Report on Texas Futile Care Law Shows Danger of Duty to Die Impositions
Critical Care Medicine, the journal for intensive care doctors, has published a study (no link available) of the Texas futile care law (Crit Care Med 2007 Vol. 35, No. 5), which allows hospital ethics committees to order unilateral termination of life-sustaining treatment, and only gives patient families 10 days to find another hospital. In reading the below, it is worth noting a few things about the society: First, Critical Care has previously published a guest editorial advocating for doing away with the dead donor rule for organ procurement, in which the doctor-authors argued that organs should be allowed to be procured from living patients if they are either cognitively devestated or imminently dying. Second, it is worth noting that way back in 1997, when the concept was relatively new, the Society of Critical Care Medicine Ethics Committee supported futile care theory--partially as a way of preserving hospital resources.
With these points in mind, here is the conclusion of the report based on hospital surveys:
A minority of hospitals reported using the TADA provision (n = 58, 30%), and an even smaller number reported actual cases via usable surveys (n = 40, 20%). Hospitals reviewing cases tended to be urban, nonteaching, nonspecialty, with >I50 beds. Most cases were resolved before the end of the 10-day period as a result of patients' deaths, patients or representatives agreeing to forgo treatments, or patient transfers. In a small number of cases, patients improved after review committees agreed with physicians that treatments were medically inappropriate. Discontinuation of life sustaining treatment against patient or representative wishes occurred for only a small number of reported cases.Note the part I italicized. A few patients improved after their families were told that their continued support was not to be countenanced. This isn't surprising, people don't die by the numbers and not even doctors always know for sure when patients will live or die. (Example: Janet Rivera surviving the removal of her respirator.)
Finally, one reason the numbers of duty to die impositions have apparently been few may be the small band of intrepid lawyers and activists willing to wage battle in the media and in court to prevent futile care theory from being forced on families. Hospitals know it isn't good PR to tell people their loved ones lives aren't worth supporting. Thus, the klieg lights remain the most potent tool in holding back this tide.
Hopefully, in the next session of the Texas Legislature this pernicious law will be repealed. Either that, or someday it will be taken down as unconstitutional in court.
Labels: Futile Care Theory. Texas Law. Critical Care Medicine Report.
posted by Wesley J. Smith @ 9:50 AM
6 Comments
6 Comments:
Framing these cases as "duty to die impositions" is misleading. Under the relevant provisions of TADA, patients can receive life-saving medical treatment if they (or their proxy) are able to find a provider who is willing to supply it. What they may not do is use the courts to force unwilling providers to supply LSMT in cases where doing so would do violence to the providers' conscience.
While the ten-day period allowed to find an alternative provider is arguably short, the clock starts running only after the ethics committee makes its determination. The reality is that, in most such cases, negotiations between the providers and (usually) the patients' families, including attempts to find an alternate facility, have been going on for a considerable time before the matter is referred to the ethics committee.
Makarios: Thanks for stopping by.
Futile care is the establishment of a duty to die. The 10 days is something of a farce since many patients can't find other institutions to take the patients, suggesting that there may be a tacit acceptance of other institutions' futility designations. That was, as I recall, part of the plan in Houston that led to the 10 day law as an increase of the 3 days that the JAMA article said Houston hospitals were going to adopt.
So, duty to die is a provocative description of what many families face with this agenda--which will get worse if it should ever really get into gear.
At least, that's how I see it.
The journal wants 30.00 to purchase the full text. Did you purchase it to read it?
I need this for a paper I'm writing.
WS: "Futile care is the establishment of a duty to die."
Makarios offers a well-reasoned post obviously based on first-hand experience and you respond with this two-dimensional aphorism? That's one way to run him off, I guess.
WS: "The 10 days is something of a farce since many patients can't find other institutions to take the patients, suggesting that there may be a tacit acceptance of other institutions' futility designations."
"Tacit acceptance?" Think "standard of care" instead. By the way, you do know which former Texas governor signed TADA into law, don't you?
Makarios: "The reality is that, in most such cases, negotiations between the providers and (usually) the patients' families, including attempts to find an alternate facility, have been going on for a considerable time before the matter is referred to the ethics committee."
This has been my experience as well, which largely dismisses the notion that hospitals are invoking futility just to save money. If that were the case, they'd do it much more quickly. In fact, it would be spearheaded by hospital discharge planners!
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In a small number of cases, patients improved after review committees agreed with physicians that treatments were medically inappropriate. Discontinuation of life sustaining treatment against patient or representative wishes occurred for only a small number of reported cases.
WS: "Note the part I italicized. A few patients improved after their families were told that their continued support was not to be countenanced. This isn't surprising, people don't die by the numbers and not even doctors always know for sure when patients will live or die."
Careful... I You may be jumping to conclusions on this point.
All this might mean it that these patients merely survived long enough to be discharged to a long-term care facility like a SNF or LTAC. It doesn't infer anything about the extent of the recoveries or how long these patients actually survived post-discharge.
Oka
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