Winslade_Minimally Conscious patient when can life support be terminated

Winslade_Minimally Conscious patient when can life support be terminated

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Unformatted text preview: Ethics William 1 Winslade, PM}, [D (Editor) The Minimally Conscious Patient: When Can Life Support Be William}. Winslade, PhD, JD fume-s Wade Rodzwell Promo:- of I ’bt’losophp in Medicine Institute for the Medical Humanities [mummy of Texas Medical Brunch 1 mines-ton I Extinguisde Visiting Profissor ofLaw Universij of Houston Law Center Houston, Texas Terminated? WWON FOR persons who have experienced traumatic brain injury is 01:3 ten tensity. arduous, and expensive. Progress is often slow; recovery is uncertain and in- compiccc. For mimic, Ruben Weadland, so- douslyhmniniurcdaficrmlflnghisuuck atahighspccml‘emahmdinzcomfor 16 mm bcfim: regaining conscioums. After 6 swaths of rehabilitation, Robert re- mained severely cognitively impaired. can» tionally voiatilc. and physically handicapped. chaspamlyacdonhisdghiside,unablcto communicaa: may, or interact consistcatiy with his Wm He was, however, able to respond to simpic commands. communi- cate (‘mconsistcnflfl by ms of z yes/no board, mcngachnsomc simpka movements (13.3.. throw and catch a bait, op- erate a wheelchair with assistance, and dmw circles and an ‘3'). Beams: he was umbic to feed himself, a. jejuuostomy tube was surgicafl'y imam It became disiodgod three times and was surgi- cally rcinscrtcd with the «consent of Robert‘s Wflnkosa'Ihcfomth time the tube came out. Rose mfuscd to consent to the surgiczi repair. Rose, their daughters, and Robert’s brother, [Head Mm Rehabs! 2062:17(1):7i-73 ® 2002 Aspen Pubiishcts. Inc. 71 293 v: to.;mmwlwmmxlwmut , . ' w v i.“ u u "awn-2mm; 39413-in"Q49...~.5m-.4.f'f51q2.“Huan'kkmwnnm ,.-4l"¢’-/‘u'n Howe" _ - - mam val» WNW»an ' " ‘- . v. ' ka’hkmflmwwwwwm—uvvwwww wva u u u u w w M “ W““MN-Wwwwrmmxww» v «mm m i. :7 y y 2 .r a y x a .s a ? 1 § i E 3 € 5 e 5 i g “'"' it.) 72 10mm 0? Bean Tam Wom/Fmam 2002 Michael. believed that Robert would not hay: agreed to the itfimostomry procedure. even if necessary to prolong his life. Rose discussed the issue with Robert’s treating physidan, other physicians. and the hospital’s om' budsrnan, all of when: supported Rose‘s decision. We hospital's Member ethics comittee unanimously approved Rose‘s But Robert's mother, Florence, and his sister. Rebekah disagreed about terminat- ing the artificial nutrition and hydration, If a severely brain-injured patient, such as Robert Woodland, is minimally conscious; suffering serious cognitive anotional, and physical dis abilities; and has a poor progtosis for further recovery. is it ethically permissible to with» drew or withhold life-prolonging procedures such as artificial nutrition and hydration? Rose petitioned a court to be appointed Robert's conservator. with the specific author itymtcrminatctheartlflcialnutritionmdhy- dation. Although the court appointed Rose as Robert’s conservator. it did not grant her the authority to remove the feeding tube. un- less she could showhyclearandconvinclng evidence either that it was Robert's desire to refosolifcsupportormatitminhisbestin- terests to do so. After mrther court proceed- ings in the California Appcfinc and Supreme Courts. the original restrictions on the orthor- ity of the conservator were upheld. For an extensive discussion of the legal issues; see the dedsion of the California Supreme Court inlfimdlandu W.2001c3LLE§GS 4943. Althoughtheleplissucsraised inthiseaso are numerous and complex. the ethical i55ues are also troubling and perplexing. 'I‘he least ethically difficult situation is one in which the patient has made his or her prefereaces clear by means of specific. preferably writ- ten, formal instructions or by appointing a medical power of attorney who is thoroughly familiar with the patients preferences regard- ing life-prolonging procedures. Although ad— vance directives have been legally available since the raid—19705, they are rarely specific enoughtoeoversituatioossuchasthecnede» scribedlllore oftenthesitualionisasitwas with Robert Woodland; he has} no advance di- reelive. Although he'had made passing com» misabootendoflifelsuestohisfamily, theywerenotsufidcntlycieartobedeci- sire.Someofhisfamilymembers(hiswife. daughters, and brother) believed than Robert would not want to continue to live with such minimal consciousnessand low quality oflife. Othersmisrnotherandsistcr)disagreedor at least objected to widzholding orwithdmw‘ log the artificial nutrition and hydration. it is always dificult to determine whether the familymemberswneithersideofthccon flict) are reporting their belief about Robert’s preferences, their own values. or a mixture ofboth.'l‘hiseese.mdotherslikeit,isof« ten fiirther complicated. because a person’s expressed preferences while competent (but not when confronted with an arena! choice) may differ from an neural choice After his recovery of consciousness, but with greatly impaired decisional capacity and no capacity for verbal responses. Robert was able to com- municate by means of a yeslno board to an- swer simple questions. But when his physi» dart asked him “Do you want to die?