Tag Archives: Dilemmas in Clinical Bioethics

Waiting to Speak – Waiting for the Surrogate to Speak Withdrawal/Withholding of Care

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…

Withdrawing Life Sustaining Treatment – Early Withdrawal of Life Sustaining Treatment in Severe Traumatic Brain Injuries, by Bernard W. Freedman JD, MPH Clinical Bioethics

CDC Statistics Traumatic Brain Injuries On August 29, 2011 the Canadian Medical Association published the findings of a multicenter cohort study evaluating the withdrawal of life-sustaining treatment for patients who had suffered a traumatic brain injury. This study is of particular interest because by the nature of the injury  patients cannot make decisions for themselves and generally such decisions in patients in end-of-life care have a variety of comorbidities which make an evaluation of the efficacy of the decisions to withdraw life sustaining care difficult. 720 patients were evaluated from six different major medical centers. Of the 720, 228 patients…

Rationing “scarce medical resources” and lying to the patient – do these go hand in hand? Clinical Bioethics

Rationing “scarce medical resources” and lying to the patient – do these go hand in hand? 7 comments Claudia Ruiz M.D • I don’t think so, I’m from Mexico, and I have worked plenty with the mayan communities, they really don’t have any acces to medicines o medical attention. We did our best to get them what they need, but sometimes it is impossible. Anyways, I never lie to my patients, they deserve to know the truth always. Maybe it is a different situation in the United States and the HMOs, but in principle, I don’t think it is ethical…

Rationing Medical Care Part II Clinical Bioethics

Efforts to encourage (or compel) physicians to lie to their patients were faced years ago when “gag clauses” were inserted into contracts between HMO’s and contracted physicians. The gag clause established a contractual obligation on the part of the physician to withhold information regarding treatment modalities that were not within the HMO protocol of allowable categories of care.  Contractually, it is common to exclude specific types or categories of care – “We will pay for this, we won’t pay for that.” Every contract of insurance has exclusions. Gag clauses, however, go further. They contractually bar physicians from fulfilling their fiduciary duties…

Clinical Bioethics – Rationing – the Ethics of Lying to the Patient – Part I Clinical Bioethics

Rationing : Withholding Medical Care by Lying to the Patient Rationing of medical care and “triage” are different. Triage prioritizes the use of limited medical resources when resources are insufficient for immediate treatment.  Rationing is the withholding of available care for political/economic reasons. With respect to rationing, therefore, it must be decided whether or not the patient is going to be told the truth. The requirement of informed consent cannot cease to exist because of political/economic policy. Nevertheless the degree of informed consent may vary with the degree and type of risk. Informed consent for a blood pressure medication may…

Withdrawing Life Sustaining Treatment -From Conscious, Non Terminal, Incompetent Part II Withdrawal/Withholding of Care

Physician Liability: Withdrawing and Withholding Life Sustaining Care From  Conscious, Non Terminal, Incompetent Patients – Part II There are different standards that must be appreciated and respected before a physician can support a decision to withdraw life sustaining treatment from a non terminal and incompetent patient. This scenario requires the highest degree of protection for the patient. Our fundamental rights are the most important when we are the most vulnerable. Patients in this category are weak, often confused and subject to the effect of bias and undue influence. When illness requires life sustaining treatment family members may experience sympathy for…

Survival in Hospital Cardiac Arrest – Challenges for Hospitalists Bioethics Conflicts

The September 2010 publication of “The Hospitalist” reviews the overall survival rates for cardiac arrest patients. This article reports that patients frequently have unrealistic expectations and overestimate their chances of survival. Patients predict post-arrest CPR survival at 64%, while the rate is 17%. Most important is that in nearly half of the patients who initially expressed the desire for CPR, once they were informed of the actual estimates, they changed their minds and code status was changed. It is difficult for many hospitalists to discuss DNR orders with patients. There is not a trusting relationship formed over time. Therefore it is…

Withdrawing Life Sustaining Treatment – Betancourt v Trinitas – Appellate Court Decision Bioethics Conflicts

The New Jersey Superior Court–Appellate Division dismissed the appeal in Betancourt v Trinitas finding the appeal moot. The court stressed it’s concern over the  “sparse record” presented at the time of  the original hearing in the trial court as well as on appeal and found that the evidence was not “conclusive in several areas necessary to fully adjudicate the substantial issues raised.” This is sometimes referred to as insufficiency of evidence. If the person or entity bringing the case does not provide sufficient evidence the court will dismiss the claim. In this case Tinitas Hospital’s request to withdraw the ventilator….

Mandated Insurance Coverage for Phase I and II Clinical Trials Clinical Bioethics

At present the Missouri State Senate is considering new legislation (SB 365), which means to provide health insurance coverage for Phase I and Phase II clinical trials for cancer treatment. The law in the state of Missouri presently limits mandated insurance coverage to Phase III and Phase IV clinical trials. Aside from the fact that this bill makes no sense whatsoever, it highlights the ignorance of what Phase I or Phase II trials are intended to accomplish. SB 365 seeks to force insurers, non profit health services plans, or health maintenance organizations to treat Phase I and II trials as if…

New York will pass the Family Health Care Decisions Act Withdrawal/Withholding of Care

 It has been 17 years since this bill was first introduced.   The New York State Senate will pass the Family Health Care Decisions Act (FHCDA), setting forth clear guidelines for family members and others close to the patient to make medical decisions for incapacitated patients. It will also provide physicians with uniform protocols to follow. In many instances there will continue to be confusion and concern for the rights of the patient. Diligent and thoughtful efforts will be needed to apply these guidelines properly. The following are some of the important points for clinicians:   If there is disagreement about…