Tuesday, April 28, 2009

The Eight Reasons that Might Justify Unilateral Refusal

It might be useful to collect and list--in very rough order of importance--the arguments for refusing medically inappropriate treatment requested by a surrogate.

1.  Prevent patient suffering:  Aggressive treatment can cause significant pain and suffering.  This is unaccaeptable if there is no countervailing benefit to be achieved by the treatment.

2.  Protect patient autonomy (re treatment):  In many cases, the aggressive treatment demanded by a surrogate is treatment not wanted by the patient.  And where patient preferences are unknown, continued treatment is not in the patient's best interests.

3.   Protect patient autonomy (re other things):  Providing unwanted treatment not only violates the patient's bodily integrity but also the patient's autonomy concerning the location and manner of her death (ICU vs. home).  It also causes the utilization of estate resources to pay medical bills that the patient wanted to go to other uses (e.g. grandchildren education).

4.  Prevent family distress:  Often the surrogate wants the burden of decision lifted from herself.  And even if not the surrogate, other family members are often relieved to see the patient’s preferences or best interests protected.

5.  Preserve the integrity of the medical profession:  Those in the health profession surely must have some role in defining the ends and goals of medicine.

6.  Reduce nurse distress:  Numerous measures show high levels of moral distress.  This can both drive people from the profession and thus reduce access.  It can also reduce staffing levels and make people operate less well, adversely impactiung other patients' quality of care.

7.  Responsibly steward scarce hard resources (e.g. ICU beds) to maximize healthcare access:  In an under-bedded region like NM, the ICU bed used by a patient with PVS and multi-organ failure is the very same bed that could be used to achieve recovery for an accident victim.

8.  Responsibly steward scarce soft resources (e.g. dollars) to maximize healthcare access:  the billions spent treating PVS patients could be used to cover more people who now have no coverage.  As costs rise, premiums rise, and access drops.

Of course, there are also arguments against unilateral refusals.  Those will vary according to the specific circumstances of a case.  Whether unilateral refusal is ethically justified, on balance, will require some sort of weighing.

11 comments:

SAFEpres said...

My Body, My Choice. Not the doctors, not the nurses, and not the bioethicists'.

SAFEpres said...

Also, nurses: Get a grip. You're here to do your job of taking care of patients, not "feel good." If you can't handle it, than, by all means, don't be a nurse.

Thaddeus Mason Pope said...

SAFEpres, the nursing response would be "We want to 'take care' of patients. We do not want to torture them." The moral distress comes from being forced to provide interventions INSTEAD OF "taking care" of patients.

SAFEpres said...

Thaddeus-but at issue here is what the patient wants/needs. If I'm a patient, and I want to "torture myself" via medical intervention for whatever reason...that's my choice. People have various reasons for choosing medical intervention and those reasons should be respected.

Thaddeus Mason Pope said...

SAFEpres, if you want to "torture [your]self" that is one thing. But in a medical futility dispute, you rarely have either a patient with capacity or a clear advance directive indicating that the patient really wanted "torture." There are, however, some "Will to Live forms."

Even if we had clear indication of patient preferences, this is not a case of you "tortur[ing] [your]self." Rather, it is a case of you asking health care professionals to torture you.

Thaddeus Mason Pope said...

SAFEpres, if you want to "torture [your]self" that is one thing. But in a medical futility dispute, you rarely have either a patient with capacity or a clear advance directive indicating that the patient really wanted "torture." There are, however, some "Will to Live forms."

Even if we had clear indication of patient preferences, this is not a case of you "tortur[ing] [your]self." Rather, it is a case of you asking health care professionals to torture you.

SAFEpres said...

I'm only using the word "torture" in deference to how you define continued medical intervention, not how I see continued medical intervention, particularly considering the wide range of intervention that could fall under these laws.

For instance, if I am PVS and my advance directive says that I am to be provided with food and water, that means that I do not consider this intervention to be "torture." Nor, moreover, should any medical professional who asserts that people with PVS won't notice if they are starved and dehydrated to death-if they're not conscious enough to know that they are being dehydrated, than they are not conscious enough to know that they are being fed through a tube. So, when patient rights are at stake, what the patient considers torture that matters, not the nurses or doctors.

SAFEpres said...

Moreover, it should be pointed out that people who are PVS are NOT cared for in ICU settings, but in nursing homes and other non-emergency settings, so they are NOT taking a bed that could be used for someone else. Saying so misrepresents the facts and thus misleads readers.

Thaddeus Mason Pope said...

Perhaps generally true. But they are in the hospital to address comorbidities and emergent conditions.

E.g. http://web.missouri.edu/~bondesonw/wanglie.html

SAFEpres said...

Yes, they are, just like you or I would. Why shouldn't they have the same right to access emergency medical care? Saying that they "take resources" simply makes the argument that only certain people whom one deals sufficiently abled or healthy should be able to use ICU/emergency resources.

victor said...

SAFEpres,
I had been here earlier and saw that you had your hands full with this Pope so I clicked your blog and left a message there asking if I could be of help.

I saw your message at SHS and I came running but wouldn't you know it, my computer would not co-operate at all and I thought I had the top of the line protection. I did what I could do to fix the problem but to no avail so I just let "IT" be and went upstairs to play cards with my wife and kept thinking about this twilight zone moment which I had just experienced.

Go figure! It seems to be working now but The Lord only knows how long "IT" will last so I'm taking this opportunity to give my Canadian two cents worth to some of this Pope Cell(s). Depending on which place and time we're at "IT" could be worth something.

Anyway now that "Me" "Myself" and "I" are ONE Unit in this time I just want to advice this Pope, and by the way, are you a Catholic Pope and if you are what relationship are you to Saint Peter and if you are please tell me also how long you've been petering out? "IT" doesn't really matter cause no one fools around with my friends and gets away with "IT" so let's try to comprehend the seriousness of this matter if "you" know what's good for humanity?

I hear ya Thaddeus Pope! Tell me SAFEpres how far did you kiss UP to find this crazy friend of yours? :)

He's no friend of mine so where were we?

What! This was all for nothing!

What can "I" "ME" and "MYSELF" say Victor, other than Jesus The Christ worked for "Nothing?"

Fine if that's how you feel go at "IT" but try to play fair! :)

God Bless,

Peace