Why Wait

The determination of a patient’s capacity to make decisions is based upon her understanding of her disease or illness and the risks and benefits of treatment. If she is unable to articulate a clear understanding it may be determined that she lacks the necessary capacity to make her own decision and is further taken out of the loop of information and adequate and legitimate updates on her condition. Concomitantly, surrogate decision makers are not always available to see the treating physicians and consults, and often get a cursory explanation of the patient’s condition.

Physicians remain exceedingly reluctant to confront the difficult subject of end of life care. The New York times, on January 11, 2009 published an article, by Denise Grady, - “Facing End-of-Life Talks, Doctors Choose to Wait.” Discussing a survey of 4,074 doctors who took care of cancer patients, who had only four to six months left, but was still feeling well. 65 percent said they would talk about the prognosis, but wait to discuss end of life preferences.

67%: Making sure family is not burdened financially by my care
66%: Being comfortable and without pain
61%: Being at peace spiritually
60%: Making sure family is not burdened by tough decisions about my care
60%: Having loved ones around me
58%: Being able to pay for the care I need
57%: Making sure my wishes for medical care are followed
55%: Not feeling alone
44%: Having doctors and nurses who will respect my cultural beliefs and values
36%: Living as long as possible
33%: Being at home
32%: Having a close relationship with my doctor

Why Wait?

As time progresses and severity of illness increases, being able to say what she – the patient - actually wants is of paramount importance. Respecting person’s wishes is both ethically required and legally mandated because we recognize that each of us is owed the respect to decide what is done to our bodies, how we wish to live. These human rights are not relinquished when sever illness must be faced. The need to provide timely information to the patient must not be ignored. If the determination of the true wishes of the patient are, in fact  paramount in decision making than the earlier information is provided then there is a greater probability of knowing – with confidence – the wishes and decisions of the patient. Moreover, be speaking early the patient has the opportunity to ask questions of her physicians that she deems important. All this is lost by waiting. When a patient loses capacity the physicians are forced to turn to the surrogate decision maker who may be reluctant to express the wishes of the patient or unable to face the harsh realities of the situation and delay decisions.

1  A surrogate cannot be permitted to cause a delay in decision making which will harm the patient by causing unnecessary suffering and costly delays.

2  If a surrogate cannot or will not be fully informed and understand the diagnosis and prognosis, he or she may not continue as surrogate

3  If a surrogate cannot or will not decide – find a new surrogate, or move to a best interest standard.

Often the surrogate is a family member suffering from fear and grief, often at odds with the views of other family members and friends. There is an understandable empathy for people in this position and the desire to help them through such a hard time in their lives is great. Yet, it is not the job of a physician or nurse or bioethicist to become involved with the surrogate to the point that the surrogate’s feelings seem more important than the need to uncover by the most reliable means possible under the circumstances to know the true perspective and intentions of the patient.

It must be of crucial importance to maintain focus on the patient’s wishes and not see the surrogate and family as a filter or as an easier method  to arrive at a decision. The surrogate must make a decision, not based on a consensus of the family or the advice of the doctor or nurse, but on the best and clearest representation of the wishes of the patient.

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At the 2013 annual meeting on Women’s Cancer by The Society of Gynecologic Oncology (March 9 2012 – Los Angeles) Dr. Robert Bristow, the director of Gynecologic Oncology at the University of California – Irvine presented a retrospective review of the medical records of 13,321 women with ovarian cancer, diagnosed from 1999 through 2006 in California. The study determined that only 37% of the care provided to this cohort adhered to the guidelines set forth by the National Comprehensive Cancer Network setting forth specific surgical procedures and chemotherapy. In women that received the specified protocol, 35% survived at least five years where as only 25% of those survived, where the guidelines were not followed.

More than 80% of the woman, as reported in the New York Times today, where cared for by what was labeled as “low volume” surgeons, who operated on 10 or fewer cases a year and hospitals with 20 or fewer cases per year.

The ethical and moral issues here arise out of the legal requirements of obtaining an informed consent. Consent is only deemed “informed” if it provides all material information - information that would be deemed important by the average reasonable person.

