Welcome to Ethics Consulting – an opportunity to discuss, debate (respectfully) and learn together. We select an ethical dilemma from a real but anonymous patient care case, and then we provide expert commentary.
Last week, you voted on whether doctors should take the wife of a stroke patient to court for staying on life support.
Should the doctor go to court to overrule his wife’s decision?
Now, says Jacob M. Appel, MD, JD, bioethicist:
From the 1970s to the 1990s, the relationship between the home and the hospital Most end-of-life conflicts among patients involve situations in which the family wants to withdraw life support and the medical institution opposes it. These families often fight openly through the court system, hoping to have their loved ones die a “natural death”.
Nearly two decades of growing rift between families and providers is reversed: In a series of high-profile disputes, hospitals try to Life support was withdrawn in some cases, while families struggled to keep their loved ones on ventilators. The earliest and most famous of these cases was Helga Wanglie, an 86-year-old Minnesota woman in a persistent vegetative state whose doctors wanted to withdraw treatment, over her husband’s objections. (The court ultimately ruled for her family, but she died 2 days later.)
In 2005, Lachlan Forrow, MD, Beth Israel Deaconess Medical Center, Boston Told The New York Times : “About 15 years ago, at least 80% of cases were the death penalty type. Today, it’s more like at least 80% of cases are going the other way: family members There is a push for continued or more aggressive life support that doctors and nurses believe is wrong.”
These cases are critical for the health care system. For example, Helga Wanglie’s medical bills in her final years in 1991 were reported to be $800,000 – about $1.5 million today.
Views of the past “futility” of keeping patients on life support vary widely. Some families have hope, often unreasonable, that their loved one will recover.
And yet the media intermittently reported precisely those miraculous stories: On family day at 56 – Nebraska aging mother Teri Roberts planned to The toxic shock syndrome patient woke up from an “irreversible” coma after her ventilator was turned off in 2015. Car crash victim Terry Wallis woke up in 2003 after nearly two decades. Canadian woman Anne Shapiro fell into a coma the day John F. Kennedy was assassinated in 1963 – and woke up suddenly in 1992!
Other families recognize their loved one will not get better but refuse to terminate care for religious or cultural reasons, as in Alexander’s case; his recovery prognosis is not relevant to his wife’s decision-making process .
Whether the hospital can override the family’s decision in these situations varies from state to state. Texas provides suppliers with the most power in the region. Under the Texas Advance Directive Act (better known as the Texas Futile Care Act), hospitals can withdraw life support from patients when such medical care is deemed “futile,” once certain procedural safeguards are met. The first patients to be affected by the law include infant Sun Hudson and terminal cancer patient Tirhas Habtegiris.
Scenes like the conflict between Alexander’s wife and his doctor are usually avoidable. Had the hospital’s medical team discussed with the couple in advance the circumstances under which life support would be withdrawn, and highlighted the social costs of keeping a patient with no prognosis of recovery on life support, Alexander would likely have accepted the terms; He was not provided with a biventricular assist device. As with many cases in medical ethics, these issues are best addressed before the fact, rather than after tragedy.
Jacob M. Appel, MD, JD, is Director of Psychiatry Ethics Education and member of the Institutional Review Board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and an MS in Bioethics from the Albany School of Medicine.
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