Can healthcare providers obtain judicial intervention against surrogates who demand "medically inappropriate" life support for incompetent patients?

OBJECTIVE: This article analyzes, from a legal perspective, a recent phenomenon involving a clash between the values of attending medical personnel and the instructions of surrogate decision-makers acting on behalf of incompetent patients. Some hospitals have gone to court to challenge decisions by surrogates to continue life support for permanently unconscious or other gravely debilitated patients. Their claim has been that continuation of life support would be medically inappropriate and that the surrogates' decisions ought to be overridden. These petitions have thus far been rejected. The objective here is to explain those decisions and to predict the outcome of future, similar litigation. DATA SOURCES: The primary data are the judicial decisions and legislation accumulated since the Quinlan case in 1976, regarding the medical handling of dying medical patients. CONCLUSIONS: Judicial rejection of healthcare providers' claims in the decided cases is explainable under traditional guardianship principles. The explanation lies in surrogates' authority to make decisions in the best interests of incompetent patients, and in judicial reluctance to brand life preservation of nonsuffering patients as abusive or contrary to patient interests. At the same time, the author anticipates a change in judicial posture, as courts acknowledge the widespread antipathy of people toward being indefinitely preserved in a noncognitive status. Because the judicial approach to the handling of dying persons often seeks to replicate what the patient would have wanted, there is room to consider consensus preferences where the particular patients has never indicated any deviation from those preferences. Courts will eventually override surrogate decisions that do not conform to widely shared preferences for avoiding the indignity of permanent unconsciousness or other gravely debilitated states.

When families request that 'everything possible' be done.

The paper explores the ethical and psychological issues that arise when family members request that "everything possible" be done for a particular patient. The paper first illustrates this phenomenon by reviewing the well known case of Helga Wanglie. We proceed to argue that in Wanglie and similar cases family members may request futile treatments as a means of conveying that (1) the loss of the patient is tantamount to losing a part of themselves; (2) the patient should not be abandoned or disvalued in any way; or (3) the patient is owed special obligations by virtue of the special relationship in which the family and the patient stand. We maintain that families can best express these important messages by caring for patients, rather than by making requests for futile interventions. Likewise, when life-sustaining measures are futile, health providers can best fulfill their professional obligations by assuring patients' dignity and comfort, rather than by applying futile interventions.

Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists.

OBJECTIVE: This article was written to argue that physicians are not ethically obligated to provide care which they consider futile, unreasonable, or both, either voluntarily or in response to patient or surrogate demands. DATA SOURCES: Data used to prepare this article were drawn from published articles, including original investigations, position papers and editorials in the author's personal files. STUDY SELECTION: Articles were selected for their relevance to the subjects of medical ethics, the concepts of futility and medical reasonableness, case law, and healthcare reform. DATA EXTRACTION: The author extracted all applicable data. DATA SYNTHESIS: Physicians may feel obligated to provide care in all clinical circumstances due to the single master view of medicine and the ethical principle of autonomy. However, care may be considered futile according to several definitions of that word, including that which describes futile treatment as something that does not benefit the patient as a whole. Furthermore, care may be considered unreasonable if it is excessive and not generally agreed upon. Physician refusal to provide futile or unreasonable care is supported by the ethical principles of nonmaleficence, beneficence, and distributive justice. The last principle is particularly relevant in the current climate of healthcare reform. CONCLUSIONS: Although the issue of physician refusal of requested care has not been resolved by case law or legal statute, it is supported by compelling ethical principles. Physicians are not ethically required to provide futile or unreasonable care, especially to patients who are brain dead, vegetative, critically or terminally ill with little chance of recovery, and unlikely to benefit from cardiopulmonary resuscitation.

Position of the American Dietetic Association: legal and ethical issues in feeding permanently unconscious patients.

Health care team members, including the dietitian, must set patient-centered treatment goals that are handled individually and that respect the unique values and personal decision of the patient. The patient's expressed desire is the primary guide for determining the extent of nutrition and hydration once the patient is diagnosed as being in a PVS. Within the extent of the law, the family should share decision making when the patient's preference is not stated and the family is in agreement about medical care. The health care team will need to discuss with the family as needed the issues of ethics, values, religious guidelines, and pastoral advice. If the patient's choice is feeding, the dietitian will ensure that the composition of the feeding promotes nutritional health. If the patient's choice is cessation of feeding, the dietitian should explain what is known about the duration of time between cessation of feeding and death. Sensitivity to the family's needs and responsiveness to their questions are imperative in both scenarios. Within institutions, the ethics committee should help establish and implement defined written guidelines for care of the permanently unconscious. The dietitian should be required to be a member of or consultant to such a committee and should serve an integral role in development of institutional policy. The dietitian must provide education about nutrition and hydration issues, serve as a patient advocate, and participate in the legal and ethical issues regarding feeding. The dietetics community is involved in the legislative arena at the state and local level to promote the use of advanced directives and to affect legislative and societal changes that result in appropriate care for patients in a PVS.