How does the Patient Self Determination Act of 1990 play out in the health care setting? Using the concepts of justice, beneficence, nonmaleficence, and autonomy how does it affect the following
-physician assisted suicide
-Oregon's Death with Dignity Act
-advanced directives/appointed decision makers
-futility of treatment/withdrawal of treatment
-terminal fasting
The Patient Self-Determination Act (PSDA) was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990. It became effective on December 1, 1991. The legislation required many hospitals, nursing homes, home health agencies, hospice providers, HMOs, and other health care institutions to provide information about advance health care directives to adult patients upon their admission to the healthcare facility. This law does not apply to individual doctors.
The purpose of the Patient Self-Determination Act is to inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider. Specifically, the rights ensured are those of the patient to dictate their future care (by means such as living will or power of attorney), should they become incapacitated. The PSDA requires information to be given to adult patients about their rights under state laws governing advance directives, including: 1) the right to participate in and direct their own healthcare decisions; 2) the right to accept or refuse medical or surgical treatment; 3) the right to prepare an advance directive; 4) information on the provider’s policies that govern the utilization of these rights. The act also prohibits institutions from discriminating against a patient who does not have an advance directive. The PSDA further requires institutions to document patient information and provide ongoing community education on advance directives
The Patient Self-Determination Act (PSDA), passed in 1990 and instituted on December 1, 1991, encourages all people to make choices and decisions now about the types and extent of medical care they want to accept or refuse should they become unable to make those decisions due to illness.
The PSDA requires all health care agencies (hospitals, long-term care facilities, and home health agencies) receiving Medicare and Medicaid reimbursement to recognize the living will and power of attorney for health care as advance directives.
The PSDA does not create new rights for patients but reaffirms the common-law right of self-determination as guaranteed by the Fourteenth Amendment. Under the PSDA, health care agencies must ask you whether you have advance directives and must provide you with educational materials about your rights under state law.
PHISICIAN ASSISTED SUICIDE :
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).
It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good.
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Physicians:
(a) Should not abandon a patient once it is determined that cure is impossible.
(b) Must respect patient autonomy.
(c) Must provide good communication and emotional support.
(d) Must provide appropriate comfort care and adequate pain control.
AMA Principles of Medical Ethics: I, VI
Code of Medical Ethics Opinion 1.1.7
Physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patient self-determination. Yet physicians are not defined solely by their profession. They are moral agents in their own right and, like their patients, are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs. For some physicians, their professional calling is imbued with their foundational beliefs as persons, and at times the expectation that physicians will put patients’ needs and preferences first may be in tension with the need to sustain moral integrity and continuity across both personal and professional life.
Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities.
Physicians’ freedom to act according to conscience is not unlimited, however. Physicians are expected to provide care in emergencies, honor patients’ informed decisions to refuse life-sustaining treatment, and respect basic civil liberties and not discriminate against individuals in deciding whether to enter into a professional relationship with a new patient.
In other circumstances, physicians may be able to act (or refrain from acting) in accordance with the dictates of their conscience without violating their professional obligations. Several factors impinge on the decision to act according to conscience. Physicians have stronger obligations to patients with whom they have a patient-physician relationship, especially one of long standing; when there is imminent risk of foreseeable harm to the patient or delay in access to treatment would significantly adversely affect the patient’s physical or emotional well-being; and when the patient is not reasonably able to access needed treatment from another qualified physician.
In following conscience, physicians should:
(a) Thoughtfully consider whether and how significantly an action (or declining to act) will undermine the physician’s personal integrity, create emotional or moral distress for the physician, or compromise the physician’s ability to provide care for the individual and other patients.
(b) Before entering into a patient-physician relationship, make clear any specific interventions or services the physician cannot in good conscience provide because they are contrary to the physician’s deeply held personal beliefs, focusing on interventions or services a patient might otherwise reasonably expect the practice to offer.
(c) Take care that their actions do not discriminate against or unduly burden individual patients or populations of patients and do not adversely affect patient or public trust.
(d) Be mindful of the burden their actions may place on fellow professionals.
(e) Uphold standards of informed consent and inform the patient about all relevant options for treatment, including options to which the physician morally objects.
(f) In general, physicians should refer a patient to another physician or institution to provide treatment the physician declines to offer. When a deeply held, well-considered personal belief leads a physician also to decline to refer, the physician should offer impartial guidance to patients about how to inform themselves regarding access to desired services.
(g) Continue to provide other ongoing care for the patient or formally terminate the patient-physician relationship in keeping with ethics guidance.
Oregon's Death with Dignity Act :
The Death with Dignity Act (DWDA) is a permissive law that allows terminally ill Oregonians to end their lives through the voluntary self-administration of a lethal dose of medication, expressly prescribed by a physician for that purpose.
