medical jurisprudencethaddeuspope.com/images/pope_9_of_9_-_dying___death.pdf · medical...
TRANSCRIPT
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Medical Jurisprudence
Behavioral Sciences Term St. Georges University School of Medicine
Visiting Professor Thaddeus Pope, JD, PhD
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Segment 8 of 8
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Death & Dying
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Objectives
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1. What is decision making capacity
2. What is an advance directive
3. Understand a patient’s right to refuse life-saving treatment
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3. What are the 3 types of substitute decision makers
4. Understand the difference between the 2 SDM decision making standards
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5. Appreciate the difference between active and passive means of hastening death
6. Identify “passive” mechanisms for hastening death
7. Identify “active” mechanisms for hastening death
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8.What is the legal standard for determining death
9.What are treatment duties after death
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An individual . . . . . is dead . . . who has sustained either
(1) irreversible cessation of circulatory and respiratory functions, or
(2) irreversible cessation of all functions of the entire brain
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Consent not required to stop LSMT
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Not a patient
Dead
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Not a patient
No duty to treat
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“After a patient . . . brain dead . . . medical support should be discontinued.”
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“Once death has been pronounced, all medical interventions should be withdrawn.”
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The rule almost everywhere
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Duty to accommodate religious objections to brain death
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Right to refuse
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“The logical corollary of the doctrine of informed consent is that the patient generally possesses the right not to consent, that is, to refuse treatment.”
- Cruzan v. Missouri DOH (1990)
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Patient may refuse treatment even if life-saving
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Ventilator CANH (= med Tx) Dialysis CPR Antibiotics
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Who is to say if amount life left to a patient is worth living Person herself
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State interests Preservation life Prevent suicide Protect 3rd parties Integrity med profession
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Almost always outweighed by patient’s right to self-determination
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Easier situation
Contemporaneous patient refusal
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“Disconnect the vent”
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Tougher situation
When patient now lacks capacity
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Many patients lack capacity at the end of life
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DNR only means “no CPR”
It does not mean “do not treat”
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Prospective Autonomy
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Patient is competent + patient has capacity to make the decision at hand
Patient decides
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Patient not lose right of self-determination when lose capacity
Who decides
What standards
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Advance directive
Substitute decision maker
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Advance Directive
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Patient lacks capacity but left instructions while did Instructions available Instructions apply to present circumstances
Follow instructions (self-executing)
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SDM bound by instructions in advance directive
SDM lack authority to contravene patient’s instructions (or known preferences or best interests)
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Limits of Advance Directives
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Not completed
Not found
Not informed
Not clear
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Not completed
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28%
30%
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Not found
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65-76% of physicians whose patients have advance directives do not know they exist
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Individuals fail to make & distribute copies
• Primary agent
• Alternate agents
• Family members
• PCP
• Specialists
• Attorney
• Clergy
• Online registry
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Not informed
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Not clear
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if ___,
then ___
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Trigger terms vague
“Reasonable expectation of recovery”
75% 51% 25% 10%
Plus: prognosis uncertain
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Preferences vague
“No ventilator” Ever Even if temporary
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More technology is the default
Patient must opt out
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POLST
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POLST Provider Order Life Sustaining Treatment
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POLST Physician Order Life Sustaining Treatment
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POST Physician Order for
Scope of Treatment
MOST Medical . . .
MOLST Medical . . .
COLST Clinician . . .
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Many acronyms
Same concept
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What is
POLST
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Order
for LST
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CATEGORIES OF LIFE SUSTAINING TREATMENTS
JAGS 58: 1241-1248, 2010 . A Comparison of Methods to Communicate Treatment Preferences in Nursing Facilities: Traditional Practices versus the Physicians Orders for Life-Sustaining Treatment (POLST) Program. Susan E. Hickman, PhD, Christine A. Nelson, PhD, RN, Nancy A Perrin, PhD, Alvin H Moss, MD, Bernard J Hammes, PhD, and Susan W. Tolle, MD.