It is, therefore, legally required and ethically and morally mandated that patients be told by the physician that:

“I do not follow the medical and surgical guidelines recommended by the National Comprehensive Cancer Network that have a statistically significant better outcome in terms of life expectancy.  Do you want me to treat your ovarian cancer or refer you to a physicians who follows these other guidelines?”

Not a likely scenario. Any physicians caring for the patients with ovarian cancer are required to keep abreast be aware of all up-to-date medical literature, and follow best practices and evidenced based medical guidelines for this devastating disease. Failure to provide such information to every similarly situated patient would be unethical, immoral, and a breach of the standard of care. That may also go further into the realm of fraud if it could be shown that the physician knew of this information, but failed to disclose it for purposes of his or her own financial gain, or the gain of the hospital.

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“Be a good girl and take your medicine.” Part 1

This statement was made to a 60 year old end stage leukemia patient who demanded to be discharged from the hospital. The patient refused the prescribed medications.  No attempt was made to discuss the risks attendant in not taking the prescribed medication. The patient was cogent and articulate - able to make medical decisions for herself. The physician walked out of the patient’s room in the ICU. No social worker, bioethicist had been called to assist. Patient Jane was merely told, “Be a good girl and take your medicine.”

What can we say about the physician who made this statement? One might speculate that perhaps the physician was elderly – old school, etc. He was not. Early forties, well trained, and well respected. Could it be a socioeconomic impasse in communication? Possibly, the pt was poor and black. There was family or friends to advocate on her behalf. Nevertheless the statement breached medical ethics and legal responsibilities. A patient has a fundamental right to determine what medical care she will accept. To ignore these requests constitutes battery and possibly false imprisonment. 

The patient reported that she never really spoke with her doctor. He would come into the room briefly, she said, early in the morning. He spent a short time examining her. Often he was interrupted by cell phone calls. He would say he had to run. The pt reported that the nurses were giving her little attention, save saying that she should take the medicine the doctor proscribed. She told the ICU nurses she was refusing meds and wanted to be discharged. She called me.

I found her curled up in a fetal position shivering with no blanket calling for help. She told me her wishes; her refusal of meds and request to be discharged. She had voluntarily admitted herself to the hospital and saw no reason that she should be kept “like a prisoner” and with her “Constitutional Rights violated." She implored me to help her; she said she had a brief time to live and did not want to remain in this hospital to wait out her days. She was feeling better and "wanted out." I contacted the primary treating physician who said she was not competent to make decisions. I recommended a psychiatric consult to confront this issue. The psychiatrist responded within a few hours and found that Jane was clearly competent to make decisions for herself, but placed her on an involuntary 72 hour hold because he found her to be paranoid that people would not listen to her.

This was a misapplication of the purpose of the 72-hour psychiatric hold statute, used for the protection of a who may cause harm to herself or others. I contacted then psychiatrist to inquire why he felt she might cause harm to herself or others. He did not think she would but did not want to cause "a problem" for the primary treating physician.

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The 9^th Circuit Court of Appeals recently heard oral argument in the case of NATURAL RESOURCES DEFENSE COUNCIL,( NRDC), vs. ENVIRONMENTAL PROTECTION AGENCY, Case# 12-70268, regarding the EPA’s conditional approval of a nano-silver product made by a Swiss company HeiQ Materials. The Amicus briefs describe it as: 

“ the EPA’s unprecedented decision to conditionally register the nano-silver pesticide products HeiQ AGS-20 …as unsupported by substantial evidence. EPA has failed to show that the conditional registration will not cause any unreasonable adverse effect” on human health and the environment. The limited studies to this point have raised significant red flags about nano-silver.”

The Product is HeiQ AGS-20, as described by its manufacturer, provides antimicrobial protection for textiles (e.g. blankets) and medical products … (wound dressings, implants) with unique durability and effectiveness… contribute to healing, increased safety and faster recovery. 

The issue in this case is the legality of the EPA’s interpretation that the interest of the public and of business trumps the EPA’s administrative mandate to first determine the safety of pesticides and to affirmatively determine that a product does not have  “unreasonable adverse effects.” In this case infants and children under 2 have not been studied regarding fabrics containing nano-silver if chewed  by infants or children 1 or 2 years of age. The fear is an increased risk of injury or death.   Although the EPA is required to evaluate risk, they did not do so in the group most likely to ingest nano-silver - infants and children 1 to 2 years old who chew on materials available to them.

