Performing Futile CPR Revisited

The May 27 issue of the New England Journal of Medicine has seven Letters to the Editor about Dr. Robert Truog’s February 11 article, “Is It Always Wrong to Perform Futile CPR?”

I’ve used that case with two ethics brown bag sessions and found the groups siding with Dr. Truog, much to my amazement.

The letters here lean toward the futility of the project and Dr. T replies, saying that “the pristine ethic of ‘treat only the patient, not the family’” is “simplistic” and “may not do justice to the complex dynamics that are often at play in end-of-life care.”

My two groups would agree!

-- Rosemary Flanigan, PhD, Distinguished Fellow, Center for Practical Bioethics

Yes, I think there are many of us who want clinicians to care for (which is maybe better terminology than “treat”) families and even communities, and not individual patients only.

The question that this does not answer, and Dr Truog doesn’t either, is what care of the family might mean in the situation Truog describes.

He assumes—without argument or support—that care for his young patient’s father meant performing “futile CPR” on a small child, and doing so in a manner that he states was so “brutal” as to make nauseous his nursing colleague.

This he claims is “treating the family.” Is it?

I ask whether one might offer care (“treating”) of families—even those who demand futile CPR or other nonbeneficial treatments—that doesn’t require futility or brutality to the patient, and that might then actually be more recognizable as care.

-- Tarris Rosell, PhD, Rosemary Flanigan Chair, Center for Practical Bioethics

Ethics and Public Health

Summer Johnson, PhD
May 21, 2010

What role does ethics play in public health, especially when it comes to emergencies? Summer Johnson, PhD explains in this edition of The Bioethics Channel.

Dr. Johnson is executive editor of the American Journal of Bioethics and director of graduate studies at the Center for Practical Bioethics.

Links:

Podcast, 13 minutes 49 seconds

Interview: George J. Annas on Worst Case Bioethics, BioEdge, May 17

Ethics Committees and Reviewing Policies

Rosemary Flanigan

May 25, 2010

I’m ashamed to say that our committee does NOT review patients’ rights policies every two years and I am going to find out who does review them!

I’ve just talked to George Flanagan who is visiting every ethics committee in our area and he tells me that almost all of them have policies to review on their agendas. Other entities in the hospital or system has recognized the need for the ethics committee to do a review—and I think that is wise.

Incidentally, in the May 27th New England Journal of Medicine there is an article by Bruce Vladeck (he gave one of our lectures several summers ago, and as I was taking him from one location to another, I “lost” I-70!!), “Fixing Medicare’s Physician Payment System.” What a conundrum!

AND that issue has seven Letters to the Editor about Dr. Truog’s article, “Is It Always Wrong to Perform Futile CPR?” I’ve used that case with two ethics brown bag sessions and found the groups siding with Dr. Truog, much to my amazement.

The letters here lean toward the futility of the project and Dr. T replies, saying that “the pristine ethic of ‘treat only the patient, not the family’” is “simplistic” and “may not do justice to the complex dynamics that are often at play in end-of-life care.” My two groups would agree!

Link: Futile CPR. Always Wrong?, Rosemary Flanigan, The Bioethics Channel

Obama: Proper Use of Bioethics Commission

Summer Johnson, PhD
May 24, 2010

Why do I say this bodes well for the Presidential Commission for the Study of Bioethical Issues?

The President had the presence of mind, for one, to remember that he has a bioethics commission and to use it for precisely what it was created to do, to in the words of its charter "identify and examine specific bioethical, legal and social issues related to the potential impacts of advances...in science and technology."

And ta-da! Here is what some have called one of the most important advances in biology in decades.

For more click here.

Ethics of Reproductive Tourism Questions

Summer Johnson, PhD

May 21, 2010

I was simply astonished to read the "ethical analysis" (if one could call it that) from DNAIndia.com in an article titled "New Age Moms Want Pregnancy Outsourced!"

Written from the Indian perspective, where everything from the UK and the US is outsourced to Indian laborers, I can understand the title, but the analysis is simply flawed every way.

For more click here.

What ethics committees AREN'T

Rosemary Flanigan

May 19, 2010

When we think of what ethics committees AREN’T, the Center for Practical Bioethics has always held that they are NOT “prognosticating”, nor do they have the “authority of judicial review”, nor are they final decision-makers.

What they are are vehicles to create islands of reflection in which participants in the case consult or in the policy deliberation or in the educational endeavor can best achieve responsible—and responsive—activity.

Maybe the success of ethics committees cannot be gauged by case consultation activities; maybe their success is in each committee’s role in policy development and evaluation or their activities in educating the institution and its outreach regarding ethical dimensions of health and healthcare.

In past ethics committee workshops, I have tried to teach participants how to develop a policy, draft it, disseminate it for comments, re-work it and send it throughout the institution—and evaluate and re-evaluate it. I’ve used our Consortium’s guideline document, “Honoring Do-Not-Resuscitate (DNR) Orders during Invasive Procedures,” as a template.

