End of Life Decision Making -Approaches to Issues of FutilityEnd of Life Decision Making -Approaches to Issues of FutilityBernard W. Freedman, JD, MPHBernard W. Freedman, JD, MPH

bwfreedman@netscape.netbwfreedman@netscape.net

In sleep, we participate in the universal anonymity, we are every being; once pain rouses us, there is no one but ourselves, alone with our disease, with the thousand thoughts it provokes in us and against us.

“Woe to this flesh which is at the mercy of the soul, and woe to this soul, at the mercy of the flesh!” - it is in the dead of certain nights that we grasp the entire significance of these words from the Gospel according to Thomas. The flesh boycotts the soul, the soul boycotts the flesh; deadly to each other, they are incapable of cohabiting, of elaborating in common a salutary lie, a tonic fiction.

E. M. Cioran

Law is born from despair of human nature.Law is born from despair of human nature.Jose Ortega y GassetJose Ortega y Gasset

Lecture Topics Lecture Topics

1) Ethically sound & legally mandated end-of-life decisions.

2) Responsibilities of Surrogate Decision makers.

3) Documenting end-of-life decision in the medical record.

4) What is futile care?

5) Dealing with a patient’s culture and religious needs.

Autonomy Autonomy The basis of respect and dignity

• Every adult has the fundamental right of self determination including decisions pertaining to his or her own health and the right to choose or refuse medical treatment.

• This right is subject to certain interests of society, such as the protection of human life and the preservation of ethical standards in the medical profession.

AgencyAgency

• You You cannotcannot serve two masters: serve two masters:

• It’s Patient, not the Surrogate, who is the Principle or It’s Patient, not the Surrogate, who is the Principle or “Master” who is owed your allegiance. “Master” who is owed your allegiance. • Patient delegates MEDICAL decision making to Patient delegates MEDICAL decision making to

Physicians.Physicians.• Physicians MUST ELECIT patient’s, or the Physicians MUST ELECIT patient’s, or the

surrogates explanation of the patient’s, personal surrogates explanation of the patient’s, personal preferences, between alternative methods of preferences, between alternative methods of treatment or non treatment. treatment or non treatment.

California Probate Code 4650California Probate Code 4650

An adult patient has the An adult patient has the fundamental rightfundamental right to have life-sustaining to have life-sustaining treatment withheld or withdrawn. treatment withheld or withdrawn.

The prolongation of the process of dying for a person for whom The prolongation of the process of dying for a person for whom continued health care does not improve the prognosis for recovery continued health care does not improve the prognosis for recovery may:may:

Violate patient dignity, and Violate patient dignity, and

Cause Cause unnecessaryunnecessary pain and suffering, pain and suffering,

While providing nothing medically necessary or beneficialWhile providing nothing medically necessary or beneficial

HopeHope

• Overly aggressive treatment can reinforce false Overly aggressive treatment can reinforce false hope and can put people through grueling and hope and can put people through grueling and costly ordeals when there is no chance of a cure costly ordeals when there is no chance of a cure or improvement in quality of life. or improvement in quality of life.

Beyond FutilityBeyond Futility

Clinicians overestimate cancer prognosis by 27%.Clinicians overestimate cancer prognosis by 27%.Glare P, Virik K, Jones M, et al. A systematic review of physicians' survival Glare P, Virik K, Jones M, et al. A systematic review of physicians' survival

predictions in predictions in terminally ill cancer patients. Br Med J (2003) 327:195-200terminally ill cancer patients. Br Med J (2003) 327:195-200

Receiving care in a teaching hospital and living in Receiving care in a teaching hospital and living in an area with more teaching hospitals predispose an area with more teaching hospitals predispose more aggressive care more aggressive care regardless of the relative regardless of the relative chemo-sensitivity of the tumor.chemo-sensitivity of the tumor.

