In the recovery room, however, there
are tough choices about what’s right for the patient, while respecting end-of-life wishes. “If I can’t get you off a ventilator, do I just shut it off right away because of a DNR order, or do I give it a little bit of time?” There are gray areas, “and dictating
the practice of medicine is not in any- one’s best interest,” said Dr. Callas, also a member of TMA’s Council on Legislation and end-of-life workgroup. The joint bill aims to preserve the eth- ics hearing process and other TADA pro- visions that physicians and hospitals say generally work as intended. However, recognizing the often emo- tional and complicated nature of the medical and ethical decision-making process, they want to ensure that best practices are the standard of care across the board, while balancing the rights of all parties involved.
“TMA is aligned with other faith-
based groups to do everything we can to respect the conscience of physicians and other health care providers so that the law does not require unethical treat- ment. We also want patients in this try- ing and difficult time to know we are acting in their best interest,” Dr. Callas said.
Improving communication When it comes to withdrawing care, a key compromise in the TMA-backed leg- islation allows families 14 days instead of 10 to find an alternative treating facil- ity and extends the time in which hospi- tals must notify patient families or sur- rogates before an ethics panel hearing from 48 hours to seven days.
The bill also clarifies that physicians and hospitals cannot withhold certain comfort care, such as artificially admin- istered hydration and nutrition, from a terminal patient unless continuing such treatment would further harm his or her condition. To assist families during the decision- making and ethics hearing processes, hospitals would have to give them a free copy of the patient’s record, invite them to attend the meeting, and provide a liaison to guide them throughout the proceedings.
TMA guidance on DNRs
The Board of Councilors adopted new ethics policy to help guide physicians in executing do-not-resuscitate orders (DNRs). Among other tenets, it says:
• When a patient suffers cardiac or respiratory arrest, attempt to resuscitate the patient, except when cardiopulmonary resuscitation (CPR) is not in accord with the patient’s ex- pressed desires or is clinically inappropriate.
• Encourage all patients to express in advance their preferenc- es regarding the extent of treatment after cardiopulmonary arrest, especially patients at substantial risk of such an event. During discussions regarding patients’ preferences, physi- cians should include a description of the procedures encom- passed by CPR. Document patients’ preferences as early as possible and revisit and revise them as appropriate.
• Honor advance directives stating patients’ refusals of CPR whether patients are in or out of the hospital. When patients refuse CPR, physicians should not permit their personal value judgments to obstruct implementation of the refusals.
• If a patient lacks the ability to make or cannot communicate a decision regarding CPR, a surrogate decision maker may make a decision based upon the previously expressed prefer- ences of the patient. If such preferences are unknown, make decisions in accordance with the patient’s best interests. If no surrogate decision maker is available, an attending physician contemplating a “Do Not Resuscitate” order (DNR) should consult another physician or a hospital ethics committee, if either is available.
• If a patient (either directly or through an advance directive) or the patient’s surrogate requests resuscitation that the physician determines would not be medically effective, the physician should seek to resolve the conflict through a fair decision-making process, when time permits.
• The attending physician should enter DNR orders, as well as the basis for their implementation, in the medical record.
• DNR orders and a patient’s advance refusal of CPR preclude only resuscitative efforts after cardiopulmonary arrest and should not influence other medically appropriate interven- tions, such as pharmacologic circulatory support and antibi- otics, unless they also are specifically refused.
February 2013 TEXAS MEDICINE 37
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