AINB Ethics in Life Sustaining Treatments Discussion

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PHHE 435/535 Ethical Decision Making for Health Professionals Module 7A Life Sustaining Treatments Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Objectives • Life saving – moral dilemmas • Identify components of ethical analysis • Written case brief Life Sustaining Treatments • Not restoration • Not meant to be a cure Photo Credit: Zdenko Zivkovic • Prolong patient’s life 1 Life Sustaining Treatments • Ventilator – Enable to live longer with the disease Life Sustaining Treatments Photo Credit: Gr8what • Dialysis Life Sustaining Treatments Photo Credit: Georgina Eltonten • Surgery 2 Life Sustaining Treatments • When is it reasonable to employ life-sustaining treatments? • When is not reasonable…? Life Sustaining Treatments Photo Credit: Lucas Kerper • Technology to support respiration when spontaneous respiration is no longer possible Life Sustaining Treatments Photo Credit: Jeffrey • Life saved – creates moral dilemmas 3 Life Sustaining Treatments • Ordinary or extraordinary medical treatment? Photo Credit: KagedFish • Ambiguous Life Sustaining Treatments • Enables a person with medical problem to breath Photo Credit: Communications and Marketing • Does not address a medical problem Life Sustaining Treatments Photo Credit: Communications and Marketing • Long term / permanent use of ventilator creates most ethical issues • Withdrawal may mean earlier death for some 4 Life Sustaining Treatments • Difficult for physician and proxy • Causal relationship between withdrawal and death Which is the sole significant cause of death? Disease Withdrawal Death Moral Issues • How can we consider moral issues? 5 Components of Ethical Analysis Components of Ethical Analysis Photo Credit: touched by light • Story Components of Ethical Analysis • Ethical Analysis – Situational Awareness Photo Credit: Billy Danze – Facts 6 Components of Ethical Analysis • Prudential Reasoning Patient’s Perspective Proxy’s Perspective Provider’s Perspective Court’s Perspective Photo Credit: Karina Valdes – – – – Components of Ethical Analysis • Court Decision Components of Ethical Analysis Photo Credit: janmennens • Ethical Reflection 7 Photo Credit: Binuri Ranasinghe Case Studies Case Study • http://archives.law.virginia.edu/dengrove/writeup/karenann-quinlan-and-right-die Case Study • Conflict between Photo Credit: LoisGillieAndrews – Parents – Physicians – Ad litem guardian 8 Case Study • What behavior is according to right reason? • How can the moral agents find a way to live well • Avoid the worse Ethical Analysis • Situational awareness Photo Credit: Billy Danze – Facts of the case? Ethical Analysis Photo Credit: Matthiew Rbnt • Irreversible PVS, not experience benefit or burden, body in constant state of flexion, not expected to survive after removal of respirator 9 Ethical Analysis Photo Credit: JourneyCare/Midwest • No advanced directives Ethical Analysis • With no decision-making capacity, proxies had to decide. Could not relay information that wasn’t given – No substituted judgement – No best interest – Rely on reasonable treatment standard Ethical Analysis • Physician not want to withdraw respirator – No substantial history in this area – NJ Attorney General opposed withdrawal – Physician’s lawyer argued imposed death sentence 10 Good / Bad Features • Expect Karen’s death – Death not good – Would not experience the process of dying – Regret and mourn death Good / Bad Features • Karen’s life was not good for her because she lacked awareness • Yet life is an important good Good / Bad Features • Suffering of Karen’s parents bad – Over tragic situation – Legal proceedings 11 Good / Bad Features • Physician’s distress at withdrawing respirator Recognize action leads to death of patient Legal action Advice from lawyer No established medical tradition Photo Credit: LoisGillieAndrews – – – – Prudential Reasoning • Enhance good whenever one can reasonably do so • Eliminate the bad features in the situation whenever possible Patient’s Perspective • Not have a perspective • Not a moral agent, because lost capacity • Not left advanced directives 12 Proxy’s Perspective • Father – primary moral agent • Decided to request withdrawal of life support – result in death • Was there a reasonable justification? Proxy’s Perspective • Bad features of dying not the same as someone else who had not had severe brain damage • No hope of recovery, no suffering • Death would not take