Ethics in Internal Medicine

Ethics at the End of LifeRichard L. Elliott, MD, PhDProfessor of Psychiatry and MedicineDirector, Medical EthicsMercer University School of MedicineAdjunct ProfessorMercer University School of LawTopicsPsychiatryMedicinePediatricsObstetrics and -GynecologyFamily MedicineSurgeryEmergency medicineYou are a recently graduated internal medicine attending at Sacred Heart Medical Center. A 21-year-old young woman is brought to the ER. She had been found not breathing in her apartment by her roommates, was resuscitated by paramedics. Toxicology was positive for alcohol and diazepam. She is unable to breathe on her own and is placed on a ventilator. After several months she has not regained consciousness and her parents request she be extubated. Ask about advance directives, expression of wishes regarding ventilator, get ethics committee consultation3Determine prognosis for recoveryAsk about advance directives, expression of wishes regarding ventilatorsAsk the medical director about relevant policies and proceduresRequest an ethics committee consultation

A neurology consultation determines your patient to be in a persistent vegetative state, and the prognosis for recovery is very smallThe medical director informs you that Sacred Heart does not condone removal of ventilators unless patients are brain deadThe parents continue to insist on extubation Attempt to transfer the patientTell the parents the hospital will pick up the costs of care if the patient remains intubated, but that the cost will be borne by the parents if they attempt to force extubation by legal meansAn accepting hospital is not found. The case is heard by the state supreme court, which decides in favor of the parents request.

On what grounds might the court base its decision?Right to privacyPatient autonomy as delegated to surrogate decisionmakersHaving received the court order, you decide to:Stop the ventilator immediately after notifying the parentsWean the patient from the ventilatorAfter being weaned from the ventilator, the patient survives another 10 years in a persistent vegetative state, succumbing eventually to an infectionWho was this woman?

Karen Ann Quinlan 1954-1985 Right to Die Cases1965 Griswold v. Connecticut1973 Roe v. Wade1975 Karen Quinlan1990 Nancy Cruzan1994 Oregons Death with Dignity Act1997 US Supreme Court Quill, Washington2004 Terri Schiavo

