End-of-life care: what do the American courts say?

End-of-life care of critically ill patients generally consists of two closely related practices: the withholding and withdrawal of life support, and the administration of palliative care. In the United States, the withholding or withdrawal of life support is legally justified by the principles of informed consent and informed refusal. The U.S. Supreme Court has held that competent patients may refuse any and all treatments, including those that sustain life. All states sanction such refusal by competent patients, and most states allow surrogates to refuse treatment on behalf of incompetent patients. Although some physicians use the concept of futility to unilaterally withhold or withdraw life support, the Supreme Court has not heard a futility case, and the only clear legal rule on futile treatment is the traditional malpractice test, which measures physician actions against standards of medical care. However, the Supreme Court has furnished guidelines on the administration of palliative care. By using the principle of double effect, these guidelines allow physicians to give sedative and analgesic agents to dying patients if they intend to relieve pain and suffering but not to hasten death.

Key legal principles for hospitalists.

In a hospitalist system, when a patient leaves the hospital, he or she will return to a primary care provider (PCP) for follow-up and continuing care. The hand-off after discharge can compromise communication with the PCP. Physicians have a legal duty to provide follow-up care to patients with whom they have a relationship. The obligation to provide follow-up care endures even when the patient misses a scheduled appointment or does not adhere to the follow-up regimen. In general, the physician who began the care must fulfill that obligation. An essential component of follow-up care includes educating the patient about what symptoms require follow-up care and why it is important. The duty to provide adequate follow-up care is shared by the hospitalist and the PCP. Virtually no malpractice case law considers the obligations and practices of hospitalists. This article uses cases involving follow-up care for patients treated in an emergency department and general cases regarding liability for follow-up care to examine the potential legal obligations of both hospitalists and PCPs for follow-up care, including circumstances involving pending test results and incidental findings.

Uses and abuses of prescription drug information in pharmacy benefits management programs.

A 1998 incident in which patients' prescription information was used to advertise a new drug exemplifies the importance of confidentiality in the era of managed care and computers. The ethical concerns voiced about this incident can also apply to pharmacy benefits management programs. The use of personal health information in pharmacy benefits management is particularly important because of increased pressures to control rising drug costs. Specific confidentiality concerns include whether the goal of benefiting patients will be achieved and whether the means are appropriate. The means may be problematic because of financial conflicts of interest, lack of patient authorization, inappropriate access to information by third parties, and inadequate safeguards for confidentiality. Policies should be crafted that protect confidentiality while allowing appropriate use of personal health information in pharmacy benefits management. Sound policies should require clear evidence of benefit to patients, an oversight committee, patient authorization, disclosure or prohibition of conflicts of interest, additional safeguards for sensitive medical conditions, strong confidentiality protections, and restrictions on advertising.

A new doctor in the house: ethical issues in hospitalist systems.

The traditional patient-primary care physician (PCP) relationship provides many ethical protections for patients, including confidentiality, shared medical decision making, and respect for patient autonomy. Hospitalist models, which introduce a purposeful discontinuity of care, threaten these protections and raise certain ethical concerns. We analyze 2 cases that explore ethical issues arising in hospitalist systems and suggest ways to ensure ethical protection for patients. The first case examines how hospitalization can disrupt the patient-PCP relationship and raise ethical issues regarding confidentiality. In the second case, we discuss decision making when the patient's goals and preferences for care change as a result of hospitalization. Effective hospitalist systems provide a model for a trusting patient-physician relationship. Although the hospitalist must take responsibility for inpatient management, the PCP has a key role in addressing important issues in the hospital and providing care after discharge. As hospitalists assume control of inpatient care, they must also provide ethical protections to patients to supplement those currently vested in the patient-PCP relationship. An approach that keeps the patient's best interests foremost, defines a clear role for the PCP, and takes advantage of the expertise and availability of hospitalists will best serve patients and physicians.

The Supreme Court addresses physician-assisted suicide. Can its rulings improve palliative care?

In June 1997, the US Supreme Court unanimously decided that competent, terminally ill patients have no general constitutional right to commit suicide or to obtain assistance in committing suicide. Thus, the broad prohibitions against any kind of suicide assistance that almost every state has enacted do not violate the constitution. While many of the rulings and the bulk of the reaction to them focused on the Supreme Court's resolution of important legal controversies regarding physician-assisted suicide, this article focuses on the resulting potential for change in physicians' opinions on palliative care. The Court's reasoning may help physicians resolve substantial ethical dilemmas regarding the provision of narcotics given in high dosages, the care of incompetent patients, and the suffering caused by symptoms other than pain. For example, the Court concluded that a physician's intent can distinguish permissible acts of aggressive pain relief from impermissible acts of hastening death. This distinction has clinical uses and can help physicians develop ethical guidelines and practice standards to improve palliative care near the end of life.

Health Care Financing Administration's new regulations for financial incentives in Medicaid and Medicare managed care: one step forward?

