Bioethicists' statement on the U.S. Supreme Court's Cruzan decision

End-of-life decision-making in the United States

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

End-of-life care for the hospitalized patient

The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Patients often die alone, in pain, their wishes unheeded by physicians. Hospitalists can improve end-of-life care in hospitals dramatically. Hospitalists must relieve symptoms, such as pain, dyspnea, nausea, vomiting, delirium, and depression; communicate clearly; and provide support to patients and families. Hospitalists can increase the number and the timeliness of hospice referrals, allowing more patients to die at home. Finally, physicians must attend to their own sense of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.

End-of-life care for the hospitalized patient

The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Too often, patients die alone, in pain, their wishes unheeded by their physicians. Because hospitalists care for many of these dying patients, they can dramatically improve end-of-life care in hospitals. Hospitalists must first relieve distressing symptoms such as pain, dyspnea, nausea, vomiting, delirium, and depression. In addition, they should communicate clearly with patients and families, and provide them psychosocial support. Hospitalists can increase the number and the timeliness of hospice referrals, thereby allowing more patients to die at home. Finally, all physicians must attend to their own senses of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.

Nutrition and hydration in terminally ill patients: an update

Many health care professionals lack knowledge about artificial nutrition and hydration at the end of life or may hold different attitudes about artificial nutrition and hydration compared with other treatments. Consequently, they may convey inaccurate or misleading information to patients or their surrogate decision makers. An updated understanding about artificial nutrition and hydration in light of prevailing medical evidence is presented.

Increasing the use of advance directives in medical outpatients

OBJECTIVE

We studied whether a simple educational intervention would increase patient completion of advance directives and discussions on end-of-life issues.

DESIGN

Randomized, controlled trial.

SETTING

Outpatient clinic of a teaching hospital.

SUBJECTS

One hundred eighty-seven outpatients of a primary care internal medicine clinic.

INTERVENTION

Study subjects attended a 1-hour interactive seminar and received an informational pamphlet and advance directive forms. Control subjects received by mail the pamphlet and forms only.

MEASUREMENTS AND MAIN RESULTS

Completion of the advance directive was the main measurement. There were no significant differences in baseline characteristics of either group. Follow-up at 1 month revealed advance directive completion in 38% of study versus 24% of control subjects (p = .04), and discussions on advance planning in 73% of study versus 57% of control subjects (p = .02). Patients most likely to complete the documents were white, married, or attendees at the educational seminar.

CONCLUSIONS

Interactive group seminars for medical outpatients increased discussions and use of written advance directives.

Allocation of resources in intensive care: a transatlantic perspective

The USA and the UK have differed substantially in approaches to health care and especially in intensive care provision. We have compared the health care systems, clinical justification for intensive care, selection of patients likely to benefit from such care, and the performance of the systems. The differences are lessening. Both countries are moving away from clinical autonomy as the driving force of medical decision-making. There is increasing recognition that not all patients will benefit from intensive care and that the doctor's obligation to the patient can be limited by constraints set by society.

Continuing problems with patient self-determination

Cruzan v. Director, Missouri Department of Health, the first "right to do die" case to be decided by the United States Supreme Court, constitutionalizes the principle of patient self-determination. The case encourages competent patients to reflect thoughtfully about the possibility that one day they may be incapacitated just as Nancy Beth Cruzan was and to prepare for that possibility by completing an advance directive. Furthermore, the recently enacted Patient Self-Determination Act requires hospitals to ask adult patients upon admission whether they have advance directives. However, a number of practical concerns arise for physicians about operationalizing these patient self-determination principles within their states and their scopes of practice. Will physicians be prosecuted for "assisting suicides" if they withdraw feeding tubes or forgo other life-sustaining treatments? Will physicians be liable in medical malpractice for "undertreatment" or "overtreatment" in such cases? Will physicians be asked to violate their own moral codes in treating patients? Will others intrude into the traditional physician-patient relationship and decision-making process? Will physicians be caught in the middle of troublesome family, staff, and institutional disputes? How will physicians learn of patients' advance directives? Will physicians be asked to continue care in futile cases? Will Cruzan's self-determination doctrine be improperly extended? Successful implementation of patient self-determination principles will require consideration and discussion of these practical physician concerns.

Drug use evaluation approach to monitoring use of total parenteral nutrition: a review of criteria for use in cancer patients

Monitoring of total parenteral nutrition (TPN) by drug use evaluation appears to be a reasonable approach to characterizing use of parenteral nutrition within an institution. Development of specific criteria for use of TPN may be difficult because of the broad nature of published guidelines. Criteria for use of TPN in tumor-bearing patients is controversial. Results from recent investigations conflict with previous generally accepted guidelines for providing TPN in cancer patients. This article reviews published guidelines for use of TPN as well as application of these guidelines for drug use evaluation. Criteria for use of TPN and results of a subsequent drug use evaluation in a cancer institution are presented.

The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision

OBJECTIVE

To determine the relative importance of factors influencing physicians to use tube feedings in patients lacking decision-making capacity.

DESIGN

Survey.

SETTING AND PARTICIPANTS

Four hundred thirty-nine members of the Missouri Academy of Family Physicians.

MEASUREMENTS

Using a mailed questionnaire, physicians were asked for a decision about feeding tube placement in an 89-year-old man who was unable to swallow or communicate after a stroke. Changing the conditions of the scenario, we then evaluated the influence of patient age, duration of disability, a living will, the Cruzan decision, and family preferences on the physician's decision.

RESULTS

After reading the initial case history, 47% of physicians opposed tube feedings. Physicians who were told that the patient signed a living will specifically excluding tube feedings were more likely to oppose tube feedings than those who were told that he signed only a standard living will (53% vs 42%; P = 0.02). Forty-two percent of physicians who initially suggested a feeding tube changed their recommendation if the family opposed it. Sixty-six percent of physicians who initially opposed a feeding tube changed their recommendation if the family "pushed" for it. Thirty-three percent of physicians who initially opposed tube feedings under the living will scenario would favor tube feedings if the patient had not signed a living will. Twenty-two percent of physicians who initially opposed tube feedings would change to favor them if the issue had arisen before the Cruzan decision.

CONCLUSIONS

Among this group of physicians, there was no consensus on whether tube feedings should be initiated. However, it was found that the family's opinion was the most influential factor affecting the physician's recommendation about tube feedings. Most physicians endorsed family preferences for tube feedings even when this intervention was specifically opposed in the patient's living will.

Ethics and hospice physicians

Advocates of compassionate care for the dying should contribute to the formulation of ethical policies for dealing with the dying. Having identified the relevant ethical principles and controversies there is a need for continued dialogue as society makes new demands on the medical profession. At a time when the concept of what is moral or immoral is under review, as societal mores change, the needs of the dying also change. The medical profession must be flexible in responding, within the constraints of maintaining the integrity of the profession.