Legal Analysis of Withholding and Withdrawing Life Support from Critically Ill Patients
Withholding and withdrawal of life support for critically ill patients remain one of the most controversial issues in legal and social aspects. A number of studies have revealed that most people lose their life in intensive care units owing to withholding or withdrawal of life support and during palliative care. This has raised ethical and legal issues regarding the implication of these processes on life of patients and impeachment of physicians. Withholding and withdraw of life support can be described as a process through which a number of medical interventions are withheld or terminated altogether for a given patient due to varying medical reasons, the most prevalent being the believe and expectation that the patient has slim chances of recovering and therefore will eventually die even after administration of the medical processes. This means that medical practitioners and relatives of the patients perceive medical processes, some of which may be very expensive, as a waste of time and resources. These processes are supported by different ethical principles including autonomy, beneficence, and many others. The debate on whether to uphold or remove the process has taken ethical and legal dimensions. While most physicians may understand the ethical implications of withholding or withdrawing life support, many do not understand laws governing these processes. This means that most clinicians make decisions based on legal misinformation which means in a way, they may endanger the life of the patient especially when they decide to withhold or withdraw life support fearing legal repercussions. Therefore, it is important for physicians to understand legal implications of withholding or withdrawing life support for critically ill patients. This paper looks into different legal implications, especially on how physicians can satisfy legal requirements during administration of these processes.
Facts and Cases
Like any other medical process, withholding or withdrawing life support for critically ill patients is governed by law. This ensures that the process is not misused and is well regulated. In the United States and in other developed countries where these practices are common, they are regulated by legal and ethical principles. These include ethical principles like informed consent which goes together with informed refusal. These two principles find strong backing and are based on common law.
The two principles, which are bases for the implementation of the two processes, dictate that there has to be informed consent of the patient before they are administered. Physicians must get the approval from patients, or patients surrogates except in some emergency situations. In addition, patients or their surrogates have the right to approve or deny any of the process. This legal provision has been put in place to ensure that there are few legal implications where either physicians or the patients or surrogate bear the blame for eventualities. The legal provision is meant to ensure that this is shared responsibility in decision making where physician has the role to inform patient or their surrogates of the implication of the process and why it has to be carried out (Douglas, 2007). On the other hand, patient or their surrogates have the duty to weigh down the option in light of the information presented by physicians to make informed decisions on whether to implement the process.
In their daily practices, physicians are always influenced by the legal issues which dictate whether they will withhold or withdraw life support. Whether real or perceived, these legal requirements have a lot of impact on the final decision that physicians make on these two processes. These legal requirements emanate from statutes in different areas of healthcare like brain death, organ transplantation, and others. However, a number of these legal requirements are expressed from case laws from the judicial ruling on those cases. In order to understand legal implications on physicians decision, it is important to look into recent court cases to see how they have expressed and reinforced the patients right to refuse and discontinue treatment, consented the fact that human life must be continued in all circumstances, defined the ways in which therapies could or could not help patients, and made decision on how disagreements between physicians or patients surrogates could be resolved, and many others.
There have been historical cases which have helped to shape legal implications on withholding or withdraw of life support from critically ill patients. The first of such cases was Quinlan case. This was perhaps the most important case in the country that kicked off a debate on right to die. After coming from a party where she had taken diazepam, dextropropoxyphene together with alcohol, Quinlan went to a coma and was kept on a ventilator machines after she had succumbed into a vegetative state. After staying in a life maintaining machine for a number of months without notable improvements, her parents made a request to the hospital to discontinue life support and let her die (Herald, 2002). The hospital could not accept the request and this kicked off a legal battle that was to set precedents in later court cases. In its ruling, New Jersey Supreme Court decided the patient had the right to approve or refuse mechanical ventilation (Cantor, 2001). The court also ruled that since the patient was vegetative and could not be able to act directly, her parents had the right to be her surrogate. The court ruled in favor of her parents and she was withdrawn from life support ventilator where she stayed in vegetative state for a period of ten years till she died from pneumonia complications. Quinlans case set important debate on right to live. It led to a number of unanswered questions that touched on moral theology, bioethics, legal, civil rights, and many others. The ruling on this case set pace for medical practices around the world. It also led to set of ethical committees in healthcare settings.
Another important legal case on withholding or withdrawal of life support from critically ill patients was Barber case. In Barber v Superior Court (1983) two physicians in California had been accused of murder. They had carried out a surgical closure of ileostomy of Herbert but he later went into coma from cardiopulmonary arrest. After five days in coma, and with his family consenting, the two physicians withdrew ventilator, IV fluids and nutrition to let him die. His family did not have any problem as they had consented to the decision but the two physicians were charged of murder by the district attorney. In this case, California Court of Appeal ruled that the physician who were facing murder charges during to withdraw of life support from a critical ill patient had not committed any murder because the patients family had permitted them to remove nutrition and hydration from the patient who was in a comatose condition. The court of appeal ruled out that both the patient surrogates and physicians had consented that it would be futile to continue treatment of the Mr. Herbert since his life was not to be restored even with those medical procedures. The court ruled that physicians had performed their duties. The court also held that the family members could act as surrogate for the patients and hence their decision could be taken as that of the patient.
