Tag: advance directives

Bioethics News

Taking Patient Autonomy out of the DNR

The law is part of an attempt to by the right-to-life movement in Texas to roll back the advance directives act, especially the futility provision.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Jewish Guide to Practical Medical Decision Making

Check out
this new 368-page
book
 from Rabbi Jason Weiner: Jewish Guide to Practical
Medical Decision Making.


Due to rapid advances in the medical field, existing books on Jewish medical
ethics are quickly becoming outdated. 
Jewish
Guide to Practical Medical Decision Making
 seeks to remedy that by
presenting the most contemporary medical information and rabbinic rulings in an
accessible, user-friendly manner. 


Rabbi Weiner addresses a broad range of medical circumstances such as surrogacy
and egg donation, assisted suicide, and end-of-life decision making. Based on
his extensive training and practical familiarity inside a major hospital, Rabbi
Weiner provides clear and concise guidance to facilitate complex
decision-making for the most common medical dilemmas that arise in contemporary
society.


1. Facilitating Shared Decision-Making 

A. Understanding Terminology: Key Concepts to Facilitate
Collaborative Decision-Making

B. Truth-Telling: When Painful Medical Information Should
and Should Not Be Revealed 

C. Mental Illness: Determining Capacity and Proper Treatment
in Accordance with Jewish Law  


2. How Much Treatment? 

A. Risk and Self-Endangerment: Determining the
Appropriateness of Attempting Various Levels of Dangerous Medical Procedures

B. Making Decisions on Behalf of an Incapacitated Patient

C. Pediatrics: Jewish Law and Determining a Child’s Consent
and Treatment 

D. Palliative Care and Hospice in Jewish Law and Thought


3. Prayer  

A. Is Prayer Ever Futile? On the Efficacy of Prayer for
the Terminally Ill 

B. Viduy: Confessional Prayers Prior to Death


4.  At the End of Life

A. Advance Directives and POLST Forms  

B. End-of-Life Decision-Making: DNR, Comfort Measures,
Nutrition/Hydration, and Defining “Terminal” in accordance with Jewish Law

C. Withholding vs. Withdrawing: Deactivating a
Ventilator and Cessation of Dialysis and Cardiac Defibrillators at the End of
Life

D. Case

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Texas Advance Directives Act – Broad Alliance Files Amicus Brief Defending TADA Constitutionality

Kelly v Methodist Hospital challenges the constitutionality of the Texas Advance Directives Act. The case is getting ready for trial in Harris County District Court.


At the end of July, a broad alliance submitted a 28-page amicus brief on behalf of the defendant. The amici include:

  • TEXAS ALLIANCE FOR LIFE
  • TEXAS CATHOLIC CONFERENCE OF BISHOPS
  • TEXAS BAPTIST CHRISTIAN LIFE COMMISSION
  • TEXANS FOR LIFE COALITION
  • COALITION OF TEXANS WITH DISABILITIES
  • TEXAS ALLIANCE FOR PATIENT ACCESS
  • TEXAS MEDICAL ASSOCIATION
  • TEXAS OSTEOPATHIC MEDICAL ASSOCIATION
  • TEXAS HOSPITAL ASSOCIATION
  • LEADINGAGE TEXAS

I will make just two observations about the brief.


1.  The amici argue that there is no state action, because clinician and hospital use of TADA is completely voluntary. They may but need not use TADA. On the other hand, the amici concede that similar process based approaches in other states “had little practical effect” because of the threat of liability. Consequently, they concede that TADA’s provision of safe harbor immunity really did change clinician and hospital behavior. Texas clinicians and hospitals would not withdraw life-sustaining treatment without consent BUT FOR the immunity conferred by TADA.


2.  Since the 1970s, numerous appellate courts (e.g. Quinlan) have held that all sorts of medical treatment issues can and should be handled by hospital committees. But these judicial opinions are very clear that conflicts and disputes should still go to court. Since TADA authorizes hospital review committees to adjudicate life and death disputes, these committees are exercising a judicial function. That is state action sufficient to make constitutional requirements apply to private hospitals like Methodist Houston.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Many Still Sidestep End-Of-Life Care Planning, Study Finds

For the analysis, published in the July issue of Health Affairs, researchers reviewed 150 studies published from 2011 to 2016 that reported on the proportion of adults who completed advance directives, focusing on living wills and health care power-of-attorney documents

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

End-of-Life Healthcare Sessions at ASBH 2017

The 2017 ASBH
conference
 in October 2017 includes over 400 workshops, panels, and
papers in bioethics and the health humanities.  Here are ones that pertain
to end-of-life issues.


THURSDAY, OCTOBER 19


THU 1:30 pm:  End-of-Life Care and Decision-Making in the ICU – Limited
English Proficiency as a Predictor of Disparities (Amelia Barwise)


Importance: Navigating choices in predominantly English-speaking care settings
can present practical and ethical challenges for patients with limited English
proficiency (LEP). Decision-making in the ICU is especially difficult and may
be associated with disparities in health care utilization and outcomes in critical
care. 


