The Cruzan Case and Advanced Directives

The Cruzan Case Missouri Supreme Court, )Treatment vs. Care Special Status of Nutrition and Hydration: Treatment is treatment Nutrition and hydration is care Treatment can be refused Nutrition can only rarely be refused, if at all What makes nutrition and hydration special?

The Cruzan Case 2)Benefits vs. Burdens No consideration of burdens on the family No consideration of burdens on the state No consideration of any burdens other than those on Nancy Cruzan herself Continued care presents Nancy Cruzan with no significant burden, therefore there is no good reason to remove it.

The Cruzan Case 3)Removal of care or treatment requires "clear and convincing evidence" of the patient's wishes Standards of Evidence: a)Preponderance of the evidence b)Clear and convincing evidence c)Proof beyond a reasonable doubt

The Cruzan Case 4)Competing state interests Interest in the protection of privacy: right to control what happens to one's body, right to refuse treatment vs. Interest in protecting life unqualified Life unqualified has greater weight

The Cruzan Case U.S. Supreme Court, )Right to refuse treatment is protected by the liberty interest of the Constitution 2)"Treatment" includes nutrition and hydration 3)Each state may set its own rules and procedures for withdrawing or withholding treatment (parallel to Webster decision on abortion) Main Issue: What counts as "clear and convincing evidence"? Patient Self-Determination Act (1991)

Advance Directives Some Form of Advance Directives: Verbal instructions (Cruzan) Living Will Medical Directive Durable Power of Attorney for Health Care Advance directives only become effective when the patient is incompetent or can't communicate

The Hierarchy: Competent Patient Incompetent Patient: With Instructions: Verbal instructions Living Will Medical directive Durable Power of Attorney for health care Without Instructions: Substituted judgment Best interests Advance Directives

Generally, advance directives are attempts to limit, withdraw, or withhold treatment Exception: Wangli Case One response: Physicians are not required to provide treatment which is futile, or no medical benefit How is futility defined?

Advance Directives Ethical Support for Advance Directives: Supports right to refuse treatment Honors individual autonomy Promotes individual decision making Tends to reduce family conflict

Advance Directives The "Push" for Advance Directives American fear of final days of life with a loss of dignity and bound to medical technology American fear of final days of life spent in unrelieved pain and discomfort American fear of final treatments reducing personal and family resources

Advance Directives Problems with Advance Directives What does "incompetence" mean? What counts as a "reasonable time" for determining terminal condition? What is a "terminal condition"? What is "irreversible"? Generally, vague and imprecise language

Advance Directives Problems with Advance Directives (cont.) Restricts physicians' clinical judgment Support study (Jamma, 1998) shows that advance directives are often ignored The bottom line: advance directives are attempts to limit treatment, however imprecise they may be Err on the side of doing less rather than doing more

Futility An issue raised by the Wangli case Futility issues can occur at any stage of life Jecker and Pagon, Fost articles What does futility (futile treatment) mean? a)of no benefit to the patient, i.e. the treatment in question is no likely, given the current state of medical knowledge, to reverse or improve the patient's condition-quantitative futility b)the quality of outcome which results from the treatment is extremely poor c)...a) or b) in such a way that it will not be felt, recognized, or known by the patient d)places an undesirable burden on the patient (e.g. continues physical pain and suffering) e)treatment is inhumane, undignified; treatment continues an existence that is not humanly meaningful

What does futility (futile treatment) mean? (cont.) c)...a) or b) in such a way that it will not be felt, recognized, or known by the patient d)places an undesirable burden on the patient (e.g. continues physical pain and suffering) e)treatment is inhumane, undignified; treatment continues an existence that is not humanly meaningful Futility

Some questions: Can a treatment be futile (in whatever sense) for the patient but beneficial for others, e.g. family, friends, caregivers? Will a treatment be called futile when it costs too much? Could futility move from being used to talk about medical benefits to cost/benefit? The assumption: Physicians need not provide, and patients should not ask for, futile treatment