Griswold v. Connecticut1965, Griswold v. ConnecticutPlanned Parenthood League of Connecticut1961, gave advice and prescriptions to married couples for purposes of contraceptionConnecticut law forbade such practiceUS Supreme Court found Right to privacy exists within the penumbra of constitutional rightsKaren Quinlan1975, New JerseyAlcohol and ValiumPersistent vegetative state, ventilatorFamily wanted ventilator removedHospital, AMA, attending physicians disagreedNew Jersey Supreme Court: right to privacyDied 10 years later15Pence: Classic Cases in Medical Ethics. Karen Ann Quinlan, just turned 21, left her adoptive parents house against their wishes, moved in with two male roommates. Described her friends as a wild free spirit, she took drugs (cocaine, heroin,methadone). A few nights after moving out she went to a friends birthday party at a local bar. She felt faint, probably after several drinks taken with Valium. She was taken back to her apartment where she went to sleep. Fifteen minutes later she was noted to have stopped breathing. An ambulance was called and she was resusitated, but did not regain consciousness. She was placed on a ventilator, and was in a PVS not brain dead (had slow wave activity), but had disconjugate eye movements. PVS not a term in use at that time. Also on a feeding tube. Less than 1 in a million chance of recovery. Placed in ER so staff could watch for vomiting. Body emaciated, severe contractures. Two doctors (pulmonologist and neurologist) just out of training, fearful of suit, opposed fathers request to remove her from ventilator. Attorney for father failed to pursue guardianship, instead raised issue of Karens right to die. The New Jersey Supreme Court ultimately upheld right of father to decide for Karen, based on her right to privacy. The physicians opposed the decision and weaned Karen off the ventilator. She died in 1986.Nancy Cruzan1983, MissouriMotor vehicle accident, PVSParents argued for feeding tube removalMissouri Supreme Court: evidence for Nancy Cruzans wishes did not meet clear and convincing standard1990 US Supreme Court: requiring evidence of patients wishes by clear and convincing not unconstitutional and right of a competent patient to refuse medical treatment (right to die)Patient Self-Determination Act 1990Patients are given written notice upon admission to the health care facility of their decision-making rights, and policies regarding advance health care directives in their state and in the institution to which they have been admitted. Patient rights include:The right to facilitate their own health care decisionsThe right to accept or refuse medical treatmentThe right to make an advance health care directiveFacilities must ask whether the patient has an advance health care directive, and make note of this in their medical records.Facilities must provide education to their staff and affiliates about advance health care directives.Health care provides not allowed to discriminately admit or treat patients based on whether they have an advance health care directive.http://academic.udayton.edu/LawrenceUlrich/315psdame.htm1. Patient self-determination act of 1990, sections 4206 and 4751 of Omnibus Reconciliation Act of 1990, Pub L No. 101-508 (November 5, 1990). "SEC. 4206. MEDICARE PROVIDER AGREEMENTS ASSURING THE IMPLEMENTATION OF A PATIENT'S RIGHTS TO PARTICIPATE IN AND DIRECT HEALTH CARE DECISIONS AFFECTING THE PATIENT. "[The Patient Self-Determination Act applies] in the case of hospitals, nursing facilities, home health agencies, and hospice programs, . . . and a provider of services or prepaid or eligible organization [to] maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization ------ (A) to provide written information to each such individual concerning ------ (i) an individual's rights under State law (whether statutory or as recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives . . . and (ii) [to provide] the written policies of the provider or organization respecting the implementation of such rights; (B) to document in the individual's medical record whether or not the individual has executed an advance directive; (C) not to condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive (this shall not be construed as requiring the provision of care which conflicts with an advance directive); (D) to ensure compliance with requirements of State law (whether statutory or as recognized by the courts of the State) respecting advance directives at facilities of the provider or organization (this shall not be construed as prohibiting the application of a State law which allows for an objection on the basis of conscience for any health care provider or an agent of such provider which as a matter of conscience cannot implement an advance directive); and (E) to provide (individually or with others) for education for staff and the community on issues concerning advance directives. . . . The written information . . . shall be provided to an adult individual ------ (A) in the case of a hospital, at the time of the individual's admission as an inpatient, (B) in the case of a skilled nursing facility, at the time of the individual's admission as a resident, (C) in the case of a home health agency, in advance of the individual coming under the care of the agency, (D) in the case of a hospice program, at the time of initial receipt of hospice care by the individuals from the program, and (E) in the case of an eligible organization . . . or an organization provided under [medicare or medicaid] at the time of enrollment of the individual with the organization. . . . the term 'advance directive' means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provision of such care when the individual is incapacitated." 2. The right to refuse treatment will be more fully explored in section five of chapter six. Its constitutionality was first established in Quinlan (cf. In re Quinlan. 70 N.J. 10, 355 A.2d 647 (1976)) based on the right to privacy and has been reiterated by many state courts on the same basis. On the federal level the right to refuse treatment was upheld in Cruzan (cf. Cruzan v. Director, Missouri Department of Health. 110 S.Ct. 2841 (1990)) on the basis of the liberty interest of the 14th amendment. Subsequent to the Patient Self-Determination Act, the right to refuse treatment has been emphatically upheld once again in Vacco v. Quill (cf. Vacco v. Quill. 117 S.Ct. 2293 (1997)) on the same basis as it was in Cruzan. 3. Lidz CW et al. Two models of implementing informed consent. Arch Intern Med 1988;148:1385-1389. 4. Berman v. Allen. 80 N.J. 421, 404 A.2d 8 (1979). 5. Canterbury v. Spence. 464 F.2d 772 (D.C.C.A. 1972). 6. Schloendorff v. Society of New York Hospital. 211 N.Y. 125, 105 N.E. 92 (1914). Cf. also Katz J. Informed consent in the therapeutic relationship: legal and ethical aspects. In Reich WT. Encyclopedia of Bioethics. New York: The Free Press, 1978, pages 770-778. 7. Meisel J, Kuczewski M. Legal and ethical myths about informed consent. Arch Intern Med 1996;156:2521-2526. 8. This examination began with Quinlan (Cf. In re Quinlan. 70 N.J. 10, 355 A.2d 647 (1976)) and culminated in Cruzan (Cf. Cruzan v. Director, Missouri Department of Health. 110 SCt. 2841 (1990)). 9. In re Dinnerstein. 6 Mass. App. Ct. 466, 380 N.E.2d 134 (App. Ct. 1978). 10. Cf. In re Quinlan. 70 N.J. 10, 355 A.2d 647 (1976) and Cruzan v. Director, Missouri Department of Health. 110 SCt. 2841 (1990). 11. In re Eichner (In re Storar). N.Y., 420 N.E.2d 64 (1981).

