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Topic: Life Sustaining Treatment
July 28, 2015 | Posted By Claire Horner, JD, MA

As Jane Jankowski, DPS, LMSW discussed in her last AMBI blog posted on June 16, 2015, the proposed rule to reimburse providers for conversations with patients about advance care planning takes a positive step toward educating patients on end-of-life medical considerations by incentivizing doctors to take the time to address these issues in the clinical setting.  Assuming that such reimbursements depend only on raising the topic of advance care planning with patients and not on the content of a patient’s choices (such as whether or not a patient chooses to forego treatment), encouraging health care providers to discuss health care decision making in advance with patients can go a long way to support patient autonomy and provide helpful guidance to surrogate decision-makers when a patient lacks capacity.  Doctors often cite lack of time as a reason why they do not address advance directives in the clinical setting, but this rule would compensate doctors for their time, allowing them more flexibility in allocating time to address these issues.  However, the proposed rule does nothing to ensure that the providers having these conversations are equipped with the proper tools and training to do so.

Advance directives, although they address the provision of medical treatments, are legal documents that can be complex and far-reaching, and therefore are not necessarily self-explanatory to patients or providers.  Many states offer a statutory form advance directive as an example, but all too often these forms may be merely printed by a provider and given to patients to sign without sufficient explanation.  These forms vary in their scope, but some sample living wills, such as forms from West Virginia and South Carolina, are little more than a declaration that no life-sustaining treatments should be provided.  Other states, such asMichigan and Massachusetts, have no law giving legal recognition to living wills at all.  It is possible that patients may be given forms such as these and not understand that they have the option to declare that they wish to receive particular life-sustaining treatments if they are terminally ill.  It is also possible that patients who do not want to limit treatment will decline to sign any advance directive at all, believing that such documents serve only to support a decision to forego treatment at the end of life, and not a decision to receive some or all interventions.  In such situations, merely starting the conversation may not be enough to help patients effectively articulate their wishes, whatever those wishes may be.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 16, 2015 | Posted By Jane Jankowski, DPS, LMSW

Last week the Centers for Medicaid and Medicare announced a proposal that would provide Medicare reimbursement for providers to spend time with patients discussing advance care planning. Though some have argued that this process will carry an inherent bias toward non-treatment, the purpose of such conversations is to seek direction from patients about preferences, values, and expectations should they lose the ability to express these things for themselves. While many persons who articulate their treatment preferences indicate the desire to forego aggressive intervention, this is hardly unanimous. There are plenty of folks who want all possible treatment offered to sustain life. The point of having discussions with healthcare providers is to determine what any given individual prefers.

Acute care providers have long been left with challenging dilemmas when patients are unable to communicate their healthcare goals, and the default is to treat and often treat aggressively. When a patient arrives to an acute care setting with documentation of preferences for treatment, interventions and goals can be set based on the individual’s prior wishes – whether this is to sustain life using any possible technology, or to allow a natural, uninterrupted dying process. The default of treating when there is any doubt will not change, but the opportunities for patients to discuss and document their own preferences will be enhanced with this legislative support. Providing muscle in the form of funding for these important conversations will only encourage more of a good thing. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

April 29, 2014 | Posted By Marleen Eijkholt, PhD

Earlier this month, the New York Times (NYT) reported on individuals in a minimally conscious state (MCS). Although the article headed: ‘PET Scans offer clues on Vegetative States’, its contents addressed the technologies around MCS: a ‘newly’ diagnosed state of consciousness. The paper commented that PET scans would be more beneficial than functional Magnetic Resonance Imaging (functional M.R.I.) in diagnosing this state. Around the same time, the NYT published a paper that headed: ‘Cost of treatment may influence doctors’. This paper quoted a doc saying: “There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors,”

In this blog post I want to focus on the cost and price of consciousness. I do not only want to focus on the economic costs, but also on costs in a more holistic sense, including the psychological and emotional costs. In the end, I want to ask you: how much is consciousness worth to you?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.bvg

January 30, 2014 | Posted By Marleen Eijkholt, PhD

When people asked my ethical opinion about Marlise Munoz’s case, the brain dead woman who was kept on support for her fetus, I believe they expected a quick answer: this is wrong. Clinical or medical ethicists are often called for a quick answer: this is right or this is wrong. However, answers about why X is right or why X is wrong do not come quickly. Often there are many rights and many wrongs in a story. My answer why it is unethical to keep Mrs Munoz on support is the result of a sum of rights and wrongs. In my opinion the ‘rights’ are less weighty than the ‘wrongs’, and I will set my arguments out below.

Marlise Munoz was 14 weeks pregnant when her husband found her unconscious and brought her to the hospital. The hospital found that she fulfilled the criteria of brain-death, but did not declare her brain death yet (according to the latest reports) . They kept her on ventilator and nutritional support and argued this was required under Texas law, suggesting that it was not allowed to withhold or withdraw life-sustaining treatment from a pregnant patient.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 16, 2014 | Posted By Jane Jankowski, LMSW, MS

Our society is once again grappling with the challenges presented when medical technology (e.g. mechanical ventilation) is used to sustain physiological function in the absence of brain function. How we should define death, and who should be allowed to decide, is part of a very public debate in the wake of the Jahi McMath case out of Oakland, California and the Munoz case in Texas (NY Times). Though this is hardly a new issue for bioethics, the reality is that there is a clearly a chasm between the acceptance of brain death criteria as a sufficient definition of death.

The acceptance of brain death criteria in the 1980s as a legally and medically sanctioned definition of death was established in response to the controversy surrounding the obligation to sustain a patient’s respiratory function despite the absence of any brain function. When this irreversible loss of brain function occurred it was widely agreed there was no benefit to any further medical intervention and machines could be turned off, organs harvested, and the loved ones could move forward with processing the traumatic loss.  If a patient was brain dead, this was dead enough to qualify as no longer living. What drives the resistance to this definition? That the life function of circulation of blood and a beating heart continues indeed suggests the body is still alive.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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