• Should the Texas Advanced Directives Act be replicated?

    Some good passages from Patients and Doctors — The Evolution of a Relationship, by Robert D. Truog:

    Physicians are seen as having expertise and authority over matters of medical science, whereas patients hold sway over questions of values or preferences.

    This division of labor reflects a recognition of the naturalistic fallacy, the erroneous notion that one can derive ethical conclusions from scientific facts; in truth, an “ought” cannot be deduced from an “is.” […]

    [Yet,] strong disagreement persists about patients’ rights to demand care that physicians regard as medically inappropriate. […]

    In recent years, the Texas Advance Directives Act has defined one very concrete approach to addressing these dilemmas. When families demand treatments that have an exceedingly low likelihood of success or that sustain life of such low quality that one might reasonably say it is of no benefit to the patient, Texas law allows physicians to refuse to provide such treatments. Under the Texas legislation, demands by families for treatments that appear to meet these criteria are adjudicated by a hospital-based committee, and if the committee agrees with the clinicians, and if other providers cannot be located who are willing to provide such care, then treatment may be withdrawn without the permission of the patient’s surrogate. Although Texas has the most experience with this approach, other states are showing interest in similar proposals that address both the financial implications of providing allegedly inappropriate care and the concerns of clinicians who must endure the moral burdens and burnout associated with being compelled to provide treatments they believe are ethically wrong.

    I don’t take this “moral burden and burnout” lightly. I imagine it is extremely hard to provide care one feels is of little benefit. Does Texas have the right idea?



    • I’m the conservator of a gentleman who has been in a coma since December 12, 2005, and his family is darned clad that his fate is in the hands of God and not in that of some “hospital-based committee” of bozos. Texas has the way wrong idea.

    • Thanks for burdening future generations with all that debt to keep someone alive for 6 years with no quality of life! Yay God!

    • “, and if other providers cannot be located who are willing to provide such care,”

      Given the financial incentives to provide not needed care, this part should make only the most egregious cases eligible for this plan. Sounds pretty reasonable.


    • J.Moses: And who is paying the astronomical costs of gentleman’s care?

    • Sounds like those “death panels” that the republicans were lying about with “Obamacare”?!?! funny….where is all the feigned outrage now?

    • Moral hazard, anyone? Anecdotal reports from Texas have suggested that hospital committees are rather more likely to make a futile-care finding for poor people who aren’t going to bring in a lot of additional billings. Now of course anecdotal reports would suggest that kind of thing, wouldn’t they.

      But absent a way to blind doctors and committee members to financial issues, this one has ice floes and hillside exposure written all over it.

      As someone who has been involved in end-of-life care decisions for family members and others, I think that the right answer for this is to start the discussion and education process much earlier, and also to work on measures that improve the quality of people’s lives before they start getting ready to die. By the time you get into futile-care committees, you’re already way too far down the cost curve, and mostly dealing with outliers at that.

    • The horror of end of life care in America can hardly be described to those that haven’t experienced it firsthand.

      “Leaving it in the hands of God” is so inaccurate a description as to be sinful (see #3).

      Who is paying for this care is of secondary concern — the chief problem is that it is incredibly abusive and cruel to inflict painful and degrading “care” and people with little hope of anything other than surviving to endure another day of pain and degradation.

      But you may say, these procedures and interventions may be lifesaving, and so they can be. But the context determines. The difference between a week of ICU care that gets a person to rehab and ultimately back to their life, and and months of futile flogging with no realistic hope of leaving the ICU or the LTAC is the difference between a baptism and waterboarding.

    • Why is our society in general so afraid to die? When is enough enough? I’ve seen hips, knees, etc replaced in 90+ year olds who have such bad dementia that they can’t speak or control any bodily functions. What kind of physician can justify billing medicare/medicaid/insurance for this procedure? Will it improve the individuals quality of life? Of course not. Will it improve the physician and hospital’s income? Absolutely. Why does the public let it happen? Because when its your own family, many want these type of things done. Sad but true. End of life discussions should not be so taboo. Everyone dies. We can choose whether we die with dignity and as little pain as possible or with multiple tubes and lines coming out in addition to a fractured sternum after futile chest compressions. Talk to your family and be very clear about your own wishes. It should not be a topic that is avoided when everyone will experience death at some point.