During oral argument in the Court of Appeal, one Justice questioned counsel for the NRDC as to whether we should do away with stairs because babies fall down the stairs all the time - isn’t there a risk in everything that we do?

This joking cynicism fails to appreciate the unknown risks of nanotechnology and perhaps parallels the ignorance of the majority of the public as to dangers of working with substances of unknown nature. According to an amicus brief filed on behalf of various organizations, both private industry and governments are spending billions of dollars on research and development of nano technology. Nano-silver is the largest area with the greatest amount of new products at the present time. To date, however, no labeling with respect to unknown risks is required.

The EPA regulates nano-silver products, as pesticides because the intended purpose is antibacterial and antimicrobial. The risks involve potential toxicity from individual one time exposure to dose related effects from the aggregate expose to numerous products such as, sunscreens, food packaging, children’s toys and pacifiers, laundry detergent, personal hygiene products, jeweler, bedding and furniture, underwear, hair brushes, creams, lotions, pillows, and toothbrushes.

Nano materials can be absorbed into the brain (able to get across the blood brain barrier), liver, heart, kidney, spleen, bone marrow as well as the nervous system.

It is the EPA’s job, its burden of proof, to determine before registering a pesticide, that it will not cause any “unreasonable adverse effects” on human health and the environment. That is the EPA’s affirmative duty and thus cannot be delegated to the manufacturer or anyone else. The EPA has in this instance chosen to give a conditional approval permitting the manufacturer to market it for 4 years – and then see what happens.

The justification for giving HeiQ conditional approval, as stated by the EPA: “the Agency has considered the nature and its pattern of use, application methods and rates, and level and extent of potential exposure. Based on these reviews, the Agency was able to make basic health and safety determinations which show that use of HeiQ AGS-20 during the period of conditional registration will not cause any unreasonable adverse effect on the environment, and that use of the pesticide is, in the public interest. “     

Whether this is a sufficient predicate to conditionally approve the product, or whether the EPA is shirking its duty under its administrative mandate, should be at the core of the Court of Appeals’ decision. The statute requires that “ The Agency will approve an application only if:… The Agency has determined that the product will perform its intended function without unreasonable adverse effects …"

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All patients are not created equal

Many emergency departments and hospitals in low socioeconomic areas, sometimes referred to as “safety net hospitals,” have closed, resulting in serious problems for poor and minority populations due to reduced or no access to emergency care. This results in exacerbating illness or injury due to either waiting time to get, or failing to seek, medical attention. When patients later become desperate, ambulance calls increase; emergency rooms in distant hospitals become overcrowded; all resulting in further delayed emergency room care. 

Medical specialists have become more reluctant to be on-call out of concern for overburdened emergency departments and perceived increased risks of liability. Loren Johnson, M.D., director of emergency services at Sutter Davis Hospital in California says that the problem of obtaining on-call coverage has grown worse over time based on the growing demand for emergency services.

In 2002, the California Senate office of Research published a report “Stretched Thin: Growing Gaps in, California’s Emergency Room Backup System.” 

“Problems with access to emergency room on-call services and specialties in many areas of the state are adversely impacting the quality of patient care and forcing hospitals, physicians, patients and in some cases, medical groups and health plans to incur significant costs.”

University of Pennsylvania News Release March 2009 showed that longer stays in the ER, referred to as “boarding” result in poor pain control and avoidable medical complications. Judd Hollander MD, at the University of Pennsylvania noted that:

 “Even prior to the economic downturn, some institutions had actually begun prioritizing hospital beds for insured patients having lucrative elective procedures. These measures will only worsen disparities for minorities. Congress needs to make certain that ‘not for profit’ hospitals do not compromise patient care in pursuit of greater profits.”

A correlation has been found between increasing poverty levels and the absence of hospitals in the area with increasing rates of ambulance use. Rates of use of emergency medical services are most dependent on age and cause, but use is also correlated with increasing levels of poverty.

For example, In 2005 State University of New York published a study finding that high poverty areas are relatively underserved by hospitals. In the 100 largest cities high poverty areas made up 44 percent of the total suburban population in 2000, but accounted for only 20 percent of total admissions, inpatient days, and outpatient and emergency visits in 2002.

