Thursday, December 18, 2014

Most Physicians Give 'Futile' Life-Sustaining Interventions

 The Medscape Ethics Report 2014 survey finds that most physicians give "futile" life-sustaining interventions.  

Wednesday, December 17, 2014

Medical Futility Lawsuit in Philadelphia Proceeds

The U.S. District Court for the Eastern District of Pennsylvania just permitted a plaintiff's medical futility lawsuit (including claims for punitive damages) to proceed against Thomas Jefferson University Hospital and several individual clinicians.

Bernice Goldberg was admitted to TJU Hospital in August 2011.  At some point, her son and POA, Gary, discovered that his mother was not being provided nourishment.  Allegedly, after seeking an explanation, a physician told Gary: "The team has decided that your mother is going to die anyway so we are not going to feed or hydrate her."

Gary went to the Philadelphia District Attorney to report that a murder had been committed.  In his civil lawsuit, he alleges that clinicians "intentionally killed" his mother.  "They intentionally took away the family's right to make medical decisions for their mother."

Tuesday, December 16, 2014

DRW v. University of Wisconsin - Facilitating Surrogates' "Illegal" Decisions to Stop Life-Sustaining Treatment

I blogged about this case over five years ago when it was first filed.  Disability Rights Wisconsin sued the University of Wisconsin and several individual physicians over their "plan of noncare" for several patients.  

Basically, DRW's argument is that because these patients were not permanently unconscious Wisconsin law does not allow life-sustaining treatment to be withdrawn (see, e.g., Edna MF; Montalvo).  In other words, the substitute decision makers in this case did not have the authority to authorize withholding or withdrawing of "potentially life-extending medical treatments."  And the clinicians knew that (or should have known that).

A few days ago, a Wisconsin appellate court held that the defendant physicians did not violate any substantive due process rights of the patients.  There is no constitutional right to medical care from the government.  The court expressed "no opinion about any potential obligations that the doctors might have . . . pursuant to nonconstitutional sources of authority that include tort law, or ethical, professional, or institutional codes."

Monday, December 15, 2014

Tracey v. Cambridge University Hospital - Duty to Consult

The December 2014 issue of Clinical Medicine (Royal College of Physicians) includes a nice summary of the impact and implications of the UK Court of Appeal's judgment in Tracey v. Cambridge University Hospital.  Under prior UK cases like Aintree and Burke, UK physicians do not need patient consent to write a DNR order.  But they must discuss and explain the decision.

Ontario Medical Board Seeks Input on Draft End-of-Life Policy

The College of Physicians and Surgeons of Ontario has just posted ’s a revised draft policy for external consultation: "Planning for and Providing Quality End-of-Life Care."  

The draft policy sets out professional expectations of physicians and provides guidance on a range of issues relating to quality end-of-life care, including futility and aid in dying.

The CPSO is inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the draft policy. Comments received by February 2015 will assist in developing a final policy which will be considered for final approval by Council.  Several good comments already appear on the online discussion board.

Sunday, December 14, 2014

Mass General - Futility Policy Experience

Andrew Courtwright and colleagues at the Massachusetts General Hospital have published "Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial" in the Journal of Critical Care.

This was a retrospective cohort study of all ethics committee consultations between 2007 and 2013 with the MGH "not offering CPR policy."  There were 134 cases of disagreement over whether to provide CPR. 

  • In 45 cases (33.6%), the patient or surrogate agreed to a do-not-resuscitate (DNR) order after initial ethics consultation. 
  • In 67 (75.3%) of the remaining 89 cases, the ethics committee recommended not offering CPR. 
  • In the other 22 (24.7%) cases, the ethics committee recommended offering CPR. 

While incidental to the focus of the study, it surprised me that in 7.5% of the conflict cases the patient herself made the request for CPR.  In contrast, in other reported studies of futility disputes, the patient almost always lacks capacity and the LST decision is made by a surrogate.

It is also worth noting that these numbers indicate a high prevalence of futility disputes.
  • These 134 cases are just those that reached Optimum Care Committee consultation.
  • 134 cases over 7 years means about 2 futility conflicts per month.
  • These are just the futility conflicts pertaining to CPR.  Presumably there are many more concerning vents, CANH, and other interventions.

Saturday, December 13, 2014

Communicating about Prognosis and End-of-Life Care in Patients with Advanced Cancer (video)

On November 19, 2014, Jennifer Temel presented "Communicating about Prognosis and End-of-Life Care in Patients with Advanced Cancer" at the MacLean Center for Clinical Medical Ethics.