Wednesday, April 4, 2007
Withdrawing life-sustaining treatments in incapacitated patients; (A friend's) Cancer is good for you?
The current Neurology has the American Academy of Neurology's updated position statement on life sustaining treatment for patients without decision making capacity (no abstract; issue table of contents here). It is explicitly written in response to legislative efforts of the last few years (post-Schiavo) to restrict the rights of patients' families and physicians to stop artificial nutrition in incapacitated patients if it is decided that that is what the patient would want. To this end it reiterates the AAN's 1988 position that it is permissible to stop life-sustaining treatment (including artificial nutrition/hydration or ANH) in incapacitated patients if that is consistent with their wishes/in their best interest. Some nuggets:
"[Recently] legislators in several states introduced bills that would create the presumption that any person who has been declared legally incompetent to make decisions affecting medical treatment or care would, in the absence of a carefully written advance directive that met specific statutory requirements, choose to receive ANH to sustain life. To withdraw ANH in these situations, the patient’s surrogate would have to prove by a clear and convincing standard that the patient would have chosen to have ANH withdrawn in the current circumstances. Furthermore, this proposed legislation would establish that elected officials, who in existing law have no legal standing as an "interested party" in such cases, would have the same right to challenge the administration or withdrawal of ANH as any true "interested party" (i.e., spouses, relatives) would. As of mid-February 2006, 20 bills, based upon model legislation from the National Right to Life Committee (NRLC), had been introduced in 13 states. Another 14 bills were modified to add additional restrictions."
These laws could, then, strip patients' families (and even legally designated health care powers of attorney) of the right to carefully deliberate over what their loved ones would want--what would be in their best interest--and give that power to the state/elected officials, at least when it comes to decisions about tube feeds. In a country in which people holding national office are willing to diagnose states of prolonged unconsciousness from watching 4 minutes of video and pass laws based on such tele-diagnoses, this is clearly not a good thing. I'm actually not sure of the status of these proposals: there hasn't been one in Wisconsin where I practice--leave comments if you know if any of these laws had been passed. I was under the impression that many of the proposals had failed to go anywhere in state legislatures because, among other things, a large majority of Americans think this is wrong--none of the state's business.
The statement is clear that the AAN doesn't endorse the withdrawing of ANH in permanently incapacitated patients of course, just when their loved ones believe it is a treatment the patient him/herself would reject, were they able to weigh in on it, upholding the long-held principle of patient autonomy over what is done to & stuck into her/his own body.
"The AAN opposes all state and federal legislation that would presume to prescribe a patient’s preferences for artificial hydration and nutrition. The AAN further opposes all state and federal legislation that limits the ability of patients to declare their preferences for health care through the use of living wills and advance directives or by discussion of their wishes with their families or surrogate decision makers. The AAN opposes all state and federal legislation that gives legal standing to elected officials (or their designees) to intercede in private decisions regarding the use of ANH. The AAN opposes all state and federal legislation that expands judicial intervention in a patient’s decisions regarding the use of ANH. The AAN supports state and federal legislation that promotes a better understanding of patient preferences for medical care (including the development of advance directives, living wills, and durable power of attorney declarations; the creation of health care directive registries; and the indication of such information on official identification cards) in accordance with existing AAN policies."
There's also a supporting editorial (TOC here) which talks about the role of the neurologist in discussing prognosis & treatment options/limitations etc. with the families of these patients. It's clearly written by a neurologist whose seen his share of poorly run family conferences. The image above is from the editorial--I have been so taken by its whimsical but straight-forward depiction of everything (well not even everything) that can go wrong in family conferences that I've decided to post it here, copyright concerns aside.
And for a complete change of tone: The Onion is now posting video 'news' clips. Today's is about how having a friend with cancer is good for your health. It's hilarious, and rather obnoxious, and if you want it could be interpreted as a commentary on cancer patients being culturally and socially erased by their disease: their face of suffering, disease, and death--hard to look at--being pushed aside by the face of health, vitality, and 'hope.' (Thanks to alert reader Dr. Steve Rommelfanger for alerting me to this.)
A Friend's Cancer: Good For Your Health?