Earle CC, Landrum MB, Souza JM, et al. Aggressiveness of cancer care near the Earle CC, Landrum MB, Souza JM, et al. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol (2008) 26:2860-2866.end of life: is it a quality-of-care issue? J Clin Oncol (2008) 26:2860-2866.

Emanuel EJ, Young-Xu Y, Levinsky NG, et al. Chemotherapy use among Emanuel EJ, Young-Xu Y, Levinsky NG, et al. Chemotherapy use among Medicare Medicare beneficiaries at the end of life. Ann Intern Med (2003) 138:639-643.beneficiaries at the end of life. Ann Intern Med (2003) 138:639-643.

Spending Not Linked to SurvivalSpending Not Linked to Survival

• Report by National Cancer InstituteReport by National Cancer Institute, showed , showed that spending for advanced cancer care that spending for advanced cancer care varied by up to 41% between high- and low-varied by up to 41% between high- and low-spending regions. But despite that range, spending regions. But despite that range, there was no direct link between regional there was no direct link between regional spending and the survival of patients with spending and the survival of patients with advanced disease.advanced disease.

Regional Variation in Spending and Survival for Older Adults With Regional Variation in Spending and Survival for Older Adults With Advanced Cancer. G. Brooks M.D., Dana Farber Cancer Inst. Advanced Cancer. G. Brooks M.D., Dana Farber Cancer Inst.

JNCI JNCI J Natl Cancer Inst (2013) J Natl Cancer Inst (2013)

Dissecting Aortic AneurysmDissecting Aortic Aneurysm

• The patient, a 98 year old man was suffering from a dissecting aortic aneurysm of 7.5 cm. He was unresponsive and near death.

• He previously, and with unquestioned capacity, executed an advance health directive indicating that he refused surgery.

• He also had previously told his physician that he would rather die than to face the probable mental and physical damage and quality of life deterioration that would accompany such damage. 

Dissecting Aortic AneurysmDissecting Aortic Aneurysm

The hospital’s anesthesiologists initially refused to participate in the surgery, stating that such an operation had never been performed on someone his age and in his condition, and also noted that patient had refused the surgery.

Principles of clinical bioethics would demand respect for the patient’s wishes and directives.

Patient’s spouse demands surgery.

The patient's clearly stated wishes and health care directives were ignored, disregarded and disrespected.

The surgeons proceeded despite the dangers, because, they said:  “We were doing what we thought was right.”

Problems with determination of futility are often Problems with determination of futility are often caused by physicianscaused by physicians

Institute of MedicineInstitute of Medicine study on improving care at the end of life study on improving care at the end of life

1.There is overuse of care;1.There is overuse of care;

2. Inconsistent with patient preferences and prognosis;2. Inconsistent with patient preferences and prognosis;

3. Underuse of care to treat symptoms;3. Underuse of care to treat symptoms;

4. Untimely referral to hospice;4. Untimely referral to hospice;

5. Poor palliative care;5. Poor palliative care;

6. Poor communication regarding prognosis and treatment 6. Poor communication regarding prognosis and treatment preferences. preferences.

Annals of Internal Medicine (2001) 135:8.Annals of Internal Medicine (2001) 135:8.

67%: Making sure family is not burdened financially by my care66%: Being comfortable and without pain 61%: Being at peace spiritually 60%: Making sure family is not burdened by tough decisions about my care 60%: Having loved ones around me 58%: Being able to pay for the care I need 57%: Making sure my wishes for medical care are followed 55%: Not feeling alone 44%: Having doctors and nurses who will respect my cultural beliefs and values 36%: Living as long as possible 33%: Being at home 32%: Having a close relationship with my doctor Patients could select more than one response

California HealthCare Foundation.http://www.chcf.org/publications/2012/02/final-chapter-death-dying

What matters to patientsWhat matters to patients

A Failure to CommunicateA Failure to Communicate

Maybe next timeMaybe next time

““It’s sometimes easier to just keep giving chemotherapy It’s sometimes easier to just keep giving chemotherapy than to have a frank discussion about hospice and than to have a frank discussion about hospice and palliative care.palliative care.””