1) Statement of the policy. (Because DNR orders in the past have been disregarded when patients underwent invasive procedures and because doing so is clearly incompatible with the Patient Self-Determination Act, a clear policy is needed.)

2) Statement of the ethical principles involved. (Autonomy, certainly, but also beneficience; and risks/benefits need to be considered)

3) Define terms.

4) State the procedures.

5) Implementation and Evaluation.

All of which leads me to ask: What policy work has your committee accomplished recently?

Stem Cell Tourism and the Power of Hope

Christopher Thomas Scott

May 18, 2010

Thousands of people are heading overseas to seek treatments for rare and terminal conditions. How do we balance the needs of these desperately sick individuals with the need for rigorous, evidence based medicine? How do we reach that balance without treading on the power of hope?

Christopher Thomas Scott, director of the Stanford Program on Stem Cells in Society, co-authored a target article on the subject in the May 2010 issue of The American Journal of Bioethics. He discusses the issue with Lorell LaBoube in this edition of The Bioethics Channel.

Links:

Podcast, 13 minutes 29 seconds

Table of Contents, May 2010 American Journal of Bioethics

Analysis: Abortion Fight in Phoenix

John Carney

May 17, 2010

For those of you who are not Catholic (and maybe even for those of you who are) this may seem like splitting hairs but the Bishop in Phoenix (who was in Wichita, KS before transferring to Phoenix) did not excommunicate Sister Margaret McBride. According to the Diocese, Sister McBride was a Catholic who substantially assisted another in an abortion and thus incurs a latae sententiae excommunication.

The Bishop’s statement simply reflects that such a sentence of excommunication is incurred “by the very commission of the offense,” (CCC 2272) and does not require the future particular judgment of a case by competent authority. The Diocesan statement points to the canon that she did this to herself.

The hospital’s position is that two ERDs (Ethical and Religious Directives - Catholic hospital rules) were in conflict with the particular condition of the patient. One directive (#45) states that abortion is never permitted, even to save the life of the mother, while the other (#47) notes that "operations, treatments and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted...even if they will result in the death of the unborn child."

The Diocese either disagreed about the procedure being necessary at the time it was allowed (11 weeks and unable to be postponed until “the unborn child was viable”) or it read the “conflict” between the ERDs differently.

The Ethical and Religious Directives are produced by the United States Council of Catholic Bishops - a national organization. But each Bishop has authority in his “see” or Diocese. It is unknown, at least at this reporting, how involved the Bishop’s office was in the decision of the Catholic hospital to permit the abortion, but given the Diocesan statement it’s not likely that it was a lot.

The church’s official position on abortion is univocal. You may remember the 2009 case of the 9 year old Brazilian girl who was repeatedly raped by her stepfather and was pregnant with twins. Clergy in Brazil and at the Vatican supported statements that the mother of the young girl (not the twins’ mother) and the doctors were excommunicated because of their proactive stance - taking the fetuses prior to any required life saving intervention.

The actions of the step-father (rapist) in the judgment of many adults, was far more morally reprehensible than the deliberate taking of the innocent babies by those acting on behalf of the young pregnant girl.

My concern is that thoughtful compassionate leaders on both sides of this issue will continue to disagree on the intersection of science and religion, and that Catholic Hospitals will struggle with what it means to be or remain Catholic or to abandon the label altogether and claim only to having once had a Catholic tradition.

Link: Phoenix hospital nun rebuked for allowing abortion, The Associated Press, May 15, 2010

Pain Contracts: Policy Implications

Final of Three Part Series

On April 27 the Center for Practical Bioethics convened a broad spectrum of pain management professionals to consider the utility and the ethics of pain contracts or agreements. The meeting focused on professional, patient and policy issues around physician use of contracts to prescribe opioids and other pain medications.

The Center will produce a policy brief from comments delivered during this gathering and the November issue of the American Journal of Bioethics will be devoted to the concept of pain contracts.

In this third and final segment of a three part series, The Bioethics Channel examines the policy implications of pain contracts.

Pain Contracts: Too Many Variables, Aaron Gilson, Director – Pain and Policy Studies Group, University of Wisconsin, 10 minutes 18 seconds

Pain Contracts: Trust but Verify?, Ben Rich, University of California-Davis, 7 minutes 33 seconds

Ethics Committees as Decision Makers?

Rosemary Flanigan
May 14, 2010

In New Jersey we have the case of the 73 year old man in a persistent vegetative state for nearly a year, hooked up to a ventilator, dialysis machine and feeding tube because the patient’s daughter did not agree to the futility conclusion reached by the medical staff and who sued—and won—when the hospital placed a “do not resuscitate” sign on his bed and halted dialysis.

Oh, we are getting good at endorsing family’s determination about “extraordinary” means—but we are not so good when family won’t agree to our clinical conclusions.

So a group of physicians and “bioethics experts” in New Jersey are advocating “for an independent ethics committee to help resolve end-of-life disputes between families and hospitals.”

