DOCTORS TRAIN TO BE SALESMEN OF DEATH

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NEW END OF LIFE FEDERAL GUIDELINES

Doctors   are now trained to implement new proposed federal guidelines developed for end-of-life care.   In their medical training, doctors were taught to save life at all costs as they swore to uphold the Hippocratic oath they took when they became doctors.  They must now develop skills to revoke legal and ethical issues that guided them in the past.

Doctors are today challenged to deal with end of life proposed medical treatments issues that center on withholding and withdrawing medical interventions.   Doctors, and their assistants are all being taught the skills necessary to negotiate with you, discuss with you, and implement decisions to withdraw life-sustaining treatments from you that are financially costly.

 For centuries, all doctors implemented medical care and provided continuity of care in their practices.   The doctor is now responsible to ensure that, despite lack of medical knowledge, his patient’s wishes are documented and supported by his medical orders.   A patient’s advance directive must now be translated into treating his present medical conditions, as defined by our federal government.

Advance Medical Directives

These are legal documents made by you and allow your surrogate to be your decision maker when you become incapacitated.  That person can accept, reject, or withdraw medical procedure and life support on your behalf.   If you don’t have this directive, the court can appoint a guardian to make medical decisions for you.

DNR 
A part of the directive is DNR, (do not resuscitate), passed in 1991 into federal law.   It instructs removing any life saving resuscitation or procedures to restart your breathing or your heart.   This is now an option offered by hospitals, and must be placed in your chart once signed.

The purpose of the DNR was to avoid suffering from a terminal illness or any condition that is medically irreversible.  Once on the chart, the hospital personnel are forbidden to use CPR and other reviving measures on your behalf.

You can revoke the DNR document anytime you communicate your desire by removing your medallion or bracelet that indicates your DNR status.   Some states will keep a registry of all people who have DNR orders.

These forms can be requested from a doctor, you can write down your wish, or some computer software for legal documents can prepare the form.   The doctor must be told your wishes and he must explain to you what happens when you sign a DNR order. The doctor must sign the DNR order before providers can honor the order.   A doctor who does not carry out your DNR order, for whatever reason, must be removed from your case.

THE QUINLAN CASE

 In 1976, artificial nutrition was withdrawn from Quinlan assuming she was in a persistent vegetative state.   Seven years later, a commission to study medical ethics found no medical treatments are obligatory, including artificial nutrition and hydration.   In 1990, the Cruzan case, said artificial hydration and nutrition are the same as all other life-sustaining treatments.   States differed in what requirements were necessary if a patient lacked decision-making capacity; some require clear and convincing evidence, while others allowed substitute decision-makers.

THE ROLE OF HOSPITALS

 Hospitals have always developed institutional policies drafted by their ethics committees, to protect your rights and interests. Other risk management committees also protect the hospital from the legal challenges of withholding and withdrawing nutrition and hydration if you lack decision-making capacity.

 The general response was,” when in doubt, choose the treatment that will prolong life”.   To bypass this goal of life at all costs, written plans of care are now being specifically written to accomplish the new goals of end of life policies.

Emergency units are required to provide resuscitation and life-prolonging treatments unless you have a DNR order in place.   Since only doctors can write orders, the doctor is being bypassed by making it the responsibility of an entire healthcare team to ensure that your wishes are followed.

Most patients enter intensive care units without attention to issues of life-sustaining treatments.   Most of them were given invasive medical treatments against their wishes, and many of them survived.

 These new guidelines require that if you are transferred to an acute care setting, your medical care orders must be completed and an appropriate end of life treatment plans must be in effect. Seventy five percent of patients transferred from nursing homes to a hospital acute care unit, do not have advanced directive orders. This will change soon.   Currently medical care orders may not transfer across settings from nursing home, ambulance, or acute care hospital. Changing this will eliminate a great deal of expensive care on your behalf.

WHAT LIFE-SAVING TREATMENTS WOULD BE ELIMINATED?

 They include: cardiopulmonary resuscitation, elective intubation and mechanical ventilation, surgery, dialysis, blood transfusions or administration of blood products, artificial nutrition and hydration, diagnostic tests, antibiotics, other medications and treatments, and future hospital or intensive care unit admissions.   A DNR directive would eliminate all of these treatments.