Dr. Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical Dr. Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical School. School.

Physicians are Obligated to Initiate Patient Dialogue Physicians are Obligated to Initiate Patient Dialogue

• Give patients the greatest opportunity to make his Give patients the greatest opportunity to make his or her own choices – or her own choices –

Speak Early or Lose your VoiceSpeak Early or Lose your Voice

Communicate with the patient while you can - Communicate with the patient while you can - before loss of capacity.before loss of capacity.

Physicians DonPhysicians Don’’t Generally Discuss t Generally Discuss End of Life DecisionsEnd of Life Decisions

In a prospective cohort study in five tertiary In a prospective cohort study in five tertiary medical centers found that:medical centers found that:

>77% of physicians failed to discuss CPR >77% of physicians failed to discuss CPR performance with seriously ill patientsperformance with seriously ill patients

(n1589)(n1589)

Ann Intern MedAnn Intern Med. 1 . 1 July 1997;127(1):1-12 July 1997;127(1):1-12

Prolonged VentilationProlonged Ventilation

12% of the group posed the question to their 12% of the group posed the question to their physiciansphysicians

20% said that they wanted it;20% said that they wanted it;80% said that they did not want it. (n 80% said that they did not want it. (n

1573) 1573)

Annals of Internal Medicine 1 July 1997 | Volume 127 Issue 1 | Pages 1-12Annals of Internal Medicine 1 July 1997 | Volume 127 Issue 1 | Pages 1-12

Effective vs. ExcessiveEffective vs. Excessive

Benefit of Treatment vs. Burden on PatientBenefit of Treatment vs. Burden on Patient

• Are we keeping the patient alive when there is Are we keeping the patient alive when there is nono benefit to the benefit to the life of the patientlife of the patient??

• Are we giving the patient time to recover to a level of quality of Are we giving the patient time to recover to a level of quality of life life that the patient will acceptthat the patient will accept,,

• Or are we merely prolonging or exacerbating the process of Or are we merely prolonging or exacerbating the process of death?death?

What does the patient/surrogate need to What does the patient/surrogate need to understand when considering futilityunderstand when considering futility

• Diagnosis, prognosisDiagnosis, prognosis

• Burdens of IllnessBurdens of Illness

• Effectiveness of TreatmentEffectiveness of Treatment

• Potential of rehabilitation, and Potential of rehabilitation, and

• Diminished quality of life.Diminished quality of life.

• Right to refuse treatment, andRight to refuse treatment, and

• Right to request palliative care/comfort Right to request palliative care/comfort carecare

Surrogates and the Therapeutic PrivilegeSurrogates and the Therapeutic Privilege

• Physicians may decide that telling a patient the Physicians may decide that telling a patient the truth about their illness is not in the patient’s best truth about their illness is not in the patient’s best interest from a medical standpoint. interest from a medical standpoint.

• This does notThis does not, however, apply to a surrogate , however, apply to a surrogate decision maker.decision maker.

• If they wonIf they won’’t listen and or will not act, they cannot t listen and or will not act, they cannot be a surrogate. be a surrogate.

• If a surrogate cannot fully and intelligently If a surrogate cannot fully and intelligently participate, then he or she cannot be the surrogate. participate, then he or she cannot be the surrogate. Then a second surrogate must be identified, if Then a second surrogate must be identified, if possible. If not turn to a best interest standard. possible. If not turn to a best interest standard.

Cultural Issues and Religious MandatesCultural Issues and Religious Mandates

• Similarities to Therapeutic Privilege.Similarities to Therapeutic Privilege.

• Ordinary vs. Extraordinary Treatment.Ordinary vs. Extraordinary Treatment.

• Pain control which may hasten death.Pain control which may hasten death.