WHOA!! Aren’t we jumping the gun here? Aren’t ethics committees designed to help OTHERS make good decisions? Haven’t we long held the conviction that “ethics committees are not decision-makers”? I see the need for help here, but let’s call it BY ANOTHER NAME.

Agree? Disagree? I’m all ears!!!

Link: New Jersey needs independent panel to resolve disputes over end-of-life care, Editorial, New Jersey Star-Ledger, May 12, 2010

"Purposeful" vs "Desired" Medicine

John Carney
May 13, 2010

We routinely don’t put some patients on transplant lists because they aren’t candidates. How is keeping a dying patient unable to receive benefit from a feeding tube off the “feeding tube list” any different? Because it is less expensive, less technically challenging, less burdensome?

A recent article suggests that feeding tubes not be inserted unless a 30 day goal was reasonable. If that kind of clinical indicator was required before insertion and was considered the standard of care we may find ourselves hesitating or waiting more often than we do now.

We used to believe that CPR attempts for frail elderly were OK - until we started studying the clinical outcomes. If it don’t work, we don’t do harm when we don’t do it.

I just think as we proceed with Comparative Effectiveness Research relying more and more on evidence based medicine to assist us in what is purposeful versus what is desired or requested, we may begin to see delays in non-emergent procedures and changes in evolving standards of care.

Patients and agents can ask, and should ask, but we may find ourselves responding more frequently “not now,” or “not yet”, or simply “no.”

Feeding Tube Futile?

Rosemary Flanigan

May 12, 2010

An 86-year old woman suffered a massive intracranial hemorrhage, was admitted to the hospital through the emergency room, intubated and then extubated per her wishes in her advance directive. Since suffering her stroke she has been in a persistent coma with no meaningful response to verbal stimuli, only spontaneous movement on the right side and facial grimacing.

The patient wrote an advance directive in 2004 witnessed and talked over with by her son but not discussed in the intervening years. On her form she initialed the life-sustaining procedures she wished withheld or withdrawn if she is in an “irreversible condition as a result of injury, disease or illness, such as extreme mental deterioration and two physicians have certified that her condition is terminal or cannot be significantly reversed.”

Those conditions are: antibiotics, CPR, respirator, radiation, surgery, prescribed medications, chemotherapy, and kidney dialysis. What she DIDN’T initial were artificial nutrition and artificial hydration. When a feeding tube was mentioned, the son agreed saying that, since her advance directive was being followed in other ways, it ought to be followed here, too.

She died with a feeding tube. I support inserting the feeding tube; if advance directives are our moral and constitutional right, then they ought to be followed.

A colleague at the Center makes an excellent argument – the feeding tube ought not have been offered. It is not palliative; it does not benefit her; it is futile.

What do you think?

24 Hour Genetic Testing at Your Local Walgreens

Summer Johnson, PhD

May 11, 2010

Courtesy of Pathway Genomics and Walgreens Pharmacy in 7500 pharmacies around the nation, you too can send your spit off for genetic analysis and find out your genetic predisposition for a wide range of conditions including breast cancer, diabetes, and Alzheimer's disease, says ABC News.

Of course, over-the-counter genetic tests have been debated to death and the ethical issues are obvious, but what I'd love to see at my Walgreens pharmacy is someone going up to the pharmacy counter and speaking to the pharmacist about whether to take such a test.

For more from bioethics.net click here.

Link: Company plans to sell genetic testing kit at drugstores, Washington Post, May 11, 2010

Biomedical ethics in a brave new world

Ken Camp
Associated Baptist Press
May 06, 2010

“We’re still dealing with the age-old question: ‘Given what can be done, ought we?’ But the list of ‘can-do’ options in health care get longer each day; hence, also the ‘ought’ questions and the complexities of knowing right from wrong, good from bad,” said Tarris Rosell, professor at Central Baptist Theological Seminary in Shawnee, Kan., and the Rosemary Flanigan Chair at the Center for Practical Bioethics in nearby Kansas City, Mo.

Click on story here.

Pain Contracts: Good for Patients?

Second in Series

On April 27 the Center for Practical Bioethics convened a broad spectrum of pain management professionals to consider the utility and the ethics of pain contracts or agreements. The meeting focused on professional, patient and policy issues around physician use of contracts to prescribe opioids and other pain medications.

The Center will produce a policy brief from comments delivered during this gathering and the November issue of the American Journal of Bioethics will be devoted to the concept of pain contracts.

In this second of a three part series, The Bioethics Channel examines patient issues involved in pain contracts.

*Pain Contracts: A Patient Perspective, Carlton Haywood, PhD, Johns Hopkins Berman Institute of Bioethics, 9 minutes 42 seconds

*Pain Contracts: Social Determinants, Carmen Green, MD, University of Michigan, 10

*Pain Contracts: Balance at the Bedside, Will Rowe, President and CEO, American Pain Foundation, 5 minutes 4 seconds