“We need a law that is nuanced enough to recognize that there are very different contexts in which these decisions are made.”
The measures emerged largely out of concerns that TADA lacks sufficient safe- guards for a patient’s right to have a say in end-of-life decisions and that the law should be reformed. Rep. Bryan Hughes (R-Mineola), who carried the “treat until transfer” bills over the past three sessions, said he will “be involved” in filing similar legislation this session.
He said some families have had “very
As end-of-life issues heat up once again in Capitol debates, protecting phy- sicians’ ability to carry out that duty un- der the 1999 Texas Advance Directives Act (TADA) is a key feature of legislation TMA developed in collaboration with the Texas Hospital Association (THA), the Texas Catholic Conference, the Texas Alliance for Life, and other faith-based groups. At the same time, the groups are
pushing for reforms they believe will im- prove transparency and communication for all parties affected by these decisions. Sen. Robert Deuell, MD (R-Green- ville), was to file the bill in January.
Finding balance TADA allows patients to issue an out-of- hospital DNR or advance directive for physicians and family members on ad- ministering or withholding life-sustain-
ing treatment if they are in a terminal or irreversible condition and cannot make their wishes known. TADA and TMA policy encourage
patients to express those wishes in ad- vance.
Sen. Robert Deuell, MD
Gerald Ray Callas, MD
36 TEXAS MEDICINE February 2013
If that does not happen, however, or if a family member or surrogate dis- agrees with a physician or hospital rec- ommendation to discontinue what the health professionals believe to be medi- cally unnecessary or unethical treatment in a patient’s final days, the dispute goes to a hospital ethics panel. If the panel determines that limiting treatment is in the patient’s best interest, and the surro- gate still disagrees, he or she has 10 days to find another facility to care for the pa- tient, during which time the patient still would receive life-sustaining treatment. But this year’s legislative session like- ly will see a resurgence of efforts to pass “treat until transfer” bills. They would require physicians and hospitals to con- tinue treating terminal patients as long as the family wishes — or until they can find a facility that will — despite medi- cal advice to the contrary. End-of-life discussions also took a turn in 2011 with legislation that sought to severely restrict and possibly criminal- ize physicians’ ability to execute DNR or- ders. The bills never made it out of com- mittee, due in part to TMA efforts.
difficult experiences” because of the cur- rent law. “This is a vexing matter, diffi- cult for the patients, medical providers, and families involved. There is a general consensus that the current law needs to be amended. The degree and nature of the amendments is where we need to continue to have a robust debate.” Another reform advocate, Elizabeth Graham, director of the antiabortion group Texas Right to Life, agrees that judgments over a patient’s care and treatment are appropriate in any medi- cal setting.
“But judgments about a patient’s quality of life rest with the family. They are the ones who should have the auton- omy to say, ‘I do want to continue treat- ment. I do understand my limitations. However that’s my decision,’” she said. Ms. Graham added that the 10-day transfer window in the current statute often is not enough time for families to find an alternative care setting. Physicians already can opt out of
providing care they find unethical, she says. But she called the decision-making process one-sided, saying patients don’t get the same choice to continue life-sus- taining care.
Beaumont anesthesiologist Gerald Ray Callas, MD, says collaboration is the standard of care. The physician, as the professional in the relationship, brings a legitimate voice in recognizing whether certain treatments help or harm a dying patient’s condition. “But these issues are not always black and white,” he said.
A patient may have an advance direc- tive to withhold care, for example. But Dr. Callas explains to patients that once in the operating room, his job is to do everything to improve a patient’s quality of life.
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