Significant delay must not be permitted to impact Significant delay must not be permitted to impact on patient’s best interestson patient’s best interests

• A surrogate cannot be permitted to cause a A surrogate cannot be permitted to cause a delay in decision making which will harm the delay in decision making which will harm the patient.patient.

• If a surrogate cannot or will not be fully informed If a surrogate cannot or will not be fully informed and understand the diagnosis and prognosis, he and understand the diagnosis and prognosis, he or she may not continue as surrogateor she may not continue as surrogate

• If a surrogate cannot or will not decide – find a If a surrogate cannot or will not decide – find a new surrogate, or move to a best interest new surrogate, or move to a best interest standard.standard.

Disqualification of a SurrogateDisqualification of a Surrogate

• A patient having capacity may A patient having capacity may disqualifydisqualify, at anytime, , at anytime, another person, including a member of the patientanother person, including a member of the patient’’s s family, from acting as the patientfamily, from acting as the patient’’s surrogate by a s surrogate by a signed writing, orsigned writing, or by by personally informingpersonally informing the the supervising healthcare provider of the disqualification. supervising healthcare provider of the disqualification. (California Probate Code Section 4715). (California Probate Code Section 4715).

• Such disqualification should be promptly recorded in Such disqualification should be promptly recorded in the patientthe patient’’s healthcare record, noting the date and time s healthcare record, noting the date and time

of such declarationof such declaration..

Cal Probate Code 4766Cal Probate Code 4766

• The Court may declare The Court may declare ““…that the authority of an …that the authority of an agent or surrogate is terminatedagent or surrogate is terminated”” when: when:

• (1) The agent or surrogate has violated, has failed to perform, (1) The agent or surrogate has violated, has failed to perform, or is unfit to perform, the duty under an advance health care or is unfit to perform, the duty under an advance health care directive to act consistent with the patient's desires or, where directive to act consistent with the patient's desires or, where the patient's desires are unknown or unclear, is acting (by the patient's desires are unknown or unclear, is acting (by action or inaction) in a manner that is clearly contrary to the action or inaction) in a manner that is clearly contrary to the patient's best interest. (AND)patient's best interest. (AND)

• 2) At the time of the determination by the court, the patient 2) At the time of the determination by the court, the patient lacks the capacity to execute or to revoke an advance health lacks the capacity to execute or to revoke an advance health care directive or disqualify a surrogate. care directive or disqualify a surrogate.

Statutory Right of a Physician to Decline the Statutory Right of a Physician to Decline the Provision of Futile CareProvision of Futile Care

A health care provider or health care institution A health care provider or health care institution may declinemay decline to comply with an individual health to comply with an individual health care instruction or health care decision that care instruction or health care decision that requires medically ineffective health care or requires medically ineffective health care or health care contrary to generally accepted health health care contrary to generally accepted health care standards applicable to the health care care standards applicable to the health care provider or institution. provider or institution.

California Probate Code California Probate Code § 4735§ 4735

Questions to considerQuestions to consider

• How do we educate surrogate decision makers as to their How do we educate surrogate decision makers as to their acceptable roles and duties? acceptable roles and duties?

  

• When should we decline to follow the apparent wishes of the When should we decline to follow the apparent wishes of the patient, or the stated desires of the family? patient, or the stated desires of the family?

• When is it prudent to exercise what is known as the When is it prudent to exercise what is known as the “therapeutic privilege” and turn to a more paternalistic “therapeutic privilege” and turn to a more paternalistic approach to patient care? approach to patient care?

    

Michael DeBakey M.D.Michael DeBakey M.D.

Do not mask futility with medicineDo not mask futility with medicine

• Things look better today, his Things look better today, his white count has come down white count has come down somewhat…somewhat…

• We think we can wean him We think we can wean him tomorrow - if not, we can tomorrow - if not, we can trach him…trach him…

• He is still fighting this He is still fighting this infection, we doninfection, we don’’t know yet t know yet if he will be able to if he will be able to overcome it…overcome it…

• If we cannot wean him we If we cannot wean him we should talk about whether he should talk about whether he would want to have a would want to have a tracheostomy and go to a tracheostomy and go to a long term nursing facility, or long term nursing facility, or refuse further treatment. refuse further treatment.