The hallmark of legal battle in withholding or withdrawing life support for critically ill patients was Cruzan v Direct, Missouri Department of Health (1990). This is considered a hallmark case as it permeated to the Supreme Court. In this case, Nancy Cruzan has remained in vegetative state and hence required tube feeding instead of mechanical ventilation. Her parents therefore requested for her life to be terminated by discontinuing tube feeding and got accent of Missouri Judges (Lewis, 2000). However the decision was reversed by Missouri Supreme Court on ground that they had no right to decide on Ms Cruzans right of life or discontinuation of treatment. This decision was also held by the U.S Supreme Court which argued that states had the right to demand for evidence to show that the patient had refused treatment themselves. This ruling brought conflict on the interests of the state and the interest of the surrogates.
In a recent case, the court showed that physicians could override family decision and discontinue life support, especially where there are conflicting interests within the family. In this case, a 72 year old Mrs. Gilgunn went comatose and had irreversible brain damage. She was being treated at Massachusetts General Hospital and physicians showed that they were wiling to put do-not-resuscitate (DNR) order on her but with consent of her family. Her husband and two daughters agreed but a third daughter disagreed. After several attempts to reach to a consensus on the issues, the third daughter refused and the rest of the family members reinstated the DNR order. Consequently, the rebel daughter filed a suit against the physician and the hospital. However, for the first time, the U.S court upheld that life sustaining process could be terminated despite objection from one of the patient or even patient surrogate.
Analysis
A review of the above court ruling reveals that there are still legal implications when it comes to withholding or withdrawing life support for critically ill patients. In all the court rulings, it has become evident that consent of the patient or the surrogate is vital before the process is continued. However, court rulings also show conflicts in identifying this consent. For example, in Quinlan case, the court held that the patient or surrogate had the right to decide whether or not to continue with life support. In this ruling, the court clearly showed that in case where the patient could not make the decision because they were in comatose or vegetative state, their surrogates, who legally speaking were closely related people and took care of the patient, had the right to make decision on behalf of the patient. This legal view was also upheld in Barber case where the court ruled that since physicians had the consent of the patient surrogates, they had not committed any murder. These two court rulings acknowledge the fact that in case where the patient cannot make decision on his or her life, surrogates have the right to make that important decision. The legal principle presented in both these cases can be accepted both in statutory and case law on life sustaining treatment. However, as was evidenced in Cruzan case, life-sustaining treatment may vary from one state to another
However, a contrasting view of surrogates was clearly demonstrated in Cruzan v Direct, Missouri Department of Health. In this case, the court showed to reverse the previous ruling which had shown that in case where patient could not make decision on their life surrogates had the right to. This principle was also upheld in Gluckersberg with the court affirming the rights of competent patients. With the court demanding evidence to show that the patient had refused to continue with treatment, it became difficult to withhold or withdraw life support in case where it was difficult to obtain such evidence from comatose patients. This means that the court had accepted the fact that the decision by a competent person to refuse treatment, which may include nutrition and hydration, can be considered to be a liberty that is carefully protected by the Fourteenth Amendment. In this case, the court did not address clearly the issue of fusibility which is quite difficult, if not impossible to quantify. Futility, which defines the inability of life support to resuscitate patient life, has been used by physicians to withhold or withdraw life support. As was evidenced in a study by Ash et al., physicians have used the concept of futility unilaterally to withhold or withdraw life support even without informing patients.
In light of the above cases, it is quite difficult for physicians to satisfy legal requirements owing to different case laws. One of the most important steps that have been made is drafting of Pain Relief Promotion Act 1999. The aim of this Act is to amend Controlled Substance Act in order to promote management of pain without allowing physician assisted suicide or euthanasia. Angle, notes that this bill will give physicians the right to administer sedatives and analgesics to terminally ill patients even when there is risk of death. However, the bill forbids administration of such drugs with intent of causing death which means patient decision is based not on consequences but on intentions.
Conclusion and Recommendations
As has been reviewed, there are a number of legal implications for physicians and patients or surrogates in withholding and withdrawing life support. Therefore physicians need to understand that withholding or withdrawing life support is legally justified when the support is unwanted treatment and should be administered or withdrawn with the patient or surrogate consent. Although patients may base their argument on futility, the concept should be invoked only with patient and surrogate consent which means it should not be a unilateral physician decision. It is also important for physicians to realize that there should be agreement between health care administrators since such disagreement raises the risk of liability for patient death and criminal prosecution. After the withdrawal of life sustaining support, patient may take several days before death occurs. During this period, maximum palliative care under the supervision of physician must be undertaken to lower the risk of criminal liability. Finally, this whole process should be followed by accurate documents which show how the decision was arrived at. This is taken in order to minimize the risk that may result from prosecution and presentation of evidence. The records should show how physicians acted to forego life sustaining and how the consequent palliative care was taken to achieve patients comfort.
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