1. Withholding Treatment from Non-Dying Patients Carol Bayley Ethics Champions Program June 2006

2. A Case Man had esophageal cancer 2 years ago. Treatment scarred his throat and eliminated his ability to taste. It also eliminated his cancer. For two years, the man has used a g-tube to supply nutrition. Now he has decided to stop using it. He says he has no quality of life and is afraid the cancer will come back.

3. Two Principles Beneficence (Do no harm; help) Self-Determination (Respect a person’s decisions about his or her treatment) HOW DO WE RESOLVE THIS TENSION?

4. (add poll) What is the lingering moral qualm? This person is not dying; this is suicide. This person is not competent; we can’t rely on his “decision.” He might be competent, but he doesn’t know what is good for him; we should discharge him if he doesn’t agree to eat. This man must be miserable, lonely and unhappy. How sad that the best we can do for him is let him die.

5. He is not dying; this is suicide Diabetic refusing insulin? Hypertensive refusing meds? Someone with gangrenous (toe, leg) refusing amputation?

6. He is not competent Capacity vs competence Capacity is assumed unless pt is determined otherwise Capacity isn’t measured by whether the decision comports with medical advice

7. Capacity to make a medical decision Understand diagnosis and prognosis Understand the nature of the treatment Understand the risk, possible benefit and the alternatives to the treatment Able to reason about the above Communicate decision

8. He doesn’t agree with us; let’s discharge him Abandonment “doesn’t know what is good for him” Coercion

9. He is sad and lonely Persuasion vs coercion Capacity?

10. (add poll) where is this case on the continuum? Gandhi’s hunger strike X Withdrawing ventilator from Karen Quinlan

11. When can a patient refuse medical treatment? When the treatment is “extraordinary” When the burdens of the treatment outweigh the benefits When the benefits are too small

12. (add poll) which are medical treatments? CPR Bathing Dialysis Oral antibiotics Oral spoon feeding Artificial nutrition through a central line Artificial nutrition through a peg tube Physical therapy

13. How to resolve the tension between beneficence and self- determination? Self Determination trumps Beneficence is still the clinician’s duty A patient’s values help determine what is in his or her best interest. Best interest is not exclusively best medical interest

14. Take Home Messages A patient has a right to refuse medical treatment, even if that refusal will result in the patient’s death. This applies to any medical treatment. Whatever a patient can refuse when capacitated a surrogate can refuse on behalf of the patient who lacks capacity. Refusal of treatment is not suicide.

15. But… Elizabeth Bouvia (California) won the right to have her feeding tube removed to be allowed to die; she is still alive. David Rivlin (Michigan), quadriplegic from a diving accident, could not get services to help him live independently and found himself trapped in a nursing home. He sued to be allowed to die, won and died.