DonDon’’t Frighten the Patient or Surrogate with the t Frighten the Patient or Surrogate with the word word ““Futility.Futility.””

• If you wait until a therapeutic impasse to tell the patient If you wait until a therapeutic impasse to tell the patient or surrogate we create panic rather than understanding – or surrogate we create panic rather than understanding –

• We risk loosing the patient’s or surrogate’s ability to We risk loosing the patient’s or surrogate’s ability to reason and discuss; reason and discuss;

• This leads to protest, denial and anger with the medical This leads to protest, denial and anger with the medical treatment that you have been providing;treatment that you have been providing;

• It sets the stage for allegations of malpracticeIt sets the stage for allegations of malpractice..

All Patients or surrogates have the All Patients or surrogates have the Right to:Right to:

• Be told the diagnosis and prognosis;Be told the diagnosis and prognosis;

• Be told what therapy is effective;Be told what therapy is effective;

• Told of the option to Refuse TreatmentTold of the option to Refuse Treatment

•To: To: Increase and enhance their Increase and enhance their knowledge of the disease process and knowledge of the disease process and alternative approaches to treatment,. alternative approaches to treatment,.

Time-Limited TrialsTime-Limited Trials

• Gives surrogate opportunity and time to participate and Gives surrogate opportunity and time to participate and gain a better understand of the benefits and burdens of gain a better understand of the benefits and burdens of treatment;treatment;

• To allow families to work through grief and intelligently To allow families to work through grief and intelligently participate in evaluating treatment options and the patienparticipate in evaluating treatment options and the patientt’’s values and wishes.s values and wishes.

Risks of Demanding Futile Treatment Risks of Demanding Futile Treatment Must be DisclosedMust be Disclosed

• Just as informed consent is required for the refusal Just as informed consent is required for the refusal of treatment, it is also required for the demand of of treatment, it is also required for the demand of futile treatment: the patient /surrogate must be told futile treatment: the patient /surrogate must be told of:of:• Unnecessary SufferingUnnecessary Suffering• Unnecessary Prolongation of Imminent DeathUnnecessary Prolongation of Imminent Death• Needless anguish, fear and insecurity of loved ones. Needless anguish, fear and insecurity of loved ones.

The degree of disclosure turns on the magnitude of the The degree of disclosure turns on the magnitude of the risk.risk.

The greater the risk the greater the required disclosure – The greater the risk the greater the required disclosure – the more detailed and justified the record must be.the more detailed and justified the record must be.

Disease TrajectoryDisease Trajectory

• A variety of options should be addressed A variety of options should be addressed as early as possible and relative to the disease trajectory. In addition to discussing the anticipated medical course, differing degrees of brain injury or damage, the likelihood of recovery and anticipated risks and treatment options and related issues of quality of life

Wendland v Wendland Wendland v Wendland

Clear and Convincing Evidence of IntentClear and Convincing Evidence of Intent

VideoVideo

California Probate Code 4765California Probate Code 4765

• 4765. …a petition may be filed by 4765. …a petition may be filed by

• (a) The patient(a) The patient

• (b) The patient's spouse, unless legally separated. (b) The patient's spouse, unless legally separated.

• (c) A relative of the patient(c) A relative of the patient

• (d) The patient's agent or surrogate(d) The patient's agent or surrogate

• (e) The conservator of the person of the patient(e) The conservator of the person of the patient

• (f) The court investigator, …(f) The court investigator, …

• (g) The public guardian(g) The public guardian

• (h) The Primary treating physician or hospital caring for the patient(h) The Primary treating physician or hospital caring for the patient

• (i) Any other interested person or friend of the patient. (i) Any other interested person or friend of the patient.