‘ Robert did not answer. Even though Robert had previv ouslyerpressedadesirenottohekeptaliveif he were severely disabled, when confronted mmadirectqmsfionwhenhcwasinmat condition, his silence is significant. At thevery least his preferences were ambiguous, if not uncertain. ' 1n the flee of uncertainty or ambiguity about patients’ preferences, is it ethically permissible for family members and health professionals to terminate lifesapport proce- dures? tot us assume that no disagreements arose among all family members. Assume also that the physicians, an ombudsman, and an orbit: committee all concurred with the 299 If-“a‘h'w'u‘k'uw'uwhmm- M.............r..ww” “MN” MW v4 K'Vw:‘i:w1\a‘s(;v.y u w 5v v “m outNurwwwvavw‘ imufily‘s desire w terminate life support. Axe quality of life considerations alone somaent to justify terminating life support? It should lie notcdthatcvenifapatientisreliabiy diagnosed as being in a persistent vegeta- live state with a poor prognosis for regain- ing consciousness, disagreements arise about whether life mppon may ethically be termi- noted on the basis ofl'amily and health profes- sionals mums about quality of life without clear patient preferli It is more diffi- cult if an extremely Womble patient, like Robert Wendianfi, is conscious. albeit mini- mally conscious anti severely impaired. How does one determine what is in his best inter- csts when his preferences are unclear? It is al ways risky and even dangerous for Others to make qualityof-iife decisions for another per- son. Itis‘no surprise that, intheaCtnal case, numerous advocates for the disabled opposed {he proposai to terminate Robert's nutrition anti hydration by filing antic-us curiae briefs with the California Supreme Court. Yet, advocating life prolongation a: all costs-economieal, emotionai. ethical. and icgai—also is probiematicl Although some te- ligious and snail-at groups micron: the idea ofthe sanctityoflife tomnanthatlifesup— port should never be terminated, this cat- treme vita-aim is neither legally requimd not ethime compelling- Family members suffer from uncertainty. economic stress, and emo» tional exhaustion. Health professionals may be able to technically sustain orpnic life hutmaybcunabietorestomemamini— Ethics 73 maiquaiityoflife.’lhebenefitsofarni1firnal quality of iii: are often disproportionate to the burdens. Resourcesmboth symbolic and actual-ware diverted away from patients who may benefit more fiorn scarce rehabilitative services. The view that any life, :egardless of its quaiiry, shown always be prolonged isasarbimryastheformalmafiveis dangerous. In view of this ethical impasse, more at- tention must be given to promoting not only patients’ prefaenees. but also patienzs' snif- zwarenesrx of the importance of making their values andprefezencesknownto theiriam— ily and their physicians before rather than after a medical crisis. All states recognize some form of advance (Interim. The M era! patient self-desermlnation act thms professional. patient, and community educa- tion. Health professionals have an opportu» nity and the proficssional responsibility to ed- nutctheirpaticntsmdfamflicstodctctmc and communicate their persona} preferences and values concerning end of life and other aspectsofhealthcare.hndpafiemshavea responsibility to communicate and doanncnt theirpreferences.ifnotfortheitownsake atlcasttolightcntheburdmsofdccisions placed on others. Only then will the ethi— cal conundmms faced by Robert Woodland‘s familyandcaxegivetshe midedAndifpa- tients' prefiemnces are clearly documented and well known, the moral authority of per- sonal autonomy wilI obviate a need to turn to the court for legal guidance. 300 m vvwvwww "ml: my 1 . p . u n “Map” - - - , V t u o u .. u oKKK A u « ."V x 9% R85 «KKK A « A J» l i MAMMN"mNMsN'szmAmmmeam’vsvmxwwwmw“vowwomewvwwwm-w-vwww-uMow-uwuvu-wu—w-u-mwwww-wwu vwvm'w w-wu u ww'h-wvvwvwv - - - - immaim 4-vaamawmv-w‘MmeWWum-wwmm-wwww-m-w www we-v ...
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This note was uploaded on 08/02/2011 for the course UGS 302 taught by Professor Staff during the Spring '08 term at University of Texas at Austin.

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Winslade_Minimally Conscious patient when can life support be terminated

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