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Articles: Douglas B. White, J. Randall Curtis, Leslie E. Wolf, Thomas J. Prendergast, Darren B. Taichman, Gary Kuniyoshi, Frank Acerra, Bernard Lo, and John M. Luce Life Support for Patients without a Surrogate Decision Maker: Who Decides? Ann Intern Med 2007; 147: 34-40 [Abstract] [Full text] [PDF]

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Letter to Editor

Rudolph J. Napodano, None   (17 July 2007)

Deciding the Fate of Vulnerable Patients

John Carney   (13 July 2007)

Letter to Editor 17 July 2007
Rudolph J. Napodano, MD Emeritus Professor, Medicine, University of Rochester, None Send rapid response to journal: Re: Letter to Editor rudnap4{at}attglobal.net Rudolph J. Napodano, et al.	An important and interesting analysis into what physicians actually do about initiating/discontinuing life support measures under this unique clinical circumstance. The authors conclude with an opinion, "it seems prudent for individual physicians to involve multiple perspectives and disciplines in the decision-making process, such as a hospital ethics committee". The presumption here is that the rights of the patient are protected. I agree with the potential benefits the authors cite. I also suspect that many physicians in this situation would welcome this help. However, some may not, thus raising caveats not addressed in the article. For example: Would this unique clinical situation require a referral to the hospital ethics committee, or would this decision be left up to the attending of record and the team caring for the patient? Suppose the hospital ethics committee renders a judgment that conflicts directly with the religious, philosophical or cultural values of the attending physician caring for the patient, and he/she then disagrees? Will the committee then have authority to replace the attending with another physician willing to carry out their recommendation? In this latter instance suppose an attending physician refuses to relinquish his/her role in the care of the patient, stating that he/she knows the clinical circumstances best and is acting within the guidelines of the ethical principles of beneficence and primum non nocere? Remember this attending and the team have an active and established patient-provider interaction. Will the process then enter the judicial system for resolution? Referral to a hospital ethics committee may yield more consistency in decisions about life support for patients without a surrogate but more evidence is needed to support this? I trust some of these questions will be answered in a subsequent investigation. Conflict of Interest: None declared
Deciding the Fate of Vulnerable Patients 13 July 2007
John Carney Center for Practical Bioethics Send rapid response to journal: Re: Deciding the Fate of Vulnerable Patients jcarney{at}practicalbioethics.org John Carney	Thank you for the timely and poignant article on Life Support for Patients without a Surrogate Decision Maker: Who Decides? (July 3, 2007) by Drs. White, Curtis, et.al. This type of study not only reveals deficits in the decision making processes in US hospitals, it provides much needed evidence of the work that remains to be done in resolving the concerns raised by the disability community in end of life decision making. Only the week before the study appeared in print, the Center for Practical Bioethics hosted a national summit on advance care planning in Chicago involving representatives from disability rights groups, life protection advocacy organizations and end of life coalition leaders from the across the country. We devoted two days to intense dialogue about the fears, challenges, and barriers that Americans face in articulating their end of life wishes. A major concern raised repeatedly by disability representatives was the issue of physicians and other healthcare professionals deciding the fates of vulnerable patients based on quality of life assessment without the benefit of independent and judicial review. This study corroborates those concerns and challenges all of us to do a better job of assessing patient preferences, prior to crisis, and absent those assessments, determine more uniform and standardized approaches to making end of life decisions befitting the patient’s condition and acceptable quality of life. We cannot make effective “best interest” decisions about the quality of patients’ lives when we act in a vacuum, or based solely on our own assessment. We must build decision making systems that take into account persons unlike ourselves who may be able to provide insights and distinctions about quality of lives that we judge differently from our own. This study echoes the cry of those we heard at the Summit. We owe it to all those we care for to remedy this substandard approach to end of life care. Conflict of Interest: None declared