much more away from Karen Proxy’s Perspective • Actual death not cause much more harm to parents • Karen already has suffered substantial loss 13 Proxy’s Perspective • No real harm to society • Already has lost her possible contribution Proxy’s Perspective • Resources in supporting life support might be wasted since it does not do good supporting a person in PVS Proxy’s Perspective • Father convinced that withdrawal of respirator was the more reasonable response • Less worse option 14 Provider’s Perspective • Were not convinced removal was morally justified • Why? Provider’s Perspective • Upset about removing life sustaining treatments from living patients because: Photo Credit: Alucco7 – Not accepted medical practice – No ethical analysis in this area developed – Threat of legal action Provider’s Perspective • Position weakened by what? • Forcing treatment on a helpless patient Photo Credit: Alucco7 • Over objections of proxy 15 Provider’s Perspective • Could have responded by stepping aside Photo Credit: Alucco7 • Chose not to take this route Court Decision • Reversed lower court decision Photo Credit: robotsrule159 • Found a person’s right to privacy can be asserted by a guardian when the patient is incompetent Court Decision Photo Credit: robotsrule159 • Constitutional right to privacy extends to decisions about medical treatment 16 Court Decision • Physician was ordered to withdraw • Instead, weaned patient from device • Transferred to nursing home Photo Credit: robotsrule159 • Died 10 years later from infection Ethical Reflections Photo Credit: robotsrule159 • Decision by both Proxy and NJ Supreme Court seemed reasonable • Efforts by physicians to continue and eventually wean not seem reasonable after court decision Ethical Reflections • Brought no good/benefit to Karen • Imposed 10 years of expensive but useless care Photo Credit: janmennens • A reasonable ethical response would have been to withdraw from case 17 Ethical Reflections • Generated lots of controversy in society Photo Credit: janmennens • Setting precedence Continue Photo Credit: Tracy Sorensen 18 PHHE 435/535 Ethical Decision Making for Health Professionals Module 7B Life Sustaining Treatments Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Brother Fox Photo Credit: Joe Catron • New York (1979) Brother Fox • 83 years old • Arrested during surgery • Had discussed with not being kept on a respirator • Physicians refused • Multiple appeals Photo Credit: Joe Catron • Brother Fox died 1 Ethical Analysis Situational Awareness – Facts • Permanently unconscious, no hope • Had made known his wishes • Apply substituted judgement, indicated desires • Hospital/physicians refused Photo Credit: Billy Danze • Take to court Situational Awareness – Good/Bad Features Photo Credit: Myles Lopez • Expected to die after withdrawal 2 Situational Awareness – Good/Bad Features Photo Credit: Myles Lopez • Use/expenses of resources not benefit that any good patient could experience Situational Awareness – Good/Bad Features • Hospital and staff distressed about withdrawing respirator • Not long after the Quinlan case Photo Credit: Myles Lopez • Not a recognized practice Prudential Reasoning Photo Credit: Karina Valdes • Patient’s Perspective – although he had lost decisionmaking capacity and consciousness, had made known his wishes • Removal was reasonable, given the circumstances 3 Prudential Reasoning • Proxy’s Perspective – acting according to the wishes of Brother Fox Photo Credit: Karina Valdes • Behaving ethically Prudential Reasoning • Provider’s Perspective – acting against patient’s wishes Photo Credit: Karina Valdes • Not unreasonable, given time in history Court Decision • Highest court (Court of Appeals) approved decision to withdraw • Incapacitated patient, no hope for recovery • Had given clear instructions 4 Court Decision • Clear and convincing evidence • Highest level of evidence in civil cases • Very few states require it – New York, Missouri Ethical Reflection Photo Credit: janmennens • The moral question: Ethical Reflection • Was Brother Fox’s prior decision to refuse treatment morally reasonable? Photo Credit: janmennens • It seems reasonable, given the circumstances 5 Ethical Reflection Photo Credit: janmennens • Hospital’s decision seems reasonable for the time, but would not be seen that way in the present Ethical Reflection • District Attorney’s actions to prolong the ordeal more difficult to justify • But since patient was not suffering Photo Credit: janmennens • And