Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, March 15, 1992 TAG: 9203130186
SECTION: CURRENT PAGE: NRV-1 EDITION: NEW RIVER VALLEY
SOURCE: RICK LINDQUIST CORRESPONDENT
DATELINE: RADFORD LENGTH: Long
Not many years ago, most hospital patients let their doctors make medical decisions for them.
Often, patients' rights to accept or reject treatment could be largely ignored. Doctors or families might make the critical choices instead, leaving the patient out of the loop.
Now a new federal law and mushrooming medical technology that makes it possible for doctors to greatly extend our stay on Earth are changing the way doctors and patients do business.
State law says every mentally competent adult has a right to determine what shall be done with his or her own body.
The federal Patient Self-Determination Act, which became effective Dec. 1, requires that patients in most health-care facilities be told of those rights.
It also encourages people to choose how much or how little medical intervention they want under certain circumstances, even if they lapse into a coma.
Instead of being told what's best, patients now can give their "informed consent" to the medical treatment their physician recommends, provided they're still able to make rational decisions.
To handle the ethical issues and explore the options growing out of today's complex health-care environment, institutions such as Radford Community Hospital have found they must formulate new policies and procedures.
"Technology has made it more evident that we need this," said Dr. William Crafford, who heads a multidisciplinary ethics committee designed to inform and support patients' freedom of choice. "Our ability now to sustain life has made this more of an issue."
On a more practical level, he points out that costly life-sustaining medical procedures taken to extreme in a losing medical battle can wreak financial ruin on a family.
As it fine-tunes its role, Crafford's committee will chart the course of future bioethical policies at Radford and other institutions looking to it for direction. But its immediate goal is to make people aware of their rights to receive only the degree of care they desire, even if they are unable to tell the doctor what they want when the time comes.
"I think up until recently, the question has been: `What do you want us to do for your dad?' " said G.C. Duck, a member of the ethics panel and the hospital's director of Patient Family Care Services. "That's a difficult thing for a family."
It also can be difficult for the doctor, said Crafford, a cardiologist who has been on the other side of the exchange.
Duck and Radford Community Hospital staffer Jean Allmann have completed a six-month program at the University of Virginia's Center for Biomedical Ethics that explored the issues and the formulation of advance directives, including living wills and durable medical powers of attorney.
Advance directives apply when the patient no longer can express informed consent about treatment. A living will directs doctors to refrain from measures that artificially prolong the process of dying in terminal cases. A durable medical power of attorney lets patients authorize an agent to make all health-care decisions on their behalf.
"We want the public to know about this sort of thing before it hits them in the face," said Duck, adding that the people who seem to respond best to his message are those who have had experience with an older relative.
Duck has first-hand experience, himself. His brother-in-law, who had not executed any advance directives, suffered a sudden, massive cerebral hemorrhage and lapsed into an irreversible coma.
While his sister knew her husband would not have wanted to be maintained in a coma, she also could not bring herself to decide to remove life support, Duck said.
"This doesn't necessarily happen when you're 70 or 80 years old. This is right now," he said. Duck's brother-in-law was 49 and appeared healthy.
Duck concedes that stories about people who have returned from long, seemingly irreversible comas make some people reluctant to file living wills, fearing treatment might be halted too soon.
Both he and Crafford agree that advance directives are not for everyone.
"It's not that we're trying to convince them to decide one way or the other. We're trying to give them the options that are available, " Crafford said.
"People don't seem to have a grasp of what the medical community can do to preserve life," Duck said. "It's just that, once that sort of thing is embarked on, it might carry that person's life beyond the point they might have wanted it to be carried."
But carrying out choices and administering extreme treatment can be hard on doctors, too. For example, Duck said, physicians must ask themselves whether they'd really be acting in the best interests of a terminal cancer patient by resuscitating him after a cardiac arrest.
In fact, the ethics committee recently established the hospital's policy on "Do Not Resuscitate" orders to make that choice an all-or-nothing proposition.
"There were a lot of ambiguities about how people were to be taken care of in an arrest," Crafford said. Under the new policy, patients can choose to let doctors take all possible measures or do nothing.
"Either you go all the way or you do not resuscitate," he said, adding that the committee prefers to have such decisions in advance, not at the last minute or during a medical crisis.
The committee still is grappling with a policy on patient-care "contentions," where patient and family disagree on the course of treatment.
"Often times, that comes down to being a communication problem between patient and physician," said Crafford, emphasizing that hospital professionals outline the ethical options but do not dictate decisions.
The ethics committee also is planning for health-care "rationing," already a reality in other countries.
Crafford said there is a rising demand for high-cost, high-tech medical intervention such as organ transplants, artificial implants and advance resuscitation techniques. Someone must decide, he said, who gets such treatment and who does not.
by CNB