The DWDA was a citizens' initiative passed twice by Oregon voters. The first time was in a general election in November 1994 when it passed by a margin of 51% to 49%. An injunction delayed implementation of the Act until it was lifted on October 27, 1997. In November 1997, a measure was placed on the general election ballot to repeal the DWDA. Voters chose to retain the DWDA by a margin of 60% to 40%.
There is no state "program" for participation in the DWDA. People do not "make an application" to the State of Oregon or the Oregon Health Authority. It is up to qualified patients and licensed physicians to implement the DWDA on an individual basis. No one is compelled to participate. The DWDA requires the Oregon Health Authority to collect data about DWDA participation and to issue an annual report.
The patient must meet specific criteria to be able to participate in the DWDA. Then, the following steps must be fulfilled:
A patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
Physicians must report all prescriptions for lethal medications to the Oregon Health Authority, Center for Health Statistics. Pharmacists must also be informed of the prescribed medication's ultimate use.
Q: What kind of prescription will a patient receive?
A: It is up to the physician to determine the prescription.
Q: Who is responsible for oversight and regulation of the DWDA process?
A: The law does not include any oversight or regulation that is distinct from what is done for other medical care. The DWDA assigned the Oregon Health Authority (OHA) the responsibility of keeping track of data on participation and issuing an annual report, but did not assign any specific regulatory responsibilities. OHA does not investigate whether patients met the DWDA criteria, nor how their diagnosis, prognosis, and treatment options were determined. OHA does not interpret the statute, other than the portion related to the reporting requirements. However, if any instances of non-compliance are found in the information received by OHA, it is reported to the Oregon Medical Board for further investigation.
Q: What will happen if a physician doesn't follow the prescribing or reporting requirements of the DWDA?
A: The Oregon Health Authority will notify the Oregon Medical Board of any deviations noted in the information received. If a formal investigation is warranted by the Oregon Medical Board, physicians might be subject to disciplinary action.
Q: Must a physician be present at the time the medications are taken?
A: The law does not require the presence of a physician when a patient takes lethal medication. A physician may be present if a patient wishes it, as long as the physician does not administer the medication him/herself.
All patients are encouraged to complete a Physician Orders for Life-Sustaining Treatment (POLST) form and register with the Oregon POLST registry. A POLST form records your wishes for medical treatment in the event emergency medical services are required. It allows you to state that you do not wish to be resuscitated if you are found unresponsive, or if the lethal medication does not work as expected. POLST forms are available from your physician, who must sign and date your POLST before it can be used.
Oregon POLST registry website
http://www.orpolstregistry.org/
Q: Can a patient rescind a request to participate in the DWDA?
A: Yes, a patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
Q: How much does participation cost?
A: We do not collect cost data. However, direct costs for participation in the DWDA might include office visits relating to the request, a psychological consult (if required), and the cost of the prescription.
Q: Will insurance cover the cost of participation in the DWDA?
A: The DWDA does not specify who must pay for the services. Individual insurers determine whether the procedure is covered under their policies (just as they do with any other medical procedure). Oregon statute specifies that participation under the DWDA is not suicide, and should not affect insurance benefits by that definition.
Q: Can a patient's family members request participation in the DWDA on behalf of the patient (for example, in cases where the patient is comatose)?
A: No. The law requires that the patient ask to participate voluntarily on his or her own behalf.
Q: Does the DWDA allow euthanasia?
A: No. In euthanasia, a doctor typically administers a lethal dosage of medication to the patient. In the DWDA, a physician prescribes a lethal dose of medication to a patient, but the patient - not the doctor - administers the medication. Euthanasia is illegal in every state in the U.S., including Oregon.
Q: What is the Oregon Health Authority's opinion of the DWDA?
A: Our position is a neutral one, and we offer no interpretation or opinion about the law. The DWDA was a citizen's initiative, enacted because a majority of voting Oregonians believed that persons afflicted with certain terminal illnesses should have the legal right to hasten their deaths. The role of the Oregon Health Authority is to collect data on participation in the DWDA and issue an annual report. These data are important to parties on both sides of the issue.
Q: What is listed as the cause of death on death certificates for patients who die under the Death with Dignity Act?
A: The Oregon Health Authority, Center for Health Statistics recommends that physicians record the underlying terminal disease as the cause of death and mark the manner of death “natural”. This is intended to balance the confidentiality of patients and their families, while ensuring that we have complete information for statistical purposes.
A death certificate is a legal document that has two primary purposes: (1) to certify the occurrence of death for legal matters (e.g., settling the estate), and (2) to document causes of death for public health statistics. To ensure that we have accurate and complete data on patients who have ingested the medications, the Oregon Health Authority regularly matches the names of persons for whom a DWDA prescription is written with death certificates. The Attending Physician is then required to complete a follow-up form with information about whether the death resulted from ingesting the medications, or from the underlying disease.
