More on Texas Advance Directive Law

I’m sure that I’m not the only one who has spent some quiet time thinking about Mrs. Clark and her family. And, I hope that those of us of faith have been praying.

I keep reading that the ethics committee has the “final say” on whether or not the life saving treatment can be stopped. That is not true, since only a doctor can practice medicine in Texas, the doctor actually has the final say, unless a new doctor willing to take over care can be found.

Please take a look at the law, especially 166.046, about one third of the way down.

The doctor has refused to continue what he or she says is inappropriate medical intervention that is not in the best interest of the patient. Treatment is usually considered inappropriate if it causes undue burden to the patient that outweighs the benefits or if it is not really treating her: if it is not allowing her lungs, heart, brain and kidneys or her skin time to heal or if it is not helping her heal at all, but is only prolonging her dying while other complications build up.

The ethics committee does not actually make any treatment decisions. The committee is charged with evaluating whether the treatment is medically appropriate or inappropriate, and in this case the committee has agreed with the doctor.

Again, maybe it would help if people think of the provision in the law as a “conscience clause.” Don’t forget that the doctor may be refusing to withdraw or withhold treatment – not just refusing to continue treatment. Before this law, doctors had to act on our own, risking lawsuits even when we did follow the Advance Directive. Sometimes, we made these decisions ourselves if no one else would or could, and we got another doctor to sign that he or she agreed with us.

However, if the doctor disagrees with the committee, he still has the option to transfer the patient to another doctor’s care.

The patient, or the person making the decisions for the patient, has the same option.

Finally, there is subsection (g), which allows the patient or the patient’s decision maker to petition the court to force the doctor to continue life saving care if the court thinks that there is a reasonable chance that another doctor or facility can be found that will accept the patient in transfer.

Most importantly, though, the doctor is not going to kill the patient. He is not going to stop artificial nutrition or hydration while refusing natural food and water. He is not going to smother her or give her poison. Unless her heart gets stronger, her brain causes her to begin breathing on her own again and/or her kidneys begin filtering her blood again, her disease will kill her and she will die a natural death.

The doctor is refusing to continue to write the orders and to monitor the intensive, life saving treatment that he or she believes is prolonging the patient’s death. If it is true that her heart is failing and that her kidneys will never function again and she will never breathe on her own again, then Mrs. Clark will never leave the ICU and she will most likely die within a few weeks, probably of a heart attack, lung damage that can’t be overcome with the ventilator, a severe, overwhelming infection, or a massive intestinal ulcer that causes her to bleed to death.

Remember, Mrs. Clark has been getting worse for about 6 months.
Warning: the following hurts to write, so it may be too graphic and painful for some readers.

I don’t know all the details in this case, but I can imagine what is going on from experience and the parts I do know about from reading the DU post, Right Wing News and Winds of Change and the original blog at the Chronicle.

Mrs. Clark has been in the hospital since November, 2005. Her heart is failing, she is on a ventilator because her brain does not stimulate her to breathe, and she has kidney failure that requires that she undergo 4 hours or so of hemodialysis at least 2 times week. She can’t go to the dialysis clinic while on the ventilator, so the machine must be brought to the ICU. She also has the underlying heart disease that caused her to need the surgery last November, and it sounds as though the infection aggravated her heart failure.

Between dialysis treatments, the fluid in the patient’s body increases and builds up, making treatment of her heart condition and the maintenance of her blood pressure and ventilation more difficult. She will need constant adjustment of her IV medications to control her blood pressure. The medicines will affect the blood flow in her fingers and toes.

Her ventilator settings will need adjustment, and the nurses will continue to suction the tubing and the patient’s upper airway to keep it clear.

Ventilation tubes and IV’s, as well as any feeding tubes or urinary catheters will have to be changed out periodically. There will be frequent blood tests to check on the kidneys and liver, blood count, look for infection, etc. Dialysis also removes some nutrients that must be replaced. Mrs. Clark’s fluids will be closely followed and severely limited so that the fluid doesn’t build up too fast.

People with kidney failure also have problems with anemia, since the kidney produces erythropoietin to stimulate the bone marrow. The lungs and kidneys each affect the blood pressure by hormones and blood vessel changes. The artificial feedings, the medicines to maintain the blood pressure, and the fluid build up as well as the backing up of blood from a poorly functioning heart can cause the liver to stop making the proteins that are required to stop bleeding. Decisions will have to be made about blood transfusions and clotting factors. Eventually, if Mrs. Clark’s heart doesn’t give out as the doctor believes, she will develop an overwhelming infection or she will start bleeding somewhere – usually in the gastrointestinal tract - and that will be the point where not all the medicines and technology that we have will be able to save her.