Judicial PowerJudicial Power

California Probate Code §3208 …California Probate Code §3208 …

• … … the court may the court may make an order authorizing make an order authorizing withholding or withdrawing artificial nutrition and withholding or withdrawing artificial nutrition and hydrationhydration and all other forms of healthcare where the and all other forms of healthcare where the recommended healthcare is in accordance with the recommended healthcare is in accordance with the patientpatient’’s best interest, taking into consideration the s best interest, taking into consideration the patientpatient’’s personal values to the extent known to the s personal values to the extent known to the petitioner.petitioner.

The Law for Withholding Life Sustaining Treatment The Law for Withholding Life Sustaining Treatment

TerminalTerminal Non TerminalNon Terminal

PVSYes Yes

Yes CCE of

Pt’s Intent

Minimally

Conscious

Record KeepingRecord Keeping

• Records should state the: Records should state the:

• Medical Question Requiring Medical Question Requiring AA Medical Medical DecisionDecision

• Describe the provision of information Describe the provision of information sufficient to make an informed decision sufficient to make an informed decision (consent) by the patient or surrogate. (consent) by the patient or surrogate.

• FormsForms

Racial and Ethnic Disparities in CareRacial and Ethnic Disparities in Care

A study of the U.S. national cancer registry (SEER) found A study of the U.S. national cancer registry (SEER) found that:that:

• African-American and Hispanic men received had longer African-American and Hispanic men received had longer time intervals between diagnosis and receipt of medical time intervals between diagnosis and receipt of medical monitoring visit.monitoring visit.

• Nearly 6% of African-American men and 5% of Hispanic Nearly 6% of African-American men and 5% of Hispanic men as compared to 1% of white men did not have any men as compared to 1% of white men did not have any medical monitoring visits or procedures during the 60-medical monitoring visits or procedures during the 60-month follow up period.month follow up period.

• Source: Shavers VL, Brown ML, Klabunde CN, Potosky AL, Source: Shavers VL, Brown ML, Klabunde CN, Potosky AL, Davis WW, Moul JW, Fahey A. Davis WW, Moul JW, Fahey A. ““Race/ethnicity and the Race/ethnicity and the intensity of medical monitoring under intensity of medical monitoring under ‘‘watchful waitingwatchful waiting’’ for for prostate cancer. Medical Care, March 2004, 42 (3):239-250prostate cancer. Medical Care, March 2004, 42 (3):239-250

Among patients in Medicare managed care (age 65 for older), Among patients in Medicare managed care (age 65 for older),

Black patients are Black patients are less likely less likely than White patients to than White patients to receive breast cancer screeningreceive breast cancer screening

Source: Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002 Mar 13;287(10):1288-94.

Patient Perception of DiscriminationPatient Perception of Discrimination

The perception or experience racial discrimination in Blacks, Hispanics and Asians has been associated with:

• Giving birth to a low birth weight infant

• Higher levels of elevated blood pressure

• Smoking

• Higher rates of depression

• Consuming higher levels of alcohol

Ethn Dis. 2009 Summer; 19(3): Ethn Dis. 2009 Summer; 19(3): 330–337. 330–337.

Physician Perception of PatientsPhysician Perception of Patientscontributes to racial/ethnic disparities in care. contributes to racial/ethnic disparities in care.

• There is a growing body of evidence suggesting that There is a growing body of evidence suggesting that provider behavior and decision-making contribute provider behavior and decision-making contribute significantly to racial/ethnic disparities in caresignificantly to racial/ethnic disparities in care

• However, little is known as to why.However, little is known as to why.

• Am J Public Health. 2006 February; 96(2): 351–357.Am J Public Health. 2006 February; 96(2): 351–357.

