End-of-life care: Who decides when to pull the plug?

September 18, 2009

Efforts to thwart the increasing costs of healthcare cannot succeed without addressing the question of how much care to provide the terminally ill.

Key Points

As politicians run for cover, the New Jersey courts, responsible for many of the nation's leading right-to-die cases, may again plow into this politically and emotionally charged territory. The matter currently before a state appeals court involves a 73-year-old man in a moribund, permanent vegetative state, who requires dialysis several times a week. The only thing prolonging biological life is the medical care he receives.

The patient's treating doctors sought to discontinue dialysis but the family objected, so the doctors pursued a court order allowing them to discontinue treatment. At a hearing, the doctors testified that continued treatment was both futile and contrary to accepted standards of care. The family produced a physician-expert who testified that, essentially, the standard of care required physicians to provide any care requested by the family. The trial court ruled for the family, concluding because it desired all possible avenues of treatment to be pursued, there were no circumstances that would justify withholding even treatments deemed inappropriate.

Given the AMA's position, it appears impossible to base end-of-life decisions on the concept of futility. However, physicians must be able to exercise their judgment, in consultation with medical experts or hospital committees, to determine when care is appropriate and when respect for life warrants cessation of treatment.

Decisions of this magnitude can be resolved if they are left to physicians and are based upon recognized standards of care, and due consideration is given to the wishes of the patient or his representatives. We can also be assured that the family can resolve any disagreements regarding what constitutes appropriate standards of care by choosing physicians who are willing to honor their wishes. Only when there is uniformity of opinion that the treatment sought deviates from accepted standards of practice will the wishes of the family remain unfulfilled.

When all physicians agree, neither the courts, government bureaucrats, nor insurance companies should reverse those decisions.

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Medical Economics Consultant Steven I. Kern, JD, is a health law attorney with Kern Augustine Conroy & Schoppmann in Bridgewater, New Jersey; Lake Success, New York; and Philadelphia. He can be reached at kern@drlaw.com
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