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Lessons from Seville: Identifying and Reducing Inappropriate End-of-Life Treatment in New Jersey
Thaddeus Mason Pope, J.D., Ph.D.Z. Stanley Stys Memorial LecturePrinceton University Medical CenterMay 10, 2011
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Z. Stanley StysDanuta Buzdygan
Delighted
Honored
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April 18, 1955
Princeton, NJ
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I want to go when I want. It is tasteless to prolong life artificially.
I have done my share, it is time to go. I will do it elegantly.
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CPR
Dialysis
Mech. ventilation
ICUs
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May 2011
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More technology
Used more
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1 / 51
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Value = QualityCost
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71%: “More important to enhance the quality of life for seriously ill patients, even if it means a shorter life.”
National Journal (Mar. 2011)
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Harm to familyEmotional
Economic
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Harm to othersLimited ICU beds
ER boarding
Antibiotic resistance
Moral distress
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Why
How to fix
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PatientsSurrogatesProvidersPayers
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Patient Problem
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EOL discussionless aggressive medicine
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EOL discussion
Earlier hospice referral
Better patient QOL
Better family bereavement
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Not completedNot foundNot informedNot clear
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28% 35-50
50% 50+
30%
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65-76% of physicians whose patients have advance directives do not know they exist
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Trigger terms vague“Reasonable expectation of recovery”
75% 51%25% 10%
Plus: prognosis uncertain
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Preferences vague“No ventilator”
EverEven if temporary
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More technology is the default
Patient must opt out
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Patient Solution
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More ACP
Better documentation
Equalized safeguards
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Prompt Providers
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1991EnforcePSDA
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VoluntaryAdvance Care Planning
BlumenauerH.R. 3200Sec. 1233
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PPACA silent on ACP. But does cover annual wellness visits.
Section 4103
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DHHS: “Notice of Proposed Rulemaking: Physician Fee Schedule” (July 2010)
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Final Rule (Nov. 2010)
Defined “VACP” as element of annual wellness visit
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Lie of the Year:“Death Panels”
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A “quiet” victory
“The longer this goes unnoticed, the better our chances of keeping it.”
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Jan. 2011: Rescind VACP
“We did not have an opportunity to consider . . . the wide range of views . . . held by a broad range of stakeholders”
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Derecho a la información asistencial
Deberes respecto a la información clínica
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R2K
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BenefitsRisksAlternativesFinancial
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Prompt Patients
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Content agnostic
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Make AD
available
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RegistriesOrgan donation
NOK
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Make AD
effective
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POLSTCloses gap between what people want and what they get
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Actionable ordersMore likely honored
No need to “translate”
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PortableTravels with the patient in all treatment settings
Home LTC Hospital EMS
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SurrogateProblem
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No capacityNo instructions
Surrogate decides
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Surrogate must comply
Written instructions
Values & preferences
Best interests
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66% accurate50% = pure chance
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Moorman & Carr 62%2010
Barrio-Catelejo et al. 63%2009
Shalowitz et al. 58%2006
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Even lower
when most needed:
intermediate zones
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Moreaggressive treatment
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FutilityP/S: Curative
P/S: Palliative
D: CurativeD: Palliative
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Surrogate Solution
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EducateMediateReplaceOverride
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Educate
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Mediate
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ConsensusIntractable
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Earnest attempts . . . deliberate over and negotiate prior understandings . . .
Joint decision-making should occur . . . maximum extent possible.
Attempts . . . negotiate . . . reach resolution. . ., with the assistance of consultantsas appropriate.
Involvement of . . . ethics committee . . . if . . . irresolvable.
