Tag Archives: Withdrawal/Withholding of Care

Exploiting despair – the death of Jahi McMath Brain Death

With the onslaught of media coverage of the Jahi McMath case it is time for a public debate on whether or not the loss of upper and lower brain function should determine death.  Brain death is the cessation of any brain activity in the upper brain as well as the lower brain or brain stem. The McMath case should be distinguished from the Terri Schiavo case where only upper brain function was in question. Ms. Schiavo was not determined to be brain dead, but rather a living person in a persistent vegetative state. Brain death is established by numerous objective…

Making Choices Withdrawal/Withholding of Care

New Year resolutions are sometimes easy to make but hard to keep. Resolutions are choices, choices to live on and to better ourselves. For patients who are critically ill, resolve is often in short supply.  So, to physicians reading this I ask that one of your resolutions this coming year is to speak with patients about their end of life choices and help other physicians do the same. Many physicians are either reluctant to broach the subject, or not very good at discussing these issues, or both. Many feel that they will “cross that bridge when they get to it,”…

The Problem with POLST – Physician Orders for Life-Sustaining Treatment Autonomy

The Problem with POLST Over the years, informed consent has been given short shrift. There is, however, a growing understanding of the importance of obtaining an actual and legitimate consent before  having a patient accept or reject medical treatment. Autonomy, transparency, respect, dignity, and other similarly recognized human rights are increasingly recognized as legal and ethical requirements. “POLST” (Physician Orders for Life-Sustaining Treatment) however, makes it easy and even inviting to avoid these requirements with the stroke of a pen on a conclusionary form. POLST only makes sense in cases of patients with terminal illnesses, in end stage disease with no…

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 – Rasouli Decision: We don’t need permission to withdraw life sustaining care Court Intervention in Medical Decision Making

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.    . 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…

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…

Withdrawing Life Sustaining Treatment – End of Life Care: the Doctor-Patient Relationship A Refusal to Communicate Clinical Bioethics

The New England Journal of Medicine recently published an article entitled: “ The Palliative Care Information Act in Real Life,” (NEJM 364;No.20 May 2011), regarding a New York statute that requires a physician to have discussions of end of life treatment options with the patient when the patient is “terminally ill.” Alan Astrow MD and Beth Popp, MD, the authors of the article, are troubled by the phrase terminal illness. They argue that the definition in the statute is vague and an improper interference with the physician-patient relationship. The fact that they find the phrase, “terminal illness” troublesome, is troublesome. The…

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…

Letting the Conscious Non-Terminal, Incompetent, Patient Die: Hold On a Minute – Not So Fast – Part I Withdrawal/Withholding of Care

It is an injustice to cause patients to unnecessarily prolong the process of dying. Actual futile care must be avoided. But it is equally an injustice to easily acquiesce to patient’s demands that my result in unnecessary death. On August 17, 2010 the Supreme Court of Pennsylvania decided a case involving a non-terminal, profoundly mentally retarded patient. The patient was conscious and non-terminal. David is 53 years old. David’s parents were the guardians. His parents argued that putting him on the ventilator was not in his best interest and requested terminal extubation. The hospital refused. After several weeks his condition…