Some have argued that by 2020 one third of hospitals will be gone.

Ambulance diversion exacerbates the problem and is most prominent in emergency rooms that serve poor populations. One way for ERs to ease overcrowding in emergency departments is to divert ambulances to other hospitals. This, however, does not help anyone. In a study recently published in the journal of “Health Affairs” delayed care in emergency room affect marginalized populations and declared that 50% of black patients in the ICU spent more than six hours waiting for an inpatient bed, compared to 37 percent of patients of other races.

The Journal of the American Medical Association in June 2011 addressed the question of ambulance diversion and survival among patients with acute Myocardial infarctions, finding that delays increased mortality rate for 30-day, 90-day, 9 months, and one-year mortality rates.

Delays in seeking care for acute myocardial infarctions were greatest in Asian and Latino populations due to the fact that Latinos and Asians utilized private transportation rather than emergency ambulance services the majority of the time (70% for Latinos, 83% for Asians).

Kaiser Foundation research found that approximately 30% of Hispanics and 20% of Black Americans lack a usual source of healthcare compared with less than 16% whites. Blacks are 13% less likely to undergo coronary angioplasty and one third less likely to undergo bypass surgery than are whites. A study in Boston found that the quality of care for Blacks at non-teaching hospitals was lower than in teaching hospitals.

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The FCC adopted rules for Medical Body Area Networks (MBANs), with multiple body-worn sensors “MBAN” that monitor blood glucose, pressure monitoring, electrocardiogram readings, and even neonatal monitoring systems. The monitors can be used in the hospital setting, nursing facilities to identify life-threatening symptoms before they reach critical levels.

Under Part 95 of Medical Device “MedRadio” Service no application will be required to use body area networks

According to a study by the Institute for Healthcare Improvement, a monitored hospital patient has a 48% chance of surviving a cardiac arrest—this number plummets as low as 6% without monitoring.
 

The challenge has been security. FCC chairman Julius Genachowski told a press conference at George Washington University Hospital (GWUH) in Washington, D.C that the move would “represent a multi-industry effort to foster innovation in the spectrum band by allowing distinct but compatible users to share these airwaves.”FCC will permit a wireless electromagnetic spectrum, the 2.36-2.40 gHz band to be used with interference from WiFi transmissions or other wireless consumer devices and , hopefully, significantly reduce the risk of  hacking. 

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 Hassan Rasouli, previously diagnosed as being in a permanent vegetative state, has now been diagnosed to be in a minimally conscious state. The reason for the change - his physicians noted that he is able to give a thumbs-up when asked by his wife and able to track with his eyes. His physicians are Drs. Brian Cuthbertson and Gordon Rubenfeld, two critical care specialists at Sunnybrook Health Science Center in Toronto Canada, one of the largest trauma centers in Canada, who have petitioned the Canadian Supreme Court for the authority to withholding life sustaining treatment without the consent or approval of the patient’s wife and family and without the review and consent by the Canadian Consent and Capacity Board – as the law requires of them.

We now know that his doctors, who where adamant about terminally extubating him without the consent of the family, were wrong in their assessment that his was in a vegetative state was permanent, (assuming that it was a vegetative state to begin with). Not only did they want to extubate him without the consent of his wife and family, they also wanted to do so without review by an ethics committee, or Consent and Capacity Act of Canada that the law required of them, nor, most curiously, would they provide the Court with a copy of the Mr. Rasouli’s medical records. The doctors argue that no consent is needed because ending someone's life is "not treatment." In short, they wanted to proceed without any questions, oversight or ethically required transparency.

When questioned about this originally, Drs. Cuthbertson and Rubenfeld posited that if they were wrong, they would bear the responsibilities and consequences of their unilateral decision. This was a fatuous statement because if Rasouli was terminally extubated, there would be no evidence or basis to question their decision and thus impossible for them to be held responsible for anything.

In bringing this case to the Canadian Supreme Court they wish to set a precedent that any physician may terminally extubate without consent of the surrogate decision makers nor be subjected to any questions, oversight or ethically required required transparency.

In the United States it has been made clear by the courts, that the critical distinguishing factor between terminal extubation and physician assisted suicide or euthanasia is the patient’s clearly established rejection of artificial life sustaining treatment. Therefore, unambiguous documentation must make this clear. Only by being forthright about these factors can real transparency reflecting respect and dignity for the patient’s life truly exist. 

