AMA 2016 Code of Ethics

amaThe AMA is in the process of updating its Code of Ethics.  The preliminary documents are available online, including Chapter 5: Opinions on Caring for Patients at the End of Life.

Based on this preliminary document, it looks as if the AMA will continue to stand against physician-assisted suicide and euthanasia. In both cases, the document states that “permitting physicians to engage” in either of them “would ultimately cause more harm than good.”  Both are “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

Although the AMA remains against active killing, it very much encourages passive dying. Of eight sections, three are dedicated to insisting that patients be left to die, sometimes even when they don’t want to.

The first two sections are about Advance Care Planning and Advance Directives.  These are new concepts that medicine has not needed before the era of cost containment because the assumption has always been that if a person comes to a medical professional, it is because he or she wants care.  Now we must ask patients again and again if they are sure they want treatment because certainly some, even many, will refuse.

We know most patients refuse certain treatments before they even need them out of fear and pride–the “I would rather die than live like that” effect.  (See Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. Published online August 01, 2016.)  When actually confronted with these conditions, patients willingly to adapt to them and go on living.

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The next three sections are all scenarios in which the AMA insists that doctors let patients die.

5.3 Withholding or Withdrawing Life-Sustaining Treatment: “When an intervention no longer helps to achieve the patient’s goal for care or desired quality of life, it is ethically appropriate for physicans to withdraw it.”  This opinion does contain hope, however.  I advise patients not to refuse any treatment in an advance directive before they are faced with that choice because even after starting a treatment it always can be stopped if it is not effective.  In other words, don’t make a decision before you actually have to make it.

5.4 Orders Not to Attempt Resuscitation: “Whether a patient declines or accepts medically appropriate resuscitative interventions, physicians should not permit their personal value judgements to obstruct implementation of the patient’s decision.”  Compare this statement to what is found in the next section.

5.5 Medically Ineffective Interventions: “At times patients (or their surrogates) request interventions that the physician judges not to be medically appropriate.”  It goes on to say, “Respecting patient autonomy does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.”

So physicians should not let their “personal value judgements” get in the way of treating someone but must insist on their judgements regarding what is “futile”?  The section states, “The meaning of the term ‘futile’ depends on the values and goals of a particular patient in specific clinical circumstances.”  While patient autonomy is the overruling factor in refusing treatment, it can be ignored when a doctor’s opinion is that something is futile.  And how often will physicians deem a treatment futile not based on the merit of the treatment, but on the arbitrary value they place on someone’s life becasue of a patient’s age or condition?

 

 

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Jerome Lejeune and End-of-Life Care

In 1969, Jerome Lejeune became the 5th recipient of the William Allan Award of the American Society of Human Genetics, the highest honor a scientist can receive in the field of genetics.  He earned this honor for discovering Trisomy 21, the cause of Down Syndrome.

His discovery, rather than leading to a greater insight and acceptance of Down Syndrome, instead led to prenatal detection and subsequent abortion of those with Trisomy 21. This consequence greatly troubled Dr. Lejeune, a devout Catholic.  He had already become very active in pro-life causes by 1969.  Like any martyr urged to denounce Christ in order to spare his or her life, Lejeune was advised to just stick to scientific information in the speech he gave to the ASHG; instead he carefully decided to use it to reflect his deeply-held beliefs.

In his eight-page, hard-hitting lecture he wrote:

Nevertheless we human geneticists have to face everyday reality: disabled children and distressed parents exist…I believe our response must be guided by two sentiments only-humility and  compassion.  Hu­mility because we must recognize we have no ready-made answers, because geneticists have not broken the secret of the human condition, and because scientific arguments are of little help in ethical issues; compassion because even the most disinherited belongs to our kin, because these victims are poorer than the poorest, and because the sorrow of the parents cannot be consoled by science. But should we capitulate in the face of our own ignorance and propose to eliminate those we cannot help?

After his speech he wrote to his wife, “Today, I lost my Nobel Prize in Medicine.”