17Nancy Cruzan Today?What if, after two years of tube feeding and no change in mental status, her physicians approached the parents with the request that her feeding tube be withdrawn, and the parents insisted that Nancy be kept alive whatever it takes?What might you consider?Obtain consultation to verify futility of careConsult with family about expectations for continued careApproach the parents again after a month or so with the request and an explanation of her prognosisSpeak with someone they trust about explaining her situation and making the requestRequest an Ethics Committee consultation to involve attending, medical team, family, administrationAttempt to mediate based on Ethics Committees findingsGive family opportunity to transfer the patientAsk medical director for adviceSeek legal counselFutility of Care PolicyNot currently available in most hospitalsNon-emergent situations usuallyContinued care is futile per consultant for functional improvementCentral elements to policy:Consultations with staff. Family, ethicistsMediation at least twiceTransfer if no resolutionA 54-year-old woman with terminal ALS approaches you with a request for something to ease me out. She would like to say her goodbyes, but breathing has become so difficult she cannot bear to live gasping much longer.What should you do?Physician-Assisted SuicideLegal in three statesOregon and Washington by statuteMontana Supreme Court ruled not illegal for physicians to prescribe lethal doses of medication to patients (Baxter v Montana)Oregons Death with Dignity ActPassed 1994 51-49 %After US Supreme Court rulings in 1997, opposition from Oregon medical Association, Catholic Church, legislature repealed ActVoters re-passed Act in 1998, 60-40 %Act requires: clearly competent patient; less than six months to live confirmed by second MD; 15 day waiting period after request; MD prescribes lethal dose, does not administer1997 U.S. Supreme CourtQuill v. VaccoWashington v. GlucksbergNew York and Washington states passed laws banning physician-assisted suicidesUS Supreme Court:No constitutional right to physician-assisted suicideLaws banning physician-assisted suicide are not unconstitutionalGonzalez v OregonChallenged Oregons Death with Dignity Act "Whether the Attorney General has permissibly construed the Controlled Substances Act, and its implementing regulations to prohibit the distribution of federally controlled substances for the purposes of facilitating an individual's suicide, regardless of a state law purporting to authorize such distribution.Court ruled 6-3 in 2006 that Gonzalez had acted impermissiblyThus the Death with Dignity Act could be implementedAMA and Code of Ethics IE-2.211 Physician-Assisted Suicide.

Physician-assisted suicide occurs when a physician facilitates a patients death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).

AMA and Code of Ethics IIIt is understandable, though tragic, that some patients in extreme duress--such as those suffering from a terminal, painful, debilitating illness--may come to decide that death is preferable to life. However, allowing physicians to participate in assisted suicide would cause more harm than good. Physician assisted suicide is fundamentally incompatible with the physicians role as healer, would be difficult or impossible to control, and would pose serious societal risks.AMA and Code of Ethics IIIInstead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling and other modalities. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.Review1976 Karen Ann Quinlan, Right to Die1990Nancy Cruzan, Patient Self-Determination ActWithdrawing Medical Treatment1973 - Roe v. WadeRight to privacyKaren Quinlan1975, New Jersey Removal of ventilatorNancy Cruzan1983, MissouriRemoval of feeding tubeTerri SchiavoFlorida, Terris Law struck down 10/04Elizabeth Bouvia1985, CaliforniaCerebral palsy, college degreeWanted to stop eating and dieHospital force fedCalifornia Court of Appeals: A desire to terminate ones life is probably the ultimate exercise of ones right to privacy.