation of Treatment at the End-of-Life: Withholding and Withdrawal

Most deaths in the United States occur under the care of a physician. In most of these cases, decisions must be made about whether to initiate and continue or withdraw life-sustaining medical technology, such as cardiopulmonary resuscitation, ventilation, nutrition and hydration, dialysis, transfusions, and antibiotics. All are part of a medical technological armamentarium that should be used when the goal of treatment is a cure. When a cure is not possible or appropriate, these medical technologies should be withdrawn or withheld. The circumstances in which end of life treatment may be ethically and legally limited through withholding or withdrawal are discussed.

Issues of ethics and identity in diagnosis of late life depression

Depression is often diagnosed in patients nearing the end of their lives and medication or psychotherapy is prescribed. In many cases this is appropriate. However, it is widely agreed that a health care professional should treat sick persons so as to improve their condition as they define improvement. This raises questions about the contexts in which treatment of depression in late life is appropriate. This article reviews a problematic case concerning the appropriateness of treatment in light of the literature in bioethics. Specific attention is paid to the concept of authenticity and the role of suffering. Suffering is often the result of a situation in which one's self is damaged. In some circumstances, this suffering should not be seen as a symptom of illness, but as a reflection, in a difficult life context, of the individual's authentic nature. Assessment of depression in the elderly must go beyond a symptom list and must consider both the context of the individual's situation and his or her authentic self. When the symptoms reflect the individual's assessment of the situation in the context of the authentic self, they may be "appropriate." However, even when the symptoms are appropriate, if they interfere with life assessment and adjustment, treatment should be considered.

Ethical conflicts between residents and attending physicians

Conflicts between residents and attending physicians over ethical issues often occur and residents must attempt to navigate these perilous waters. A brief description of a conflict concerning informed consent and professional role expectations in a neonatal intensive care unit is presented. The discussion then explores contextual features that often shape such ethical conflicts and presents ways of understanding ethical conflicts that occur in the course of medical training. Constructive approaches for residents to engage in conflict resolution are offered.

Emergency physicians and physician-assisted suicide, Part I: a review of the physician-assisted suicide debate

Physician-assisted suicide (PAS) has been one of the most hotly debated bioethics and health policy issues of the past decade. Part I of this 2-part article defines key terms in the debate, reviews the history of the debate, and articulates leading arguments for and against legalization of the practice of PAS. Part II of the article will examine the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS.

Conflict resolution at the end of life

OBJECTIVE

Limited empirical research has examined how decisions are made when the preferences of terminally ill patients conflict with physicians' recommendations. This study sought to investigate physicians' strategies for resolving conflicts with dying patients.

DESIGN

Cross-sectional, qualitative interviews.

SUBJECTS

Subjects were 158 physicians caring for at least one terminally ill patient.

SETTING

University medical center.

MEASUREMENTS AND MAIN RESULTS

We analyzed physicians' responses to the open-ended interview questions, "How do you handle a situation when a patient wants a treatment that you believe does not provide any benefit?" and "How do you handle a situation when a patient does not want a treatment you think would be beneficial?" For patient requests of nonbeneficial treatments, physicians reported the following as important: negotiating with and educating patients (71%), deferring to patient requests for benign or uncomplicated treatments (34%), convincing patients to forgo treatments (33%), refusing patient requests for nonbeneficial treatment (22%), using family influence (16%), not offering futile treatments (13%), and referring to other physicians for disputed care (9%). Potential harm (23%) and cost of treatment (18%) were reasons cited for withholding treatments. In response to patient refusals of beneficial treatments, physicians report the following as important: negotiating with patients (59%), convincing patients to receive treatment (41%), assessing patient competence (32%), using family influence (27%), and referring to other physicians (21%).

CONCLUSIONS

Physicians vary in the communication and negotiation strategies they use when their medical judgment conflicts with dying patients' preferences. Medical ethicists could play a greater role in teaching ethically important communication skills. Physicians providing care at the end of life report strategies for respecting patients that reflect graduated degrees of accommodation tailored to the costliness and riskiness of requests; they are most accepting of patient requests for benign, technically easy, inexpensive, and medically effective treatments.

Special challenges of withholding artificial nutrition and hydration

Despite society's increasing understanding of and comfort with end-of-life decision-making, questions about the appropriate use of artificial hydration and nutrition remain particularly challenging to both professional and family members. These decisions are complicated by misunderstandings about likely benefits and burdens, concern about patient suffering, and ambivalence regarding the moral status of feeding. Data regarding the effectiveness of tube feedings in terms of prolonging survival, improving wound healing, or preventing aspiration do not support the widespread use of this intervention in states of severe dementia or end-stage disease. Further, there is evidence that withholding feeding is not associated with suffering, so long as adequate mouth care and desired sips of water are provided. Nonetheless, surveys of both long-term care residents and family members of persons with dementia indicate that at least 30% to 50% of those queried expresses a preference for artificial feeding if they (or their relative) could not eat. Given the absence of conclusive data about the efficacy of feeding and the apparent plurality of values surrounding the provision of this intervention, health professional must focus efforts on using a careful, deliberate approach to decision-making that involves all interested parties and make use of valid empirical data.