 In France, at the Centre Hospitalier Universitaire, Henri Mondor,  just outside Paris, they follow a standardized collective decision-making process, noting that “… terminal extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units.” They explain:

“This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting.

 The meeting's conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview.

At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision.” …

It is a fundamental right and requirement for a patient, to consent to terminal extubation, and only after all risks have been explained and all options presented. In the case of Hassan Rasouli his wife, as surrogate decision maker must consent,

It is this rejection of treatment that distinguishes respecting the patient’s decisions from assisting in a patient’s suicide.

Even in circumstances where consent has been given, physicians must be extremely reluctant and guarded to end a patient’s life, especially in cases where the patient is not suffering from a terminal disease. Surrogate decision makers often have an incentive, personally, emotionally and financially that may make their “consent” to the withdrawal of life sustaining treatment, suspect. 

Must consent to treat, as well as consent to withdraw treatment, be required?

None of this should be interpreted that Drs. Cuthbertson or Rubenfeld are acting in bad faith and do not have the interests of the patient as paramount. Whether or not that are mistaken in Mr. Rasouli's case does not mean that they will not be correct in the next hundred cases. The issue is whether on not consent is a prerequisite to ending someone's life. Stated otherwise, must consent to treat as well as consent to withdraw treatment required.

Wearing two hats is always dangerous - filled with conflict of interest. Drs. Brian Cuthbertson and Gordon Rubenfeld however, seem to want to wear two hats: deciding what the best medically and when it is best to end a patient’s life. Cuthbertson and Rubenfeld must have concluded that a patient’s personal beliefs – their personal life history and experiences, religious beliefs, and cultural customs should be subjugated to their personal beliefs. Yet, their expertise is as critical care physicians, not as oracles.  In areas other that critical care medicine they have no more ability than anyone else and should not hold sway over other peoples decisions.

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Dr. Nicola Riley is being held without bail in Utah following her arrest on December 28. 2011. She worked for Dr. Steven Brigham in New Jersey, who owns abortion clinics.   Both of them have been charged with the crime of murder for performing late-term abortions in Maryland. Their apparent modus operandi was to “start” abortions in New Jersey and complete them in Maryland where abortion laws are less stringent.

Maryland has a Fetal Homicide Law that permits murder charges to be brought against people who “intend to cause the death of a viable fetus, yet specifically excludes physicians carrying out abortions. Section 2-103(e)  Murder or manslaughter of viable fetus states:

Inapplicable to medical professionals administering lawful care. -- Nothing in this section subjects a physician or other licensed medical professional to liability for fetal death that occurs in the course of administering lawful medical care.

Reuters News reported on January 9^th that : Cecil County State's Attorney Ellis Rollins said the case could be the first of its kind to test Maryland's 2005 fetal homicide law, under which murder charges can be brought against people who intend to cause the death of a viable fetus. The charge of murder could only stand if the medical treatment – the abortion – was found to be unlawful medical care.

About 38 other states have similar statutes and for the most part, these statutes have been applied, as the legislature intended, in criminal cases where an intentional injury to a pregnant woman that kills a fetus would result in a charge for murder.

The cases against Drs. Riley and Bingham are seemingly intended to test the use of this statute in cases of abortion. This case is especially egregious, as 35 and 36 week term fetuses are alleged to have been found in the doctors’ freezer.

Charges include both first and second degree murder.

In 2003, the United States Congress passed the partial birth abortion ban act defining defined as any abortion where the death of the fetus occurs when the “entire fetal head or any part of the fetal trunk passed the naval is outside of the mother’s body.”

(a)    Any physician who…, knowingly performs a partial-birth abortion and thereby kills a human fetus shall be fined under this title or imprisoned not more than 2 years, or both.

In the 2007 case of Gonzalez versus Planned Parenthood, the United State Supreme Court in a five to four decision held that the congressional ban on partial birth abortion was not unconstitutionally vague and did not impose an undue burden on the right to have an abortion.

Under this federal statute, the penalty:

Any physician who, … knowingly performs a partial-birth abortion and thereby kills a human fetus shall be fined under this title or imprisoned not more than 2 years, or both.

