While Wesley Smith and I agree on 99.9999% of ethics issues, we disagree on the Texas Advance Directive law. One portion of that law, 166.046 covers cases where the doctor refuses to carry out the end of life decisions of a patient and/or his or her surrogate.
Mr. Smith is predicting the "repeal" of what he calls the Texas Futile Care Act.
For more on the law, here's commentary from Houston Lawyer.com.
Please note, the word "futile" isn't in the law. The same clause could be used where the doctor refused to end artificial hydration and nutrition, with simultaneous withholding of oral fluids and food.
A very sad case in Houston this week, ended after a judge intervened in what sounds like brain death, as there was no blood flow to the brain:
Beaumont Enterprise.
Hospitals don't practice medicine. Lawyers and judges shouldn't. But sometimes the law is needed when there are disagreements.
The doctor determines what he or she can do in good conscience. The committee agrees whether or not the doctor's decision is medically appropriate.
However, the law recognizes the fact that doctors may disagree on the point of "medically appropriate" in a few cases. It's rare to find such a disagreement, since doctors actually try not to fail (and we consider even the contemplation of the death of a patient as failure - see the "Cheerful Oncologist," here ), and we know that the course of system, organ, tissue and cell breakdown follow a certain course.
Just as in this last, sad, case at Hermann Memorial, in the case of Andrea Clarke, another doctor stepped in and took over her care in the same hospital. A gallbladder procedure done on Mrs. Clark did not find the speculated stones or localized infection, and the poor woman died soon after of her disease by way of the overwhelming infection. Unfortunately, it appears that the signs of sepsis were mistaken as signs of improvement by the family at the time.
"First, do no harm." The physician must weigh the good against the harm. Our wish to "do something" must be tempered by non-maleficence, or the duty to do no harm. Eventually, the procedures we do only prolong dying while increasing the times we - or the nurses and techs, because of our orders - hurt and manipulate a patient.
Instead of being a conspiracy or even a "gentleman's agreement," it's evidence that our experience and knowledge of the usual consequences are consistent. Doctors aren't so easy to intimidate - if there were disagreement on the benefit to the patient, there'd be more than one doctor on this list.
Tuesday, August 08, 2006
There's still no "Texas Futile Care Act"
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1 comment:
You are somewhat off-base about the Beaumont case. No objective testing had been performed prior to the futility review. The neurologist actually told the family there was no evidence of brain damage.
The doctors and hospitals dispensed with good communication and compassion toward the family at the ethics meeting and afterward.
The physician who stepped in at our request, actually thought, upon clinical assessment, that the patient was responsive. He noted that no blood flow study had been performed and he performed the test and objectively determined brain death.
The court did not make a mistake in issuing the TRO. In fact, the court gave the family the opportunity to involve a physician who performed a simple, objective test that proved brain death. He treated the family humanely and fully explained his findings and even prayed with the family for wisdom and guidance.
After this, the family decided to withdraw treatment with a clear conscience. They aren't stupid people--although the doctor and ethics committee treated them as such.
Had they been bulldozed over by the hospital and doctor in the matter of withdrawal of treatment, they would have been burdened with guilt and despair forever. They never would have been able to make their own conclusion that brain death was present, and that the withdrawal of treatment was in accordance with their values and morals.
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