Search

An 8-step plan is presented for physicians to help them deal with requests for physician-assisted suicide. Patients who make such requests should be evaluated for depression and other treatable conditions that could be affecting their mood. Their competence to make decisions should also be tested. Physicians should discuss the goals for care and should evaluate the degree of patient suffering, including physical, mental, social and spiritual. The patient should be given complete information about this option and professional colleagues should be consulted.

The physician-patient relationship needs to be redefined to allow both the physician and patient to take an active role in treatment decisions. Four models for the physician-patient relationship have been proposed. In the paternalistic model, the physician has a parental role, and decides which treatment would be best. In the informative model, the physician tells patients of treatment options and relevant medical information, but patients select their own treatment. In the interpretive model, the physician helps patients explore their values, and select the treatment that best fits these values. In the deliberative model, the physician helps patients explore health-related values, and choose their treatment based on those values. A shift towards the informative model has occurred; patients are more involved in choosing their treatment. These models have weaknesses, but the deliberative model may be the best for the physician-patient relationship. It allows the physician to guide patients in a caring manner, but does not limit patient independence.

Adults who are incompetent may need to have a family member act as a proxy (surrogate) to make decisions about their medical care. Family members have traditionally been expected to make decisions for incompetent patients by physicians and the courts. A legal precedent was established when a court appointed Karen Quinlan's father the authority to refuse medical care for her. Many states have subsequently enacted statutes that endorse proxy decision making. Family members may be most qualified to make decisions for incompetent patients because they know the patient's wishes, and they are concerned for the patient's welfare. But proxy decision making may only approximate the patient's wishes, and family members may have interests that conflict with the patient's. Research studies have found that proxies may have difficulty assessing the patient's wishes. The debate about decision-making for incompetent adults may be resolved by giving the family the right to make these types of decisions for family members. Or, individuals could complete advance care documents that appoint a proxy and state treatment preferences. Another solution is to establish community standards that set guidelines for caring for incompetent patients.

A seven-step method is presented for managing end-of-life care and other situations that require good communication between doctor, patient, and family. The seven steps are preparing for the discussion, establishing what the patient and family already know, determining how to present information, delivering the information, responding to the family's emotions, establishing treatment goals, and creating a plan to meet those goals.

Very few terminally ill patients would consider euthanasia or physician-assisted suicide and even those who do may change their minds. In a survey of 988 terminally ill patients, only 11% seriously considered euthanasia or physician-assisted suicide and half had changed their minds several months later. On the other hand, an equal number who had not been considering these options also changed their mind.

Over the last decade the use of living wills has been supported by the courts, lawyers, government and physicians. Despite all this support, they are seldom used because of technical defects which render them vague and difficult to apply. A new advance care document, the Medical Directive, has been delineated to more clearly define the method of treatment that should be extended, based on the patient's previously delineated preferences, to the patient if he or she becomes incompetent. The directive provides four paradigmatic scenarios that outline the level of care that is to be provided for varying levels of prognosis and disability of incompetent patients. A proxy can optionally be designated to make decisions for when the patient's preferences are uncertain. The directive also has a section which, for those who desire it, provides for the donation of organs. This legal vehicle provides for a better documentation of the patient's preferences. It is hoped that the Medical Directive will be honored by the courts, as it should facilitate physician-patient discussions of critical and terminal care options., ABSTRACT: Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.

The US medical profession is facing a crisis as big as the one faced in 1847. At that time, physicians were not required to be licensed and some physicians felt the profession was suffering as a result. To resolve this dilemma, a group of physicians formed the American Medical Association and developed a strict Code of Ethics. This was one of the first professional ethics codes in the country. However, the arrival of managed care in the 1990's has placed corporate executives in charge of many health care plans. These executives are often unimpressed by the AMA Code of Ethics.

The American Medical Association's Council on Ethical and Judicial Affairs recommends that all hospitals develop a medical futility policy and use an approach similar to one described. Medical futility refers to treatments for critically ill patients that probably will have no benefit. The problem occurs when the patient's family disagrees with this assessment. It is preferable to resolve these discrepancies without going to court. A seven-step sample procedure for resolving discrepancies between doctors and family members is presented. Doctors should also be careful not to claim medical futility just to ration care or save resources.