It is unclear at this point what type of abortion was performed by Drs. Riley and Brigham. 

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On December 22, 2011, the Supreme Court of Canada agreed to hear the case of Cuthbertson and Rubenfeld versus Hassan Rasouli. The appellants, Drs. Brian Cuthbertson and Gordon Rubenfeld) are Mr. Rasouli’s physicians.

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The question before the court is whether physicians must seek approval from a legislatively created board of review before withdrawing a patient from life sustaining treatment. The statue was passed for a variety of reasons, including establishing a uniform standard of practice for the protection of patients across the country.

The review by the Consent and Capacity Board is only required if there is some objection by the surrogate decision maker. If the decision maker objects, he or she is required to follow principles of acting in the patient’s best interest as set forth in the “Health Care Consent Act.”  

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm

“...a health practitioner … may believe that the SDM (substitute decision maker) is not following these principles. If this happens, that person may apply to the board for a determination as to whether the principles have been followed and order to the SDM to comply with the act. Use of this application is limited to the health care provider of the incapable person (e.g. family members cannot apply to the board). Whenever an application of this type is received, the law provides that the patient is deemed to have applied for a review of his or her capacity to make the relevant decision…”

  Purpose of the Health Care Act:

  As a set forth in the appellate decision, the purpose of the Health Care Act is to establish rules that can be used consistently in all settings; provide and facilitate treatment, admissions, and other assistance for persons who lack capacity; and ensure a significant participation of family members when the person lacks capacity to make decisions.

The Consent and Capacity Board is an independent provincial tribunal created to adjudicate issues of consent in capacity and whether or not the substitute decision maker is acting  in accord with the patient’s wishes or in his or her best interest.

• There is no charge to the participants
• Any party may attend
• Family members and friends are also encouraged to attend.
• Each party may have a lawyer, call witnesses and bring documents. 
• Each party, and the board members, may ask questions of each witness. 
• Thereafter, the board meets in private to make a decision. 
• The board will issue its decision within one day.
• Written reasons will be issued if any of the parties request them.

Drs. Cuthbertson and Rubenfeld argue that the patient is in a persistent vegetative state and other physicians have examined Mr. Rasouli and agreed with this assessment. 

They want to take him off life support and provide palliative care until he dies.

The decision maker argues that he is minimally conscious and remains aware of his surroundings and that if the physicians do not want to follow her wishes that they should apply to the Consent and Capacity Board and let the board decide whether the proposed course of action is in the respondents best interest. 

A three day hearing was held in the Canadian Superior Court of Justice in February and March of 2011. The court found in favor of the respondent (Rasouli) and against the appellants Cuthbertson and Rubenfeld. 

The court ordered that the question of continued life sustaining treatment must be referred to the Consent and Capacity Board, and, pending that decision the physicians were not permitted to withdraw or withhold life sustaining treatment nor place the patient in palliative care.

Rather than doing so, Cuthbertson and Rubenfeld brought their case to the Court of Appeals (Court of Appeal for Ontario, original case Rasouli versus Sunnybrook Health Science Center, 2011 docket number C53442).

Indeed, if they are wrong the patient will be dead.

Cuthbertson and Rubenfeld make two arguments to avoid compliance with the law:

1.  “…if it is found that their decision to withhold or withdraw treatment falls below the requisite standard of care, they may be held accountable.” (Page 7 of the appellate decision). Indeed, if they are wrong the patient will be dead. The standard as set for the by the Canadian legislature, is to seek approval from the Board. The legislation protects physicians from being held liable:

If a treatment is withheld or withdrawn in accordance with a plan of treatment and with a consent to the plan of treatment that a health practitioner believes, on reasonable grounds and in good faith, to be sufficient for the purpose of this Act, the health practitioner is not liable for withholding or withdrawing the treatment.

2.         Cuthbertson and Rubenfeld argue that withdrawing life sustaining care and prescribing a shift to palliative care is not “treatment” and that, therefore, no consent is needed to withdraw life sustaining care. Putting Mr. Rasouli on life support was a treatment decision and taking him off life support is a treatment decision, just as much as prescribing a medication for a patient and stopping the medication because it is not working.

Part 2 of this article will discuss the relevant ethical basis, legal reasoning and competing moral viewpoints.  

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