MedicalFu+lityDisputeResolu+onOp+onsintheUnitedStates:Law&EthicsFundamentals
ICEL2(HalifaxNS),Sept.15,2017
ThaddeusMasonPope,JD,PhD MitchellHamlineHealthLawIns5tute
2
Whatisamedicalfu+litydispute
SurrogatewillnotconsentwhenMDthinkstheyshould
Fu5lityisaboutlinedrawing
Inappropriate Appropriate
Inadvisable Advisable
Disproportionate Proportionate
Non-beneficial
Beneficial
Outside the standard of care
Inside the standard of care
Therapeutic obstinacy
Surrogatedrivenovertreatment
Surrogate
LSMT
Clinician
CMO
SurrogatewillnotconsenttoCMOrecommenda5on
14
Whenmay/should/mustaclinicianstopLSMTwithoutconsent?
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
Categoriesoutlinedinanewmul5-societypolicystatement
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
Interven5onscannotaccomplishphysiologicalgoals
Scien5fic
impossibility
An5fungalsastreatmentformyocardialinfarc5on
• Cptrigormor5s
CPRwhenshowrigormor5sordependentlividity
Valuefree
objec5ve
37
MaytheclinicianstopLSMT?
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
LegallyProscribed
Treatmentsthatmayaccomplisheffectdesiredbythepa5ent
Prohibitedbyapplicablelaws,judicialprecedent,orwidelyacceptedpublicpolicies
Might“work”
Butillegal
Iftreatmentrequestislegallyproscribedà
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
LegallyDiscre+onary
Laws,judicialprecedent,orpoliciesthatgivephysicianspermissiontorefusetoadministerthem.
Appropriatemedicine
Surrogate
• Pics5nson• PicothersSFKYetc• Clickclickclick
IsraelS+nson
Trisomy18/23
22-weekgesta5on
ECMO
Not5-societystatement“fu5lity”
MightrestoreCPfunc5on
“imminentdeath”
3daysh^p://healthvermont.gov/regs/ad/dnr_colst_instruc5ons.pdf
78
MaytheclinicianstopLSMT?
Legallydiscre5onary
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
Poten+allyInappropriate
Somechanceofaccomplishingtheeffectsoughtbythepa5entorsurrogate
Not“fu5le”becausemight“work”
E.g.dialysisforpermanentlyunconsciouspa5ent
E.g.ventforpa5entw/widelymetasta5ccancer
Wecallthem“fu5litydisputes”
...BUT...
Disputedtreatmentmightkeeppa5entalive.
But...isthatchanceorthatoutcomeworthwhile
Notamedicaljudgment
92
MaytheclinicianstopLSMT?
95
Still no consent
Lastresort
Notresponsiveinanycase
Op+onswhenintractablePITconflicts
199
Replacesurrogate
SDMstepsintoshoesofpa+ent
Hierarchy1. Subjec5ve2. Subs5tuted
judgment3. Bestinterests
2105
Greenlights
StopLSMTwithoutconsent
PhysicianmaystopLSTwithoutconsentforanyreason,ifreviewcommi^eeagrees
Givethesurrogate
48hrno5ceRC
Wri^endecisionRC
10daystotransfer
A^emptstoCOPYTexas
116
NotchangenatureNarrowscope
117
H.B.3074(2015)
ar5ficiallyadministerednutri5on&hydra5on
119
S.B.11(2017)
Consentalways
124
Nondiscrimina5oninTreatmentAct
November2013
“healthcareprovidershallnotdeny...life-preservinghealthcare...directedbythepa5entor[surrogate]”
MedicalTreatmentLawsInforma5onAct
November2014
“Ifsurrogatedirects[LST]...providerthatdoesnotwishtoprovide...shallnonethelesscomply....”
131
Discrimina+on
inDenialof
LifePreserving
TreatmentAct
132
“Healthcare...maynotbe...deniedif...directedby...surrogate” 133
DNRwithoutparents’consentorknowledge
137
“Nohealthcare...staffshallwithhold,withdraworplaceanyrestric5onsonlife-sustainingmeasuresforany...under18yearsofagewithoutthewrifenpermission....”
142
ThaddeusMasonPope,JD,PhDDirector,HealthLawIns5tuteMitchellHamlineSchoolofLaw875SummitAvenueSaintPaul,Minnesota55105T651-695-7661C310-270-3618EThaddeus.Pope@mitchellhamline.eduWwww.thaddeuspope.comBmedicalfu5lity.blogspot.com