Friday, May 8, 2009

Clarifying Texas Advance Directives Statute

Kendra J. Belfi, MD, CMD, FACP
Private practice of internal medicine and geriatrics
Fort Worth, Texas

May 8, 2009

Elizabeth Graham of Texas Right to Life was quoted recently in a story about the Texas Advance Directive Statute. (

I was particularly concerned about what she said about doctors writing unilateral DNR orders without consulting patients.

In my experience as an ethics consultant at a hospital in Fort Worth-the main problem is that doctors write unilateral full code orders on everyone without asking patient or family their wishes.

In our institution, in order for the doctor to write a DNR order without patient input the patient needs to be unable to express his wishes and there needs to be no available surrogate--AND there must be two physicians signing, one whom must be a member of the ethics committee.

I also think Ms. Graham’s statement about euthanasia is very misleading.

There is neither physician assisted suicide nor euthanasia legalized in the state of Texas. Before the dispute resolution process is even invoked, there has generally been a long hospitalization, multiple attempts to resolve things outside the process and then a series of meetings before the 10 day clock even begins to run.

The San Diego Bioethics consortium has recently drafted a model hospital policy on non-beneficial treatment and conflict resolutions which I believe has some very good definitions. They point out that parties may disagree on the best course of action in the care of a patient. Steps must be taken to resolve the dispute if the treatment team believes that 1) continuing treatment is non-beneficial or 2) The burden of suffering and intrusiveness of treatment significantly outweighs any potential benefit or 3) treatment is contrary to generally accepted medical standards but the patient or surrogate continue to request the disputed treatment.

I wholeheartedly agree with their statement that "A health care provider or institution is not obligated to comply with health care instruction(s) or decisions(s) that requires non-beneficial treatment or treatment contrary to generally accepted health care standards. "

This is a long-standing ethical principle in American medicine and I believe that physicians need to be courageous enough to stand up to families that are requesting treatment that is neither appropriate nor medically beneficial to patients.

The political compromise that was reached when the Texas Advance Directive act was passed was that patients had a virtually total right to refuse treatment but did not have a corresponding right to demand inappropriate treatment. The example I use for lay audiences is that you cannot demand a liver transplant if you do not meet the criteria for liver transplantation.

People seem to understand that scenario--but often do not understand that there are many other scenarios in which patients/surrogates are demanding inappropriate care.

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