• Maynard C, Fisher LD, Passamani ER, Pullum T. Blacks in the Coronary Artery Surgery Study Maynard C, Fisher LD, Passamani ER, Pullum T. Blacks in the Coronary Artery Surgery Study (CASS): race and clinical decision making. Am J Public Health. 1986;76:1446–1448(CASS): race and clinical decision making. Am J Public Health. 1986;76:1446–1448

• Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med. 1999; 341:1661–1669differences in access to renal transplantation. N Engl J Med. 1999; 341:1661–1669

• Strakowski SM, Lonczak HS, Sax KW, et al. The effects of race on diagnosis and disposition from Strakowski SM, Lonczak HS, Sax KW, et al. The effects of race on diagnosis and disposition from a psychiatric emergency service. J Clin Psychiatry. 1995;56:101–107a psychiatric emergency service. J Clin Psychiatry. 1995;56:101–107

Whites have Greater Odds of Receiving CareWhites have Greater Odds of Receiving Care

Patients who received a cardiology consultation had 5.13 Patients who received a cardiology consultation had 5.13 greater odds of receiving coronary angiography.greater odds of receiving coronary angiography.

•White patients had 2.2 greater odds of receiving a White patients had 2.2 greater odds of receiving a cardiologist consultation.cardiologist consultation.

•White patients had 3.04 greater odds of receiving coronary White patients had 3.04 greater odds of receiving coronary angiography.angiography.

LaVeist TA, Arthur M, Morgan A, Plantholt S, Rubinstein M. Explainig LaVeist TA, Arthur M, Morgan A, Plantholt S, Rubinstein M. Explainig racial differences in receipt of coronary angiography: the role of physician racial differences in receipt of coronary angiography: the role of physician referral and physician specialty. Med Care Res Rev. 2003 Dec;60(4):453-67referral and physician specialty. Med Care Res Rev. 2003 Dec;60(4):453-67

TransparencyTransparency

• Issues of futility address the most serious and Issues of futility address the most serious and fundamental rights; fundamental rights;

• In cases where a patient has no surrogate, it is advisable In cases where a patient has no surrogate, it is advisable to have the Ethics Committee at your hospital review the to have the Ethics Committee at your hospital review the case and support your decision. Note in your progress case and support your decision. Note in your progress record your meeting with, and recommendations of the record your meeting with, and recommendations of the Ethics Committee.Ethics Committee.

• Discussions with patients and families regarding, DNR Discussions with patients and families regarding, DNR orders; transfer to hospice; withdrawal or withholding of orders; transfer to hospice; withdrawal or withholding of treatment, must be noted with specificity, and if possible, treatment, must be noted with specificity, and if possible, before a witness. before a witness.

Seeking Review and Recommendations of Ethics Seeking Review and Recommendations of Ethics CommitteesCommittees

• Protects the patient;Protects the patient;

• Protects and supports the Primary Treating Protects and supports the Primary Treating PhysicianPhysician’’s decision;s decision;

• Assists the Court, if itAssists the Court, if it’’s assistance is soughts assistance is sought

Fundamental Right = Autonomy = Fundamental Right = Autonomy = Ultimate responsibilityUltimate responsibility

• Health and Safety Code Section: 123100.

•  Every person has

• The ultimate responsibility for his or her own health care, and

• Possesses a concomitant right of access to complete information respecting his or her condition and care provided.

 Health and Safety Code Section: 123105 It is, therefore, the intentf others. It is, therefore, the intentf others.

• (d) "Patient records" means records in any form or medium maintained by, or in the custody or control of, a health care provider relating to the health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient.

 

Fundamental Right = Autonomy = Fundamental Right = Autonomy = Ultimate ResponsibilityUltimate Responsibility

• It is, therefore, the intent of the Legislature in It is, therefore, the intent of the Legislature in enacting this chapter to establish procedures enacting this chapter to establish procedures for providing access to health care records or for providing access to health care records or summaries of those records by patients and summaries of those records by patients and by those persons having responsibility for by those persons having responsibility for decisions respecting the health care of others. decisions respecting the health care of others.