Medical Decisions: In Whose Best Interest at End-of-Life and PVS?

Today, on ABC’s “Good Morning America”, physician and Senator Bill Frist commenting on the autopsy results of Terri Schiavo said “She had devastating brain damage, and with that, the chapter's closed." But is the chapter really closed?

Today, Gov. Jeb Bush said he might ask a state attorney to investigate allegations that Terri Schiavo's husband waited more than an hour to call 911 after her 1990 collapse.

Today, Terri Schiavo's brother Bobby Schindler said they knew all along that Terri was profoundly brain damaged but they just wanted to bring her home and take care of her.

And the “right to life” groups are putting pressure on several state houses to write laws to prevent physicians from removing nutrition and hydration from patients.
No, the chapter is not closed.

And I think, neither is an ethical discussion of the Terri Schiavo case a closed chapter. In previous postings, I have brought out the concept of “best interest” in the treatment decisions of patients and have remarked on the issue of “in whose best interest” is a decision being made. This is particularly of note in end-of-life or persistent vegetative state patients. Doctors are taught that their primary interest and fiduciary responsibility is for their patient. And most doctors practice their medicine that way. Of course, they are also taught to consider the psycho-social impact of their patient’s disability on the patient’s family. But it is their patient, whose needs and the attempt to meet the patient’s goals which usually trump all else. The question I want to bring up now and perhaps as a “devils advocate” is whether we should begin to consider seriously changing of the paradigm when the patient is terminally ill or in a permanent vegetative state. Should we, at that point in the patient’s medical course, look seriously at the needs of the family? Should we begin to consider requests and decisions that now might be in the best interest of the family since the patient’s interest as a cognitive person is virtually gone or now gone forever? Would it have been in the best interest of the Schindler family to have allowed them to take home and nurse their heart beating “doll”. For Terri as a person, this would have been irrelevant. Of course, and this is where best interest for the family may not be a simple consideration, Mr. Schiavo may have found that his best interest was to follow what he understood was his wife’s request.

Physicians practice their profession at the desire of society. If society comes to a consensus that they want more consideration of the family’s best interest and their views including medically extra-ordinary treatment or even “right to life” decisions in the terminally ill or persistent vegetative state patients can physicians ignore this request?

..Maurice.