Assisted suicide compared with refusal of treatment: a valid distinction? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel

The continuing debate over the deeply controversial issue of physician-assisted suicide has been complicated by confusion about how this practice resembles or differs from refusal of life-sustaining treatment. Perspectives on ethics and policy hinge on the contested issue of whether a valid distinction can be made between assisted suicide and withdrawal of treatment. This paper uses three illustrative cases to examine leading arguments for and against the recognition of a fundamental distinction between these practices. The first case involves assisted suicide by ingestion of prescribed barbiturates, the second involves withdrawal of artificial nutrition and hydration, and the third involves a decision to stop eating and drinking. On theoretical and practical grounds, this paper defends the position that there is a valid distinction between assisted suicide and refusal of treatment.

Is there a lingua franca for bioethics at the end of life?

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live.

Law and ethics in emergency medicine

Ethical issues in emergency medicine often are accompanied by legal issues. Although the legal aspects of an ethical problem are important factors to take into consideration, the law may not directly address the problem, and following the law does not always ensure an ethical outcome. Emergency physicians should have an understanding of ethics and law, understand the legal aspects of bioethical issues in emergency medicine, and finally have a guide to analyze ethical issues, including the consideration of legal issues that may have an impact on the case.

High technology near the end of life: setting limits

High technology interventions near the end of life exact a high cost both in human and economic terms. Breathtaking advances in cardiology have helped to prolong life and improve its quality for many. For some, it has transformed the process of dying into a medical nightmare. The "do everything possible" attitude that prevailed during the past few decades is both inhumane and wasteful. In contrast, in the new era of managed care with its focus on profit, a well meaning physician may become suspect whenever he recommends against a medical intervention that he deems to be futile. More than ever before, there is a pressing need to develop rational guidelines for end of life medical interventions to ensure primacy of patients' best interests, protect the integrity of the doctor-patient relationship and affirm the duty of the medical establishment toward society at large. This weighty issue must not be relinquished to medical ethicists, health care alliances or the courts. It is the domain of physicians and the public at large. Medical futility should be defined as a treatment unlikely to affect the course of illness or that which has failed to achieve its desired effects. Rational guidelines for cardiopulmonary resuscitation and do not resuscitate orders should be formulated for both inhospital and out of hospital victims of cardiac arrest. These guidelines need to be developed through a process similar to those for the treatment of unstable angina, with involvement from all relevant medical specialities. Proposed guidelines must be negotiated, reviewed and ratified by the lay public. Appropriate legislation is necessary to establish the framework and policies to carry out agreed on recommendations. The focus of the "living will" should change so that it covers the last chapter of life rather than its terminal phase. The document should serve to express the person's wishes regarding specific medical interventions when the quality of life is seriously diminished beyond what is uniquely desirable for the particular patient. Living wills must be comprehensive, clear and specific. They must be honored. The Uniform Health Decisions Act, now pending legislation, should enhance the utility of the living will.

Collective decisions about medical futility

The debate about medical futility is no longer in its infancy. Scholarly literature on this seemingly intractable problem is voluminous. The list of widely publicized cases in which physicians have wanted to discontinue life-sustaining medical treatment that families demand has grown to include not just Helga Wanglie, but also Baby Rena, Baby L, Jane Doe, Joseph Finelli, Baby K, and Teresa Hamilton. A futility case has now been decided at the appellate court level.

Commentators have generated three kinds of proposals for resolving these conflicts. One group contends that the problem can be solved within the physician-patient-family relationship. While some in this group view professional authority broadly enough to warrant unilateral judgments by physicians that interventions desired by the patient or family should not be provided, others contend that physician authority does not extend that far, and that any resolution must be constrained by informed consent requirements.

Can complex legislation solve our end-of-life problems?

Over a 20-year period, the United States has developed a consensus of legal opinion concerning living wills and other advance directives. At the heart of this consensus are two interconnected principles. First, the state should minimally interfere with the wishes of patients and surrogates and the decisions of physicians about foregoing life-sustaining treatments. Second, state interference is permissible for the sake of protecting a compelling state interest. The overwhelming majority of states with advance directive laws have attained this balance of minimal interference and compelling state interest in developing their laws.