Stopping Life Supporting Treatment without Patient/Surrogate Consent

Under what conditions, if any, should a physician deny further attempt to keep a patient alive but continuing comfort care in defiance of the known request of the patient or the family to continue life supportive treatments?

Modern medical science has provided physicians the ability and tools to continue life despite inability to cure the patient of the illness yet maintaining the patient’s life even if the life is one of being permanently unaware or, to an average patient, a life of no further personal value.

It is not unusual these days that physicians are challenged by the patient or the patient’s families to continue the life supportive treatments until death regardless of the negative consequences to the patient and others.

Should physicians be permitted to reject such requests? Currently, physicians can reject requests for treatment which has not been found to have any scientific basis for its use and which its use is not in keeping with professional standards. Such a treatment is characterized as “physiologically futile”. But what if the treatment has a scientific basis for use and if used can keep the patient alive but the treatment doesn’t cure? This form of treatment cannot be considered futile (of no value) if on continuing such a treatment the patient accepts the consequences of maintaining their life with this treatment but without cure. Nevertheless, does the patient's or family's desires trump any advice of the physician to terminate life support? Any answers? ..Maurice.

Patient Modesty: Volume 39

Is there anything more to discuss regarding patient modesty issues that hasn't been discussed in all the previous literally thousands of previous comments on this thread? I suspect there still is..so here is another chance to start the discussion going on another aspect of the issue. ..Maurice.

NOTICE: AS OF TODAY APRIL 24, 2011 "PATIENT MODESTY: VOLUME 39" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 40.

Should a Non-Identifiable Picture of a Patient's Body or Tissue be Posted on Social Media without Patient Permission?

[Note: This thread here is a copy of the Question I posted today on Medpedia and to which I encourage my visitors to go there and read the responses of the Medpedia subscribers to my question.]

Randy Cohen, columnist and ethicist, received the following request and then wrote about his response in his New York Times column "The Ethicist" Here was the request: "Some of my Facebook friends are medical students who post cellphone pictures of patients with what these friends believe to be comical maladies, with captions like 'A 5-foot-9 Hispanic male walks into a bar . . ' under a picture of a patient with a piece of rebar piercing his abdomen. The postings don’t include faces or names but still seem questionable. Doesn’t this violate patient privacy? NAME WITHHELD, NEW YORK"

Would a rebar piercing an abdomen be an identifying feature or would adding " a 5 foot 9 Hispanic male" make the picture identifying?

How about a nursing student posting to Facebook a picture of the students holding up a placenta but with no patient identification?

What if a photograph was published in a medical book without patient identification? If such book publishing of a picture of that placenta is legal, wouldn't holding up a placenta by a group of nursing students also be legal to publish on Facebook?

What are "identifying features" and if there are no identify features, would the INTENT of an unidentified body or body part on a social media be the guiding factor with regard to whether such public distribution is ethical or not? Would the intent to be funny or any other reason except for strictly educational intent be considered an ethical (and ?legal) violation of patient privacy? ..Maurice.

The Rare Cure and Doctors’ Goal: Recognizing the Goals of Their Patients

When a physician proposes a treatment for any illness, there become two goals which must be reached and resolved, one of the patient and one of the doctor. The goal the patient usually would be a cure, relief of pain and suffering and a return to an active and normal life. If cure is unlikely some patients’ goal would be to continue the attempt while others would accept the prognosis and seek other reasonable goals. Treating an illness, the goal of the doctor would be to control the pain and suffering and to perform what could be professionally accepted as clinically reasonable management to reach for a hopeful cure. If the cure is found to be rare, then some doctors might find the goal should be to follow what they think the average patient would want, a cure, and continue with energetic treatment toward that goal but failing to ask for their patient’s own goals. Other physicians faced with the possibility of only a rare cure would communicate with the patient and learn about the patient’s goal and then provide education of the patient about the reality of the situation and go from there stressing realistic management.

An example of the behavior of two doctors facing the incurable disease of the same patient can be found in the blog description by the patient “Can Good Care Produce Bad Health” by Amy Berman. Read the story and return and tell me what you think. If you had a disease with only a rare cure, what would you want? ..Maurice.

Should a Dead Pregnant Woman’s Body be Preserved until Term Delivery of the Baby?

So consider this realistic scenario: a 23 year old woman is 3 months pregnant and suffers a massive brain hemorrhage which cannot be stabilized and the woman is pronounced dead on the basis of neurologic criteria (“brain dead”). On her driver’s license she permits, upon her death, for her organs to be removed for the use of transplant to a needy patient. She has never written an advance directive nor had prepared a legal Will. She has a husband, a mother and father and several siblings. There is chance, by prolonged intensive medical care, supporting her breathing, heart action and blood pressure and many chemical and endocrine changes that occur with death that her body can be preserved long enough for the fetus to be developed sufficiently so that it can be safely delivered into the world. And, at that time, organs can be removed for transplant. (Want to read how this has been done? Go to this link.) But who should give permission or deny permission to attempt to continue the pregnancy? If no prolonged support to the mother’s body is given and the fetus perishes, would this be considered an abortion? What if State law doesn’t allow for the fetus to die along with the mother and the State at this point assumes responsibility to direct the physicians to maintain the pregnancy? Who should pay the perhaps millions of dollars cost to continue the pregnancy? It would seem that the medical insurance company would not pay for preserving the body of a woman who was already pronounced dead. There are many other aspects to these real but rare scenarios, but first I would be interested to know what you think might be the right decision to be made. ..Maurice.