Danger: Mandating End of Life Discussions
John Lantos, MD
John B. Francis Chair in Bioethics
Center for Practical Bioethics
July 16, 2008
The California legislature is trying to mandate certain conversations between doctors and patients. Such an approach to medical practice is dangerous.
Doctors ought to talk to patients about many things. Patients ought to know about the importance of good nutrition, weight control, and smoking cessation. They should know the risks and benefits of every treatment that their doctor recommends and of alternative treatments. They should know their prognosis.
Such discussions require time. Patients must be helped to understand complicated treatment algorithms and complex probabilities. Discussions of end-of-life care can be emotionally complex. The process of initiating and structuring such discussions is the art of medicine.
Some doctors are better at it than others. Medical educators try to improve doctors’ skills at such conversations, with only limited success. It is unlikely that legislative mandates for such discussions will succeed where education has failed.
Attempts to legislate specific conversations will quickly run into legal, moral and semiotic problems. If the legislature can mandate certain discussions, can they forbid others? What sort of policing mechanisms would be necessary to nab violators? Will California cops be carefully monitoring every clinic to insure compliance?
Doctors may not always get things right. Legislators would be even worse.
What do you think? Share and view your thoughts by clicking on "comments" below.
Links:
California bill would mandate discussions of end-of-life options, American Medical News, July 14
Making Your Wishes Known for End-of-Life Care
California State Assembly Bill 2747 on end-of-life care
Religion, Conscience, and Controversial Clinical Practices, abstract, New England Journal of Medicine, Feb. 8, 2007 (Note: co-authored by John Lantos, MD, John B. Francis Chair in Bioethics, Center for Practical Bioethics)
Medical Futility Blog, Thaddeus Pope, July 7
John B. Francis Chair in Bioethics
Center for Practical Bioethics
July 16, 2008
The California legislature is trying to mandate certain conversations between doctors and patients. Such an approach to medical practice is dangerous.
Doctors ought to talk to patients about many things. Patients ought to know about the importance of good nutrition, weight control, and smoking cessation. They should know the risks and benefits of every treatment that their doctor recommends and of alternative treatments. They should know their prognosis.
Such discussions require time. Patients must be helped to understand complicated treatment algorithms and complex probabilities. Discussions of end-of-life care can be emotionally complex. The process of initiating and structuring such discussions is the art of medicine.
Some doctors are better at it than others. Medical educators try to improve doctors’ skills at such conversations, with only limited success. It is unlikely that legislative mandates for such discussions will succeed where education has failed.
Attempts to legislate specific conversations will quickly run into legal, moral and semiotic problems. If the legislature can mandate certain discussions, can they forbid others? What sort of policing mechanisms would be necessary to nab violators? Will California cops be carefully monitoring every clinic to insure compliance?
Doctors may not always get things right. Legislators would be even worse.
What do you think? Share and view your thoughts by clicking on "comments" below.
Links:
California bill would mandate discussions of end-of-life options, American Medical News, July 14
Making Your Wishes Known for End-of-Life Care
California State Assembly Bill 2747 on end-of-life care
Religion, Conscience, and Controversial Clinical Practices, abstract, New England Journal of Medicine, Feb. 8, 2007 (Note: co-authored by John Lantos, MD, John B. Francis Chair in Bioethics, Center for Practical Bioethics)
Medical Futility Blog, Thaddeus Pope, July 7
Labels: advance directives, end of life, medical futility
posted by Practical Bioethics at
8:12 AM
3 Comments:
This is part of a larger issue of how to assure that members of the learned professions practice in an excellent manner, and what to do when they don't. People's expectations are so high, and yet people are so imperfect, that we need a truly informed discussion of how to both insist upon excellence, and deal with failure. So far, we're ineffective and inconsistent at both.
It is a sad commentary on healthcare providers that state legislators are pushing for disclosure for patients regarding end of life care conversations. Apparently, the failure of healthcare providers to have these conversations is driving this. As healthcare dollars become more scarce, it only makes sense for healthcare providers to utilize these resources more wisely and compassionately. Extending the suffering of a patient whose outcome is certain is not only inhumane but futile. How many healthcare dollars are spent on futile care?
Each commentator raises interesting and I think valid concerns. However, I am in agreement with Dr Lantos that legislating/mandating EOL conversations between providers and patients is a wrongheaded solution to what is likely a real problem. My sense is that physicians are expected to cover more and more verbal or other territory in the exam room but with ever smaller time increments in which to do so. Patients often then experience less opportunity to express 'what's really going on' to a clinician who literally has insufficient time to really listen. Therefore any mandates of the sort considered in California, although well intended, are apt to be met with legitimate resistance--not due to death denying clinicians, but by those who continually are being asked to do more with less.
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