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For whom
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Terminal illness
Advanced chronic progressive illness
Frailty
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In last year of life
Others who want to define care
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MOLST supplements AD
Does not replace
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The present
Here & now
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MOLST benefits
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1. Bright color
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Original MOLST printed on lilac card stock
But a copy has the same force as original
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2. Single page
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3. More informed
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4. Immediately actionable
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Provider Order Life Sustaining Treatment
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No need to “interpret” advance directive
No need to “translate” into orders
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5. Easy to follow
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6. Better honored
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Can follow
Will follow
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7. Portable
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Home LTC
Hospital EMS
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8. Updatable
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MOLST does not expire
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MOLST can be revised or revoked at any time
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Review with change in condition or location
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Can be completed by surrogate, if patient lacks capacity
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70% patient
30% surrogate
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9. Proven Effective
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Closes gap between what people want and what they get
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Recap
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Mostly well settled patient with capacity may refuse life-saving treatment contemporaneously
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Mostly well settled patient without capacity may refuse life-saving treatment through advance instructions
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Mostly well settled patient without capacity may refuse life-saving treatment through decision of authorized SDM
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This is all “passive”
Refusing something (chemo, CPR, ventilator, CANH, antibiotics)
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Contrast active means to hasten death
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126
What is a medical futility dispute
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127
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128
Surrogate driven over-treatment
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Surrogate
LSMT
Clinician
CMO
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Consent always
130
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Assisted Suicide
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Illegal everywhere
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“Whoever intentionally . . . assists another in taking the other's own life may be sentenced to imprisonment for not more than 15 years . . . .”
Minn. Stat. 609.215
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“aid in dying”
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Physician prescribing medication to a mentally capacitated, terminally ill patient, which the patient may ingest to bring about a peaceful death”
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1997 SCOTUS
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No Constitutional right
Not a “fundamental” right
Not a violation of equal protection
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“States are presently undertaking extensive and serious evaluation of physician assisted suicide . . . .”
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“In such circumstances, the . . . challenging task of crafting appropriate procedures for safeguarding . . . liberty interests is entrusted to the laboratory of the States . . .”
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1994 Oregon
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Ballot initiative 51%
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In operation 1997 - ongoing
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Terminal illness (6 months) Resident 18+ Capacity
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Doc educates patient about all options – palliative care pain management hospice
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Oral request 15 days 2nd oral request Written request 48 hours
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Doc writes prescription
Patient gets at pharmacy
Must self ingest
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Self ingest Patient takes final overt act leading to death
If physician did it, that would be euthanasia & crime everywhere USA
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97% white
98% health insurance
90% enrolled in hospice
72% gone to college
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2008 Washington
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Ballot initiative 58%
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May 2013
Vermont
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Legislation instead of ballot initiative
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Dec. 2009 Montana via court decision
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Jan. 2014 New Mexico via court decision
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June 2014 Quebec
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February 2015
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Activity in the states
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Other exit options
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In order of acceptability
Stop LSMT okay
AID – PAD 5 states
Euthanasia illegal
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In order of acceptability
Stop LSMT AID – PAD Euthanasia
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High dose Opioids
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Mostly accepted
Risks respiratory depression and death
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Double Effect 1. Action good in itself (not immoral) 2. Intend the good effect (foresee but
not intend bad effect) 3. Bad effect not necessary for good
effect 4. Proportionality (sufficiently grave
reason to risk bad effect)
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More controversial --- palliative sedation to unconsciousness
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VSED
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Find existence intolerable Nothing to turn off Dehydrate = death 10-14
days Generally accepted, if
patient decides herself
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Controversial to make advance decision
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VAE IVAE
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Voluntary active euthanasia: doctor administers lethal agent
Illegal everywhere in North America
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189
Thaddeus Mason Pope Director, Health Law Institute Hamline University School of Law 1536 Hewitt Avenue Saint Paul, Minnesota 55104 T 651-523-2519 F 901-202-7549 E [email protected] W www.thaddeuspope.com B medicalfutility.blogspot.com