The Virginian Pilot, Elizabeth Simpson – January 31, 2015
The bedside request has put many a doctor in a quandary: Relatives want to continue aggressive treatment of loved ones that won’t improve their condition and may even prolong suffering.
The cases aren’t a daily occurrence, but they’re important and difficult enough that a local delegate is sponsoring a bill to bring some clarity to the law.
Del. Chris Stolle, a Virginia Beach Republican who is a doctor, was approached by other doctors to clarify state law to say a physician has the right to stop care that’s “medically and ethically inappropriate” over the objections of the patient, family or advocate after a 14-day period of trying to transfer the patient to a doctor or hospital who will provide such care.
Currently, the law says a doctor must try to find other care during that period but leaves hanging what can be done once the time comes to a close.
“There needs to be some closing of the loophole,” Stolle said in a phone interview.
can be done once the time comes to a close.”There needs to be some closing of the loophole,” Stolle said in a phone interview.
Dr. Earl White, a retired doctor who sits on Sentara Healthcare’s ethics advisory council, said he supports the idea, but he would like to see language added to the bill to include an ethics committee review.
That is what happens at Sentara hospitals, according to White and David Cochran, who directs palliative care for Sentara Healthcare. Cochran said a “medical appropriateness review committee” pulls together an interdisciplinary group of people, some of whom aren’t involved in the case, along with clergy, patient and nurse representatives and other health care providers, to determine whether continuing treatment is appropriate.
If the committee agrees the care is not appropriate, it is stopped after the 14-day period, and comfort measures such as pain control are used.
Cochran said the committee was set up in 2006 and has reviewed about a dozen cases. He said that only three of the cases went the full 14 days, and that most patients died during that period even with aggressive treatment.
He said the cases have commonalities:
In most, patients do not have living wills or advance medical directives that spell out end-of-life desires. The patients are usually unable to communicate what kind of treatment they want. Relatives usually don’t want to stop care such as a ventilator that helps a patient continue breathing or dialysis that would do the work of failing kidneys.
“There are technical aspects of end-of-life care that don’t work like they do on TV. So people have unrealistic expectations,” Cochran said.
White said in some cases the patient’s chest is rising and falling, or eyes are open, and families are unwilling to stop the technology that is making that happen, even if the patient has no hope of improving.
There’s been an upswing in such cases as science and technology have advanced to the point where people can be kept alive by machines.
“We can sustain people who previously would not have survived,” White said. “We have gotten to where, physiologically, they’re alive, but we can’t restore them to their former self or to the quality of life they would like to have.”
He said in such cases, palliative care, which treats pain and provides comfort, may be more appropriate than measures such as CPR, dialysis and ventilators.
Spokeswomen from Bon Secours Hampton Roads and Children’s Hospital of The King’s Daughters said those systems also have ethics review committees that hear cases when an impasse occurs between hospital staff and family.
Chesapeake Regional Medical Center also has an ethics committee, according to spokeswoman Sarah Kehr, who emailed this response:
“An ethics consult can be requested by a physician, nurse, any other medical professional, a patient’s designated decision maker, significant other, or other family member if an ethical issue is identified.”
White said these situations point out the need for people to write advance medical directives. A collaboration of local health systems and area agencies on aging recently set up a website – AsYouWishVirginia.org – to help people do that.
In a follow-up interview Friday, Stolle said his bill is an attempt to close a gap in the code regarding care that doctors provide, rather than hospitals, so he’s not planning to add anything else to it at this time. He said it’s the first time he has presented such a measure, so he’s not sure of its chances of passing:
“It’s one of those bills that it’s hard to predict. It makes sense, but it also makes people nervous.”