YOUR DOCTOR, NOW A SALESMAN

 Your doctor or his surrogate will now discuss specific treatments with you and your families and tell you whether these treatments will achieve the overall goals.  Your family will be asked whether you prefer an invasive intervention or an alternative noninvasive intervention. The doctor will get an idea of your priorities as you make treatment decisions.  How you answer about antibiotic decisions and surgery decisions will indicate to him how successful he will be in selling you a “noninvasive decisions”.

SOCIETY VIEWS ON PROLONGING LIFE

 Very few nonwhite patients have DNR orders. Asian cultures oblige children to take care of their parents in gratitude for the parents taking care of them. Withholding life-support is seen as unfaithfulness.    Even if you do not want life support, the family is expected to do everything possible to prolong your life and keep honor in the family.

Different cultures see suffering in different ways.   Obama care sees the withholding of life measures at the end-of-life as a very compassionate act that prevents you from needless suffering.  Many others, however, see pain and suffering as redemptive, to be endured as a test of faith rather than to be avoided.  Many religions feel that only God knows when it’s time to die.  This affects how they feel about life sustaining therapies.

 Most religions teach that when death is inevitable and not caused by the absence of hydration or nutrition, withholding these treatments would be appropriate.   Most religions however teach that, as found in the Hippocratic oath, human beings must do all in their power to prolong life.

TO FEED YOU OR NOT TO FEED YOU

 Most family members are troubled if they’re sick member is not eating.  It has always been considered ordinary care to provide oral nutrition if you want to eat. This included bringing food to your mouth even if you are too weak to do so. You are given assistance, and special attention was given to the consistency and smell of the food to make it appetizing.

Your doctor will now tell you that this is an emotional and spiritual issue, not a biological medical care issue.   When a family member is given a feeding tube, you will be told it only sets you up for a later disappointment.

The current guidelines propose that decreasing your caloric intake, increasing your metabolic rate, and helping you get vitamin and nutritional deficiencies are all good treatments.   These new findings contradict popular wisdom by doctors that provision of nutrients improves quality of life and survival.   The new approach is to tell you withholding treatment is guided by “current medical evidence”. Today it is considered unethical and even illegal to force you to eat if you do not wish to do so.   If you taken no calories, you soon develop ketosis, as fats and proteins are metabolized to give you an energy source.

If you cannot eat, and you appear hungry, nutrition by intravenous methods was used.    This maintained your electrolyte and fluid balance while you are temporarily unable to drink adequately.  

COMMENTARY

The federal government is building institutions to reduce the cost of healthcare. Goodness of different treatments are being compared is a so-called Medicare innovation Center and a Medicare oversight board that sets payment rates.

All of us knew the disasters of managed care 20 years ago.  These new agencies are already being accused of rationing Medicare.   Donald Berwick, a physician who now runs Medicare, will tell you that we all want the best possible care.  He will tell you that unnecessary care causes a lot of pain and even death.  Berwick made his fame by campaigning against medical errors.

These agencies are now seeking to tell you what treatments work and what ones do not work.   They will tell you that the data is incomplete or unavailable. Over half of treatments lack clear evidence of effectiveness, and therefore should not be available.

 You will be given information about potential benefits and risks to invasive care.   They are hoping you are not willing to accept the risks and side effects that may come with treatment. They will encourage you to leave an intensive care unit and enter a hospice.

RELATED POST:   ICU GUIDELINES CHANGING

The new health-care bill requires that Medicare and its agencies help hospitals and doctors give patients more programmed information.   Under the pretense of giving you more control and more choices, they hope you will choose the treatments that they advocate.

 What do you think?  Your comments are always appreciated.

Visit www.drneedles.com for more discussion of controversial medical issues.

Sources

 EPEC™-O: Education in Palliative and End-of-life Care for Oncology. The EPEC™ Project, Chicago, Ill, 2005).  

 (The EPEC™ Project, receives major funding from the National Cancer Institute, and the Lance Armstrong Foundation.)

Deciding to Forego Life-Sustaining Treatment: Ethical, Medical, and Legal Issues in Treatment Decisions. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, DC: US Government Printing Office; 1983.