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Replace
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Early famous failure
Helga Wanglie
(Minn. 1991)
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85-year-old
End-stage kidney failure
Chronic respiratory failure
DementiaAlbert Barnes
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Lana BarnesSDM
“Continue”
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Feb. 4, 2011
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Material COI
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Court: “Your own personal issues are “impacting your decisions”
“Refocus your assessment”
Barbara Howe
DaughterCarol Carvitt
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Limits of surrogate replacement
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Providers cannot show deviation
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Surrogates often faithful
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57%: God could heal patient even if physicians had pronounced further efforts futile
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20%: “More important to prolong life.”
National Journal (Mar. 2011)Archives Surgery (Aug. 2008)Pew Ch. (Nov. 2005)
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If cannot replace surrogate, then provide the treatment
Truog
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Capacity and
Consent Board
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Dispute resolution
mechanisms for
intractable cases in
which surrogates are
“irreplaceable”
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Override
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Physicians usually cave-in to surrogate demands
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“Remove the __, and I will sue you.”
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“Why they follow the instructions of SDMs instead of doing what they feel is appropriate, almost all cited a lack of legal support.”
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Mass. Med. Society (Nov. 2008)
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Providers have won almost every singledamages case brought after unilateral withholding
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HCP exposure = IIED
Secretive
Insensitive
Outrageous
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Risk > 0
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Betancourt v. Trinitas Hospital
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73yo male
PVS
COPD
End-stage renal disease
Hypertensive cardiovascular disease
Stage 4 decubitusulcers
Osteo-myeletitus
Diabetes
Parchment-like skin
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“The only organ that’s functioning really is his heart.”
“It all seems to be ineffective. It’s not getting us anywhere.”
“We’re allowing the man to lay in bed and really deteriorate.”
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Intramural processNo consensus
Unilateral withdrawalDNR order writtenDialysis port removed
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January 2009
Jacqueline files
Court issues TRO
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February 2009
Evidentiary hearings
Medical experts
Family members
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March 2009
Permanent injunction
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NJHA MSNJNJPGNYHACHPNJ
April 2010Disability coalition
Jewish coalition
Pope
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August 2010
Appeal dismissed
No guidanceNo clarity
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You can stop LSMT for any reason if your hospital ethics committee agrees
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48hr notice
Ethics committee meeting
Written decision
10 days
No judicial review
Tex. H&S Code 166.046
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[N]ot civilly or criminally liable or subject to review or disciplinary action . . . complied with . . . procedures
Tex. H&S Code 166.045
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Statement on Futility and Goal Conflict in End-of-Life Care in ICUs
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Intractable value conflict
Pure process
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If process is all you have, it must have integrity and fairness
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Notice
Independent, neutral decision-maker
Judicial review
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Physician Problem
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OKFutilityP/S:
Curative
OKOKP/S: Palliative
D: CurativeD: Palliative
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Informed consent
FutilityP/S:
Curative
OKOKP/S: Palliative
D: CurativeD: Palliative
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EOL communication
Defensive medicine
Offensive medicine
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Communication
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AbsentLate Wrong Bad Inconsistent
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1% 2%“improve life expectancy
by 50%”
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Defensive Medicine
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Offensive Medicine
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Would you recommend or give life-sustaining therapy when you judged it futile?
Yes 23.6%MedScape (Nov. 2010)
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Physician Solution
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Communication
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R2K
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Limited effectivenessSide effectsOptions
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Defensive Medicine
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Clinical Practice Guidelines
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Offensive Medicine
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El médico limitará el esfuerzo terapéutico, cuando la situación clínica lo aconseje, evitando la obstinación terapéutica
Art. 21
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Hargettv.
Vitas
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Strachan v. John F. Kennedy Memorial Hospital (N.J. 1988)
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FalseClaims
Act
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Medicare Problem
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Medicare Solution
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Hos
pice
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Autonomy
Beneficence
Nonmaleficence
Justice
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Thaddeus Mason Pope, J.D., Ph.D. Widener University School of Law4601 Concord Pike, Room L325Wilmington, Delaware 19803T: 302-477-2230 F: 901-202-7549E: tmpope@widener.eduW: www.thaddeuspope.com
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