The medical and scientific communities severely punished Dr. Lejeune for his beliefs. The video demonstrates the hatred he and his family endured from the public for his views, some even calling for his death.  As grants were denied and colleagues shunned him, he no longer could work in genetics.  That was in the 1970’s.

Today, abortion as a result of prenatal screening is commonplace and abortion itself–for any reason and at any stage of development–has claimed the lives of millions.  Just as we are turning the tide in public opinion regarding the moral acceptability abortion, now at only 43%, we are seeing the rise in the acceptability of doctor-assisted suicide, now at 53% according to the a May 2016 Gallup poll.

The same medical establishment that martyred Dr. Lejeune professionally, one which has steadily grown in its acceptance not only of abortion but also of expensive technology to manipulate embryos, now wants to minimize our end-of-life care through physician-assisted suicide and physician orders for life-sustaining treatments (POLST). Society is aging, they claim, and it is too expensive to continue giving “futile” care.

POLST forms require patients to make decisions on the spot that go into effect immediately about treatment options for any future condition they may face (crystal ball not included.) They vary significantly from state to state and cover a wide array of treatments on only one page.  Accompanying instructions for clinicians filling out the form are extensive, and when actually put in practice these forms are commonly misinterpreted in a manner leading to even less care than the form specifies.

Had the medical establishment heeded Dr. Lejeune, we would not have aborted millions of lives; the percentage of the population considered elderly would be much lower and we would have many more people paying into Medicare than depending on it. Now that we have killed so many grandchildren we seek to hasten the deaths of grandparents.

Dr. Lejeune concluded his lecture with the following:

For millennia, medicine has striven to fight for life and health and against disease and death. Any reversal of the order of these terms of reference would entirely change medicine itself. It happens that nature does condemn. Our duty has always been not to inflict the sentence but to try to commute the pain. In any foreseeable genetical trial I do not know enough to judge, but I feel enough to advocate.

Replace genetic trial with decline in health and those words call out still more loudly today.

Don’t Sign Your Life Away with MOLST

 

MOLST MAYou will know a MOLST form when you see it by its bright pink color. (MOLST stands for Medical Orders for Life-Sustaining Treatment.) If you are elderly or seriously ill, you are likely to see it soon. But will it really get you the care you want? Rather, choosing a health care proxy is the best way to keep control of your end-of-life medical care.

Medicare now pays doctors $89.55 to engage patients in end-of-life discussions. These discussions include advance care directives — legal documents that indicate the medical treatment you will, and will not, receive prior to even needing it. A Health Care Proxy form (including the Catholic version) is the only type advance directives accepted in Massachusetts.

MOLST, on the other hand, is a medical order that takes effect immediately. While end-of-life care is complex for every patient, MOLST tries to reduce it to a few check boxes. It asks about only six areas of care but it can have implications far beyond them.

The first area – cardiopulmonary resuscitation – is the biggest problem. The first choice is Do Not Resuscitate. Most people understand this to mean that if my heart stops beating and I stop breathing, do not make any attempts to revive me. Yet studies have shown that many physicians think that “Do Not Resuscitate” equals “Comfort Care Only” — that you somehow also meant that you did not want any medical treatments other than what will keep you comfortable, not even treatment for conditions that can be cured. While your primary care doctor may know exactly what you mean, he or she most likely will not be the one caring for you in a hospital or nursing home.

A patient is not obligated to sign a MOLST form. Some doctors convince us to sign MOLST forms by asking if we want someone pounding on our chests, crushing our ribs, or putting tubes down our throats.  Do we sign these forms hoping to avoid such things? Usually what we are trying to avoid is being resuscitated only to have our health so severely impaired that our lives are sustained by a machine. Should we be revived and end up dependent on a machine to live, a health care proxy could withdraw care as we would want.

Before even talking about MOLST, clinicians should first discuss appointing a health care proxy with all their patients 18 years or older, according to the “Clinician Checklist for Using MOLST with Patients.” A proxy can make medical decisions for you if you are unable to at the time of illness.

People usually want to live on once they are in health situations they never thought they could tolerate. Let the doctor’s role be to explain your condition, treatments, expectations, and the impact on your life. You, instead, remain in complete control of your care until you no longer can make decisions. When that happens, your health care proxy — a person who knows you better than your doctor does, who knows your fears, desires, and hopes — will make those decisions.