Objective: To determine if code status, advance directives, decisions to limit
life support, and end-of-life decision-making were different for ICU patients
with LEP compared to English-proficient patients. 


Methods: Retrospective cohort study of adult ICU patients from
5/31/2011-6/1/2014. 779 (2.8%) of our cohort of 27,523 had LEP. 


Results: When adjusted for severity of illness, age, sex, education, and
insurance status, patients with LEP were less likely to change their code
status from full code to do not resuscitate (DNR) during ICU admission (OR,
0.62; 95% CI, 0.46-0.82; p


Conclusion: Patients with LEP had significant differences and disparities in
end-of-life decision-making. Interventions to facilitate informed
decision-making for those with LEP is a crucial component of care for this
group.


THU 1:30 pm:  “But She’ll Die if You Don’t!”: Understanding and
Communicating Risks at the End of Life (Janet Malek)


Clinicians sometimes decline to offer interventions even if their refusal will
result in an earlier death for their patients. For example, a nephrologist may
decide against initiating hemodialysis despite a patient’s rising creatinine
levels if death is expected within weeks even with dialysis.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Hard lessons: learning from the Charlie Gard case

by Dominic Wilkinson and Julian Savulescu

 

On the 24th July 2017, the long-running, deeply tragic and emotionally fraught case of Charlie Gard reached its sad conclusion (Box 1). Following further medical assessment of the infant, Charlie’s parents and doctors finally reached agreement that continuing medical treatment was not in Charlie’s best interests. It is expected that life support will be withdrawn in the days ahead.

Over the course of multiple hearings at different levels of the court in both London and Strasbourg, the Charlie Gard case has raised a number of vexed ethical questions (Box 2). The important role of practical ethics in cases like this is to help clarify the key concepts, identify central ethical questions, separate them from questions of scientific fact and subject arguments to critical scrutiny. We have disagreed about the right course of action for Charlie Gard,1 2 but we agree on the key ethical principles as well as the role of ethical analysis and the importance of robust and informed debate. Ethics is not about personal opinion – but about argument, reasons, and rational reflection. While the lasting ramifications of the case for medical treatment decisions in children are yet to become apparent, we here outline some of the potential lessons.

1. Parents’ role in decision-making for children: We need to clarify harm

Much of the media attention to the Gard case has focussed on the rights of parents in decision-making for children, and whether the intervention of the courts in this case means that doctors frequently overrule parents in the UK.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Burke, Briggs and Wills: Why we should not fear the judgment in Charlie Gard

In a blog post today, Julian Savulescu argues that in a parallel adult version of the highly controversial Charlie Gard case, a UK court might thwart an unconscious patient’s previously expressed desire for self-funded experimental medical treatment. He finds the Gard decision deeply disturbing and suggests that we all have reason to fear the Charlie Gard judgment.

I respectfully beg to differ.

Julian’s thought experiment of the billionaire ‘Donald Wills’ is not analogous to the real Charlie Gard case, his analysis of the UK legal approach to best interests cases for adults is potentially mistaken, his fear is misplaced.

Wills and Gard

Thought experiments are an important tool in philosophy and medical ethics. They enable us to analyse our intuitive responses to ethical questions. Comparing parallel cases – for example as James Rachels did in his now famous 1975 paper ‘Active and Passive Euthanasia’ – can helpfully identify factors that are relevant to ethical analysis, as well as factors that aren’t relevant. However, like scientific experiments, thought experiments need to be carefully designed. Otherwise they can mislead.

Julian imagines a wealthy adult patient, Donald Wills, who has a rare mitochondrial illness very similar to Charlie Gard. While Wills’ wife has identified a potential treatment and requested that he be transferred overseas for an experimental treatment, the imaginary court, in a decision parallel to the Gard case, finds that this treatment would not be in Donald’s best interests. The judge denies the request and Donald’s treatment is withdrawn.

However, in a divergence from the Gard case, Julian tells us that Wills

“wishes to live as long as possible.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Chris Dunn – Careful Use of TADA Medical Futility Dispute Resolution

While the Chris Dunn lawsuit against Houston Methodist questions the very constitutionality of the Texas Advance Directives Act, it is worth noting that the hospital does appear to have employed the TADA dispute resolution mechanism carefully.


For example, a review of the affidavits by Cheney and Moore shows a number of family meetings before the process was formally invoked.  Later, when looking for a transfer, Houston Methodist contacted more than 60 other facilities.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Kelly v. Houston Methodist Hospital – Trial on TADA Constitutionality

I (and others) have written about the constitutionality of the Texas Advance Directives Act for years.  Now, for the first time, a court case may actually reach the question.  Trial is scheduled to begin in Kelly v. Houston Methodis…

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.