§ 166.046. PROCEDURE IF NOT EFFECTUATING A DIRECTIVE OR TREATMENT DECISION.
My comments are interspersed and at the bottom. Emphases are mine.
(a) If an attending physician refuses to honor a patient’s advance directive or a health care or treatment decision made by or on behalf of a patient, the physician’s refusal shall be reviewed by an ethics or medical committee. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review.
Please note that the decision is the doctors’ to make. The committee may affirm or not.
(b) The patient or the person responsible for the health care decisions of the individual who has made the decision regarding the directive or treatment decision:
(1) may be given a written description of the ethics or medical committee review process and any other policies and procedures related to this section adopted by the health care facility;
(2) shall be informed of the committee review process not less than 48 hours before the meeting called to discuss the patient’s directive, unless the time period is waived by mutual agreement;
(3) at the time of being so informed, shall be provided:
(A) a copy of the appropriate statement set forth in Section 166.052; and
(B) a copy of the registry list of health care providers and referral groups that have volunteered their readiness to consider accepting transfer or to assist in locating a provider willing to accept transfer that is posted on the website maintained by the Texas Health Care Information Council under Section 166.053;
(4) is entitled to:
(A) attend the meeting; and
(B) receive a written explanation of the decision reached during the review process.
(c) The written explanation required by Subsection (b)(2)(B) must be included in the patient’s medical record.
(d) If the attending physician, the patient, or the person responsible for the health care decisions of the individual does not agree with the decision reached during the review process under Subsection (b), the physician shall make a reasonable effort to transfer the patient to a physician who is willing to comply with the directive. If the patient is a patient in a health care facility, the facility’s personnel shall assist the physician in arranging the patient’s transfer to:
(1) another physician;
(2) an alternative care setting within that facility; or
(3) another facility.
Either the doctor or the patient or the person making decisions for her may object to the ethics committee conclusion.
The doctor who has decided that the treatment is inappropriate may transfer to another doctor in the hospital or another place in that hospital or another hospital.
(e) If the patient or the person responsible for the health care decisions of the patient is requesting life-sustaining treatment that the attending physician has decided and the review process has affirmed is inappropriate treatment,the patient shall be given available life-sustaining treatment pending transfer under Subsection (d). The patient is responsible for any costs incurred in transferring the patient to another facility. The physician and the health care facility are not obligated to provide life-sustaining treatment after the 10th day after the written decision required under Subsection (b) is provided to the patient
or the person responsible for the health care decisions of the patient unless ordered to do so under Subsection (g).
(e-1) If during a previous admission to a facility a patient’s attending physician and the review process under Subsection (b) have determined that life-sustaining treatment is inappropriate, and the patient is readmitted to the same facility within six months from the date of the decision reached during the review process conducted upon the previous admission, Subsections (b) through (e) need not be followed if the patient’s attending physician and a consulting physician who is a member of the ethics or medical committee of the facility document on the patient’s readmission that the patient’s condition either has not improved or has deteriorated since the review process was conducted.
(f) Life-sustaining treatment under this section may not be entered in the patient’s medical record as medically unnecessary treatment until the time period provided under Subsection (e) has expired.
There is a distinction here between “inappropriate” treatment and “medically unnecessary” treatment.
(g) At the request of the patient or the person responsible for the health care decisions of the patient, the appropriate district or county court shall extend the time period provided under Subsection (e) only if the court finds, by a preponderance of the evidence, that there is a reasonable expectation that a physician or health care facility that will honor the patient’s directive will be found if the time extension is granted.
(h) This section may not be construed to impose an obligation on a facility or a home and community support services agency licensed under Chapter 142 or similar organization that is
beyond the scope of the services or resources of the facility or agency. This section does not apply to hospice services provided by a home and community support services agency licensed under Chapter 142.
First, I probably would not remove the ventilator against the patient’s or the patient’s family’s wishes. But I would cease hooking Mrs. Clark up to the dialysis and stop the tests and as many of the other invasive procedures as possible if I were convinced that I was hurting her more than I was helping her. As organ system after organ system failed, each added treatment requires more and more complicated coordination and has less and less chance of actually helping.
Unfortunately, I’m not sure that the TADA allows for refusal of some of the intensive treatment, while maintaining the rest.
There are still comments about what the hospital or the ethics committee is doing. While I suspect that there is some hostility between the family and some of the hospital personnel, the hospital cannot practice medicine.
I’m surprised that any facility that is capable of both ventilation and kidney dialysis cannot give any sort of medications that a patient would need. The hard part would be finding someplace that can monitor both the ventiliation and the dialysis. The only guess I have is the need for constant supervision of pressors – medicines that make the blood vessels tighten up so that the blood pressure can be maintained high enough. These medicines are very dependent on nurses and protocols, unless the doctor can stay at the bedside and turn the dials himself.
I’m surprised about the way people are talking and writing about the doctors, the ICU nurses and the hospital personnel in general. In your experience, are ICU nurses likely to be in on the conspiracy that is alleged?
On the contrary, the nurses are probably struggling to suppress their grief at the torture they are forced to inflict on Mrs. Clark.
For that matter, I haven’t seen many conspiracies hold up as well as the rumored “aggreement” between the Houston hospitals that are said (by Wesley Smith and others) to refuse to accept Andrea because St. Luke’s has declared her treatment futile.
More than likely the truth is that other doctors and hospitals understand the medical situation and agree that the care is prolonging death and actually adding complications that may lead to death.
As to pain and sedation: 75% of patients on dialysis have itching. I’ve had to practically knock them out with antihistamines and tranquilizers.
Now then, I’ve seen criticism about the doctor going on vacation this week. In most large facilities, the vacation times are planned a year in advance. And I know that I have to buy airplane tickets and make reservations in advance to save money. And I can’t imagine telling my kids they can’t go on vacation. They were used to the phone ringing in the night, but they expected me to be home on my vacations and other times I’d arranged for another doctor to cover for me. If doctors only went on vacation when none of their patients were sick, they’d never get to go.
It’s likely that the doctor thought the family would be swayed by the ethics committee and/or their decision and that this would all be over before he left.
Edited 3/18/2012, for changes in formatting necessary after moving the blog from Blogger.com to WordPress.com. For some reason, I got extra characters in the old posts. In this case, I also added that the “Emphases are mine.”
>I am so glad to read a blogger who has some concept of what might actually be happening in this case. As I have posted elsewhere, I'm sure we don't have the whole story… I wonder why we don't hear of what her son (who is 23) wants for his mother or why we aren't hearing what the patient herself wants (if she is capable of communicating as her sisters say that she is). Having worked with clinicians, I know of the complexities of these fragile patients. You are so right about the unfairness of criticisms of the doctor's vacation time, etc. Thanks for being a voice of reason in this whole thing.
>Thank you, your support means a lot.