To refuse a specific treatment with any advance directive before you actually face a medical situation is to literally sign your life away.

  • For more information on MOLST see Advance directives; for a proxy form see Resources at www.witnessforlife.com.

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Witness for Life Huddle

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Huddle

 An Invitation to

Pro-life Leaders and Advocates

on End-of-Life Issues

Friday, May 20th

7:00 to 8:30 pm

The Johnson Room at Christ the King parish

1052 Pleasant Street, Worcester

  • Get connected with the work of the Witness for Life committee
  • Learn the end-of-life issues of concern for pro-life advocates
    • Physician-assisted suicide–MA legalization H. 1991 in committee now
    • Advance directives–attemps to limit medical care
    • Euthanasia–where this is going and has gone in Europe
  • Find out about getting programs in your parish
  • Network with other parish pro-life leaders
  • Expand your pro-life community to people interested in these issues

Interested? 

Leave a reply below.

Undying Love The Palliative Care Deception

CFP seriesMuch is being made of palliative care these days, especially in the doctor-assisted suicide debate.  Prominent palliative care specialists such as Ira Byock and former assisted-suicide advocate Diane Meier  strongly oppose such legislation in our new era of palliative care.

According to the Center to Advance Palliative Care (CAPC), headed by Dr. Meier, palliative care “is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness,” and “is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”

Palliative care is not hospice, as anyone in the field would tell you.  Here is a graphic from CAPC demonstrating the “old” and “new” models of care:

My step-father, Dick, had congestive heart failure, stage IV renal cancer in his lungs, and required dialysis.  His appetitie and sleep were poor and he had bouts of breathing difficulties, much of which was due to untreated clinical anxiety. But he still cared for himself, drove himself to dialysis, and received chemotherapy.  My mother had difficulty coordinating the different instructions from the nephrologist, oncologist, and cardiologist, which sometimes conflicted, none of whom addressed his symptoms.  I told her to ask about palliative care for him, since he was the perfect patient for such services based.  She received a resounding, “No,” from all the doctors.

This reaction truly confused me until I learned that under Medicare palliative care services are paid through hospice benefits.  In other words, Dick needed to go on hospice in order to receive palliative care.  Signing on to hospice means giving up all other treatments, the so-called “life-prolonging care” in the models above.  Without dialysis, Dick would die in a matter of days, so hospice was out of the question.

That “old” model of palliative care is not so old.  That makes the push for palliative care in reality a push to surrender life-sustaining treatments.  Beware of former assisted-suicide advocates turned palliative-care-specialists and the false hope they present.

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Undying Love, Hope, and Communication

I receivCFP seriesed an early morning phone call from my aunt.

“Your mother is very upset. She doesn’t know what to do. You need to stop pressuring her about treatment. Dick is dying and the doctors told her he doesn’t need all these tests. You should not go down to visit today.”

Decision-making for caregivers has become a tremendous burden in the wake of physician-assisted suicide and cost-cutting measures. You don’t know who to trust. My mother was pushed to her limit and my aunt was frustrated watching it happen. I prayed I could give them peace.

“The hospitalists don’t know Dick that well.  We will talk to his oncologist who knows him and his condition far better.  He wanted the CT scan to start him on radiation treatments.”  All of this happened over the weekend when they could not easily reach the doctors they trusted and I was at work, so it all spiraled out of control. “Let me talk to the doctors directly and I won’t put any pressure on Mom.”  I said a prayer of thanks for these two tremendous women in my life.

When I arrived, Dick was dressed and the nurse was going over his discharge medications with Mom.  My aunt told me his oxygen level had dropped too low when he was walking with the physical therapist for him to go home.  Dick, meanwhile, could not wait to get back home.  A resident arrived at the door.

“His heart is in normal rhythm, his blood count is better after the transfusion, but he is still hypoxic (has low oxygen levels.)  Maybe he needs his effusion tapped.”

