MATT RAINWATERS
LEGISLATIVE AFFAIRS
Difficult choices TMA seeks balanced end-of-life debate
BY AMY LYNN SORREL When Bellaire emergency physician Arlo F. Weltge, MD, received a chronically and terminally ill patient in the emergency department, he knew he had to make some quick and complex decisions. The man had ter- minal cancer and end-stage HIV-AIDS and, because he was nearing cardiopulmo- nary arrest, could not ex- press his care wishes. Nor had he signed an advance directive.
After calling EMS to
take the patient to the hos- pital, his caregiver told Dr. Weltge her partner did not want aggressive cardiopul- monary resuscitation (CPR) or to end up on a ventila- tor in his final days; nor did she want that for him. Dr. Weltge had no re-
cord of the patient’s wish- es, no verification of a for- mal relationship with the caregiver, and no time. “I needed to make a decision now, and it was clear to me where this situation was headed,” said Dr. Weltge, a consultant to the Texas Medical Association’s Council on Legislation and a member of TMA’s end-of-life workgroup.
Emergency physician Arlo F. Weltge, MD, can testify that end-of-life decisions are among the most difficult decisions doctors have to make in balancing their medical and ethical duties with patients’ wishes.
resuscitate (DNR) order. “On the one hand it was
very appropriate for me to give the patient some comfort care, like fluids and treatment of his in- fection. But I also had the tough job of saying, ‘If his heart stops, I don’t think we need to inflict further pain by breaking his ribs, pushing on his chest, or placing a plastic tube in his throat,’” he said. At the same time, Dr.
Weltge recognized that his decision in the emergency room would have “down- stream effects.” The DNR order meant that instead of putting the patient in an intensive care unit, where his partner could not be with him, Dr. Weltge could transfer him to intermediate level care where he could receive pal- liative treatment with her there. Dr. Weltge also dis- cussed the situation with the physicians who would care for him, and they agreed with the decision.
Different circumstances bring different levels of complexity
The lack of signed documentation, for example, would have made it difficult to take the matter to a hospital ethics com- mittee. So after discussing the situation with the caregiver and verifying the patient’s terminal condition in the medical re- cord, it was up to Dr. Weltge to honor the patient’s wishes and record the treatment plan. He did so in the form of a do-not-
to end-of-life care decisions, but one thing stays the same, Dr. Weltge says. “As physicians, our job is to act in the best interest of the patient, but with the ethical responsibility of not doing any intentional harm.” That responsibility does not end just because a patient is
nearing his or her final days. “We need a law that is nuanced enough to recognize that there are very different contexts in which these decisions are made,” he said.
February 2013 TEXAS MEDICINE 35
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