helped to clarify situation in New York Case Study 6 William Bartling (1984) • Seriously ill – Severe emphysema, hardening arteries, abdominal aneurysm, lung cancer, collapsed lung, need respirator to breathe, depressed • Multiple hospitalizations William Bartling (1984) • Appeared to physicians that patient would never leave ICU • Despite experiencing depression, still had decisionmaking capacity • Wanted to have respirator withdrawn William Bartling (1984) • Physicians were going along with that decision, but were advised against it by their lawyers • Patient’s lawyer went to court to have request honored 7 Ethical Analysis Situational Awareness – Facts • Still had decision-making capacity, despite being depressed • 70 years old, incurable lung cancer, little hope of leaving ICU Photo Credit: Billy Danze • Maintain decision over long period of time Situational Awareness – Facts • Physicians seem prepared to honor request Photo Credit: Billy Danze • Refused by hospital administration and legal counsel 8 Good / Bad Features • After withdrawal, death would occur • Patient was conscious, and would experience death Photo Credit: Myles Lopez • Both death and suffering bad Good / Bad Features Photo Credit: Myles Lopez • Continuing the life support would continue patient’s distress • Patient’s hands were tied (literally) • Not according to patient’s wishes • Was aware of what was going on Good / Bad Features Photo Credit: Myles Lopez • If request not honored, patient’s family would be in distress over this as well as original medical condition 9 Good / Bad Features • Hospital/staff worried over legal liability after conferring with legal advisors Photo Credit: Myles Lopez • Although concerns are understandable, not well grounded Photo Credit: Karina Valdes Prudential Reasoning Prudential Reasoning • Patient’s Perspective – wanted the treatment that was bringing him more burden than benefit stopped • Did not want to live with both ventilator and cancer Photo Credit: Karina Valdes • All things considered, this was reasonable 10 Prudential Reasoning • Proxy’s Perspective – no real role since patient still had capacity. However, if patient had lapsed into coma, would have been able to have request honored Photo Credit: Karina Valdes • Does this seem reasonable? Prudential Reasoning • Provider’s Perspective – although had concern for criminal prosecution, Photo Credit: Karina Valdes • There had been cases in California, New Jersey, and New York that had established the right of patients to refuse respirators Prudential Reasoning • Provider’s Perspective – • Due to questionable legal advice, hospital/staff wanted to avoid exposure to prosecution Photo Credit: Karina Valdes • Set up conflict between patient and institution 11 Prudential Reasoning • Provider’s Perspective – Photo Credit: Karina Valdes • Should have sought a declaration of immunity to protect themselves Court Decision • Trial Court did not support patient’s decision • Only honored right to withdraw if comatose or terminally ill • Would not allow patient’s hands to be untied to withdraw himself Court Decision • Court of Appeals later reversed decision • However, patient died during the process 12 Court Decision • Ruled right to refuse treatment not restricted to comatose/terminally ill • Based on right of privacy Ethical Reflection • A primary moral agent can make a decision between two ethically reasonable options, not necessarily between an ethical and unethical choice Photo Credit: janmennens • Patient’s ultimate choice was not morally irresponsible Ethical Reflection • The right answer in this case provided by the patient Photo Credit: janmennens • Best able to determine how to achieve his own good – or avoid the worse 13 Ethical Reflection • Respirator was not a cure • Only sustained life with incurable lung cancer Photo Credit: janmennens • Benefits not outweighed burden Ethical Reflection • No need for the hospital to use the legal system to force unwanted treatment on the patient Photo Credit: janmennens • Could have avoided putting patient and family through ordeal if they had sought legal protection for honoring request Ethical Reflection • Previous court decisions – Satz v. Perlmutter (1980) 14 Ethical Reflection • Previous court decisions Photo Credit: janmennens – Florida Supreme court affirmed lower court decision to honor request of conscious patient to have respirator removed Conclusion Photo Credit: Ben Seldelman 15

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