Dick has a collection of fluid in his lung lining caused by his lung tumors, and that fluid makes it harder to breathe.  The amount of fluid has been stable, and the resident said it still looked the same on x-ray, though he admitted that was not the best measure of it.  A tap is done to drain the fluid and make it easier to breathe.  He went to discuss it with the attending physician who came by soon after.

As it turned out, the hospitalist knew he was on home oxygen and so she presumed his oxygen saturation (a measure of oxygen in the blood) was below 88% without oxygen; he was at 91% now.  But he had not been using the oxygen, and his saturation was 97% at the oncologist’s office just before he was admitted.  “Maybe he needs a tap

During the conversation she mentioned my mom had been very upset that morning.  “That’s because a hospitalist over the weekend told her that they were not getting the CT scan because it wasn’t going to change his treatment. His oncologist plans to start radiation.”

“I was on over the weekend,” she said.  “I told her it wasn’t going to change his treatment while he was in the hospital.”

“That’s not what she heard.” I paused a moment and said with some sympathy, “Well, let that be a lesson learned.”

Dick went home with an additional appointment with is thoracic surgeon in two days to see if he needs his lung fluid drained, which can be done in the office.  His CT scan will be scheduled soon.

Thank you for your continued prayers.

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Undying Love in the Hospital

CFP seriesThe healthcare system has a very distinct line separating hospital care from outpatient care. Hospitals are expensive and so they are the main target of cost containment.  Here is where caregivers need to me the most vigilant.

They moved Dick out of the ICU after he received his most critical treatments–loading of the new anti-arrhythmia drug, a blood transfusion, and dialysis.  He was weak still but doing much better.

Two nights later Mom tells me they will not perform the CT scan to better image his brain lesions.  The hospitalist explained that he should not get radiation therapy so he did not need to have the CT.  I reminded Mom about our visit with the oncologist just before this admission.

“He said if he had brain lesions then he would need radiation, and I asked him if that would be too harsh. He said Dick would only get five treatments and about the most that would happen is that he would lose his hair.”

“Half of it is gone anyway,” my aunt quipped, giving us all a chuckle.

“But the hospitalist said that was before he had the heart arrhythmia,” Mom continued.

“But he doesn’t have an arrhythmia any more, and they gave him a medicine to keep it from coming back.”

“Well if it comes back then he said Dick would need a pacemaker.”  She told me that caused Dick to respond with some concern, but he is letter her make the decisions.  “We can worry about that when and if it even happens.  They are just trying to scare you out of treatment.  I’ll be down tomorrow to visit Dick and talk with the hospitalist myself.”

Hospitalists are doctors that care for patients only while they are hospitalized.  They change from shift to shift, even day to day.  They have no personal relationship with patients, nor do they have time to form any.  Patients do not get much information or input about their own care.  Since hospitals get paid a set amount of money from Medicare for a particular diagnosis, the less the hospital spends caring for a patient then the more money they earn.  And maybe that is why they are trying to talk Dick out of a CT scan.

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Undying Love End of Life Care

CFP seriesDick would commonly be thought of as my stepfather because he married my mother, but since they have only been married for nine years I consider him my mother’s husband.  He’s a wonderful man who is dying of renal cancer, and I am his healthcare proxy.

As a physician assistant and because I know Dick more as someone important to my mother rather than a father, my perspective on this process is somewhat unusual.  I have a medical perspective of what is happening, and he is an important figure in our family such that I have some emotional involvement but certainly not as deeply as I would with a parent who had raised me.

They live 35 miles from me and I drive there along a highway that makes getting there torturous at rush hour yet rather easy otherwise. While I have been advising my mother all along, this past month Dick’s health began to decline and she started to get overwhelmed.  I needed to meet with his doctors so I could introduce myself and find out from them what was happening.

Just as I have the Emergency Encounters series in which I write about my work in emergency medicine, I am starting this series, Undying Love, to write about end-of-life care-giving in today’s shifting medical climate.  Even in the short time I have been so actively involved, I have seen a lot.

Please pray for him and our family as I ask that the Holy Spirit allow these entries to bless other care-givers fighting to get medical treatment for their loved ones.

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