medical fu+lity dispute resolu+on op+ons in the united
TRANSCRIPT
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?
Itdepends
typesofLSMT4
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
Categoriesoutlinedinanewmul5-societypolicystatement
20
21
22
23
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
Fu+le
Interven5onscannotaccomplishphysiologicalgoals
Scien5fic
impossibility
Goal=fill
Example1
Example2
An5fungalsastreatmentformyocardialinfarc5on
Example3
• Cptrigormor5s
CPRwhenshowrigormor5sordependentlividity
“Fu+le”
Valuefree
objec5ve
37
MaytheclinicianstopLSMT?
“Fu+le”
May&shouldrefuse
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
LegallyProscribed
Treatmentsthatmayaccomplisheffectdesiredbythepa5ent
>0%
Not“fu5le”
Prohibitedbyapplicablelaws,judicialprecedent,orwidelyacceptedpublicpolicies
Example1
Might“work”
Butillegal
Example2
Example3
Iftreatmentrequestislegallyproscribedà
May&shouldrefuse
Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
LegallyDiscre+onary
Permi^edlimi5ng
Laws,judicialprecedent,orpoliciesthatgivephysicianspermissiontorefusetoadministerthem.
Appropriatemedicine
Surrogate
Example1
Example2
brightlinerule
Jahi McMath
• Pics5nson• PicothersSFKYetc• Clickclickclick
IsraelS+nson
Aden Hailu
Example3
Trisomy18/23
22-weekgesta5on
ECMO
Example4
75
Not5-societystatement“fu5lity”
MightrestoreCPfunc5on
“imminentdeath”
3daysh^p://healthvermont.gov/regs/ad/dnr_colst_instruc5ons.pdf
78
MaytheclinicianstopLSMT?
Legallydiscre5onary
May&shouldrefuse
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
Valuejudgment
92
MaytheclinicianstopLSMT?
95%94
95
Still no consent
5%96
Lastresort
Notresponsiveinanycase
Op+onswhenintractablePITconflicts
199
Replacesurrogate
SDMstepsintoshoesofpa+ent
Hierarchy1. Subjec5ve2. Subs5tuted
judgment3. Bestinterests
~60%accuracy
103
104
2105
Greenlights
107
6steps
1999
StopLSMTwithoutconsent
PhysicianmaystopLSTwithoutconsentforanyreason,ifreviewcommi^eeagrees
Givethesurrogate
48hrno5ceRC
Wri^endecisionRC
10daystotransfer
A^emptstoCOPYTexas
BUT
116
NotchangenatureNarrowscope
117
H.B.3074(2015)
ar5ficiallyadministerednutri5on&hydra5on
119
S.B.11(2017)
CPR
ChrisDunntrial
122
3123
Redlights
Consentalways
124
Nondiscrimina5oninTreatmentAct
November2013
“healthcareprovidershallnotdeny...life-preservinghealthcare...directedbythepa5entor[surrogate]”
MedicalTreatmentLawsInforma5onAct
November2014
130
“Ifsurrogatedirects[LST]...providerthatdoesnotwishtoprovide...shallnonethelesscomply....”
131
Discrimina+on
inDenialof
LifePreserving
TreatmentAct
132
“Healthcare...maynotbe...deniedif...directedby...surrogate” 133
Kansas
135
Simon’s Law
SimonCrosier
DNRwithoutparents’consentorknowledge
137
“Nohealthcare...staffshallwithhold,withdraworplaceanyrestric5onsonlife-sustainingmeasuresforany...under18yearsofagewithoutthewrifenpermission....”
140
142
ThaddeusMasonPope,JD,PhDDirector,HealthLawIns5tuteMitchellHamlineSchoolofLaw875SummitAvenueSaintPaul,Minnesota55105T651-695-7661C310-270-3618EThaddeus.Pope@mitchellhamline.eduWwww.thaddeuspope.comBmedicalfu5lity.blogspot.com