Because financial incentives for managed care physicians may create conflicts of interests, new regulations have been instituted that will result in disclosure of certain financial incentives to the Federal Government and to some patients. Given the limitations of these regulations, health plans and physicians should take the lead in addressing concerns about the harmful effects of financial incentives. For example, public disclosure may deter unusually strong financial incentives. Purchasing coalitions, advocacy groups, and journalists should have increased access to information about physician-level incentives. These nonregulatory measures might reassure patients that managed care physicians are committed to their best interests.

Criminal act or palliative care? Prosecutions involving the care of the dying.

Author examines criminal investigations and prosecutions of physicians and nurses in connection with their care of dying patients and concludes that the criminal law has failed to protect patients and families and has significant power to deter appropriate pain management for dying patients.

Detention of persistently nonadherent patients with tuberculosis.

CONTEXT: Patients with tuberculosis (TB) who are persistently nonadherent to treatment present a public health risk. In 1993, California created a new civil detention process and allowed detention of noninfectious but persistently nonadherent patients. OBJECTIVES: To determine (1) which patients TB controllers attempt to detain, (2) how often and where patients are detained, and (3) how many of these patients complete TB treatment. DESIGN: Case series with cross-sectional comparison to other adult TB patients in the study counties. SETTING: Twelve California counties with the largest number of new TB cases reported in 1994. SUBJECTS: All patients whom TB controllers sought to detain during 1994 and 1995 because of persistent nonadherence to treatment. DATA SOURCES: Public health records, interviews with county TB officials, and Reports of Verified Cases of Tuberculosis to the California Tuberculosis Control Branch. RESULTS: Tuberculosis controllers sought the civil detention or arrest of 67 patients during the study period (1.3% of adult TB patients with the same disease sites). Forty-six percent of these patients were homeless, 81% had drug or alcohol abuse, and 28% had mental illness. Tuberculosis controllers sought civil detention of 15 patients. Fourteen patients were detained (median length of detention, 14.5 days). Tuberculosis controllers sought to arrest 62 patients during the study period. Fifty-three patients were arrested (median time in jail, 83 days). In 10 cases, both civil and criminal detention were attempted. We analyzed completion of therapy after excluding patients who were not detained or who died or moved. Overall, 41 (84%) of the remaining 49 detained patients completed therapy. Of the patients who completed therapy, only 17 were detained until treatment was completed. Compared with other TB patients in these counties, detained patients had 4 times the proportion lost to follow-up and half the proportion completing therapy within 12 months. CONCLUSION: Further improvements in the care of persistently nonadherent patients may require more psychosocial services, appropriate facilities for civil detention, and detaining patients long enough to assure completion of treatment.

Does it make clinical sense to equate terminally ill patients who require life-sustaining interventions with those who do not?

Two US courts of appeals have ruled that competent, terminally ill patients have a constitutional right to physician-assisted suicide. The cases are now before the US Supreme Court, which is expected to issue a ruling later this year. This article analyzes the keystone of the courts' ruling: their assertion that competent, terminally ill patients who are being kept alive on life support are equivalent to competent, terminally ill patients who do not require such support. Because the former are permitted to end their lives by refusing treatment, the courts found that the latter also have a right to determine the time and manner of their death, through prescriptions for lethal doses of medication. This article analyzes whether the courts' thinking is premised on a clinically plausible view of the care of terminally ill patients. Based on a discussion of common situations involving terminal illness, we argue that the courts' reasoning is deeply flawed. The article also analyzes how the implications of the courts' reasoning might undermine the care of terminally ill patients.

Report of the Northern California Conference for Guidelines on Aid-in-Dying: definitions, differences, convergences, conclusions.

In September 1996, the Stanford University Center for Biomedical Ethics convened a conference entitled "Comprehensive Care of the Terminally Ill: The Northern California Consensus Development Conference for Guidelines on Aid-in-Dying." The regionally based, multidisciplinary conference gathered people from a variety of disciplines and diverse perspectives on physician aid-in-dying. This report documents important points of convergence, disagreement, and uncertainty that emerged from the conference and provides commentary on crucial issues: the definition of terminal illness, ensuring adequate palliative care, psychiatric challenges, coping with family pressures, the doctor-patient relationship, the managed care context, the role of ethics committees, and institutional challenges. Should physician aid-in-dying become a legal practice in California, the report will provide guidance to health care organizations, health professionals, and public policy officials engaged in local or state guideline or policy development.

Efficacy of high-velocity low-amplitude manipulative technique in subjects with low-back pain during menstrual cramping.

Previous studies have shown that dysmenorrhea produces low-back pain and an electromyographic (EMG) pattern typical of trauma-induced low-back pain. To determine the effects of high-velocity low-amplitude osteopathic manipulative treatment (OMT) on this type of low-back pain, 12 dysmenorrheic subjects were assigned to a group receiving OMT or to a group not receiving OMT (or both). Eight subjects participated in both groups, the other four being equally distributed between groups. Osteopathic manipulative treatment significantly decreased EMG activity during extension of the lumbar spinae erector muscles and abolished the spontaneous EMG activity. These EMG changes coincided with the patient's report of alleviated low-back pain and menstrual cramping. Osteopathic manipulative treatment did not change the creatinine kinase, lactate dehydrogenase or lactate-dehydrogenase isoenzyme activity, or myoglobin concentration.