Withholding Treatment from NonDying Patients

1
Withholding Treatment from Non-Dying Patients

• Carol Bayley
• Ethics Champions Program
• June 2006

2
A Case

• Man had esophageal cancer 2 years ago. Treatment
  scarred his throat and eliminated his ability to
  taste. It also eliminated his cancer.
• For two years, the man has used a g-tube to
  supply nutrition. Now he has decided to stop
  using it. He says he has no quality of life and
  is afraid the cancer will come back.

3
Two Principles

• Beneficence (Do no harm help)
• Self-Determination (Respect a persons decisions
  about his or her treatment)
• HOW DO WE RESOLVE THIS TENSION?

4
(add poll)What is the lingering moral qualm?

• This person is not dying this is suicide.
• This person is not competent we cant rely on
  his decision.
• He might be competent, but he doesnt know what
  is good for him we should discharge him if he
  doesnt agree to eat.
• This man must be miserable, lonely and unhappy.
  How sad that the best we can do for him is let
  him die.

5
He is not dying this is suicide

• Diabetic refusing insulin?
• Hypertensive refusing meds?
• Someone with gangrenous (toe, leg) refusing
  amputation?

6
He is not competent

• Capacity vs competence
• Capacity is assumed unless pt is determined
  otherwise
• Capacity isnt measured by whether the decision
  comports with medical advice

7
Capacity to make a medical decision

• Understand diagnosis and prognosis
• Understand the nature of the treatment
• Understand the risk, possible benefit and the
  alternatives to the treatment
• Able to reason about the above
• Communicate decision

8
He doesnt agree with us lets discharge him

• Abandonment
• doesnt know what is good for him
• Coercion

9
He is sad and lonely

• Persuasion vs coercion
• Capacity?

10
(add poll)where is this case on the continuum?

• Gandhis hunger strike
• X
• X
• X
• X
• Withdrawing ventilator from Karen Quinlan

11
When can a patient refuse medical treatment?

• When the treatment is extraordinary
• When the burdens of the treatment outweigh the
  benefits
• When the benefits are too small

12
(add poll)which are medical treatments?

• CPR
• Bathing
• Dialysis
• Oral antibiotics
• Oral spoon feeding
• Artificial nutrition through a central line
• Artificial nutrition through a peg tube
• Physical therapy

13
How to resolve the tension between beneficence
and self-determination?

• Self Determination trumps
• Beneficence is still the clinicians duty
• A patients values help determine what is in his
  or her best interest. Best interest is not
  exclusively best medical interest

14
Take Home Messages

• A patient has a right to refuse medical
  treatment, even if that refusal will result in
  the patients death.
• This applies to any medical treatment.
• Whatever a patient can refuse when capacitated a
  surrogate can refuse on behalf of the patient who
  lacks capacity.
• Refusal of treatment is not suicide.

15
But

• Elizabeth Bouvia (California) won the right to
  have her feeding tube removed to be allowed to
  die she is still alive.
• David Rivlin (Michigan), quadriplegic from a
  diving accident, could not get services to help
  him live independently and found himself trapped
  in a nursing home. He sued to be allowed to die,
  won and died.