"Do everything you can to save my father." Doctors hear this often. It's the way many families respond as they obviously do not want to lose a loved one, but it's not necessarily what their father would have said. That's why people need to think about advance directives (sometimes called living wills) for medical care and the appointment of a health care agent.
What are advance directives?
Advance directives are documents, written while a person is still able to make decisions, that express their wishes related to life support in case they are not able to express their wishes in the future. These include cardiopulmonary resuscitation (CPR), respirators, and any other measures that the person cares to list.
Why does the advance directive only apply if the person is mentally unable to make decisions?
When the person is still mentally capable, the doctor can just ask the person about his or her preferences concerning treatment. The advance directive is a document that gives the health care team guidance on the patient's wishes only if the patient is unable to express those desires.
Why would someone not want CPR?
Most relatively healthy people would want CPR if their heart were to stop. That's because if CPR is successful, they can expect to recover, leave the hospital, and continue with their active lives for a reasonable period of time. Some elderly or terminally ill people who have become incurably frail might decide not to have measures instituted that will either only extend their lives in a vegetative state or result in their being senseless because of their specific medical condition. Some people decide that they won't want CPR and respirators once they can no longer remember the names of their children (or their own names).
Why would someone want CPR?
Some people might make the opposite decision. They might decide to have CPR and machines to support artificial breathing because they want to live as long as possible. If you make a decision like that, it will be respected by doctors and hospitals. The doctor is expected to make a reasonable decision about which measures might help and are reasonable. The input of the patient in this process is very important. Your personal and religious beliefs will influence these decisions.
Contents of an Advance Directive
What should the advance directive say?
It's hard to predict your medical situation when an advance directive document takes effect. You could be confined to a bed or a chair. You may not be able to recognize people or have a conversation. You may not be able to read or understand what is said to you. You may feel that if you reached a point when sustaining your life would not be your wish.
Appoint a Decision Maker
Who should be your designated health care decision maker?
In a document separate from your advance directive, name a particular person to be your health care decision maker. Name an alternate in case the first person named is unable to be your health care surrogate when the time comes.
What to Do With Your Advance Directive
If you already have an advance directive, but you decide that you want it to say something different, then change it.
Write a new one, give copies to your family, your friends, your doctor, and the hospital you're most likely to use. Tell them to throw out the old one.
Having advance directives gives the family your message when you are no longer able to express the message. It gives them the license to say to the doctor, "Do everything you can to keep my father comfortable, but don't prolong his life artificially with tube feedings and antibiotics."
For More Information
Withdrawal of treatment is a common practice in critical care settings, perticularly when treatment is considered futile. The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes. Under such a circumstance, withdrawal of treatment will inevitably be considered, although his family refused to do so. Consequently, acritical question must be answered: Who should make the decision?
Ethical dilemma identification
Danny decided to withdraw the use of life-support, whilst his wife and adult children refused to do so. The ethical dilemma is illustrated by the following question: Who decides the withdrawal of treatment in a critical care setting?
Analysis
To provide an opotional solution to this case and make the best moral decision, the current study will critically discuss this issue in conjunction with ethical principles, philosophical theories and the values statement of the European and Chinese nurses’ codes of ethics. Additionally, the associated literature relative to this case are analysed before the decision-making.
Ethical decision-making
The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.
Results
In Danny’s case, health professionals opted to respect his decision to withdraw treatment. The medical staff maintained an effective communication with the family involved, and provided the appropriate intervention to collaborate with other health care professionals to perfect further care. Withdrawal of treatment is a complex decision-making process. In such a circumstance, a patient's autonomy is critical in decision-making. The general principles of law and medical practice indicate that people have a right to decide. In a few cases when a patient is no longer capable, the family should be informed on the former's ‘treatment options in an honest way’. That is, a patient's family should be involved in the discussion to enable them to provide their opinion. Health care professionals should balance the ethical principles of autonomy, beneficence, non-maleficence and justice when they make the decision and allocate reasonable resources for patients. A few moral theories have been applied to explain the decision-making process. Utilitarianism entails that every decision is guided by the desire to achieve maximum benefit, whereas deontology is an approach to ethics that focuses on the individual. With empathy and perspective-taking, medical staff members will consider the patients' benefits and interests when they make the decisions. Apart from ethical regulation, moral integrity and ethical sensitivity also play an essential role in healthcare organisations. Medical staff members should act ethically and do the right thing because it is the correct thing to do and not mandated. With the support of ethical leadership, medical staff members, as moral agents, should develop their ethical capabilities. Once an ethical team is formed, it would promote a safe ethical practice and enhance harmony in the medical service 6 . TEREMINAL FASTING . Examination of the phenomenon of terminal fasting (refusal of food and drink as a means of accelerating death). The article and accompanying chapter list evidence from a wide variety of sources and consider practical application in the West.
How does the Patient Self Determination Act of 1990 play out in the health care setting?...