Medically Ineffective Intervention

Background

According to California law, a healthcare provider or institution "may decline to comply with an individual health care instruction or health care decision that requires medically ineffective care or health care contrary to generally accepted health care standards" (Cal. Probate Code §4735). When a healthcare provider or institution declines to comply with an individual healthcare instruction or healthcare decision that requires medically ineffective intervention or treatment contrary to generally accepted standards, the provider or institution must: (1) promptly inform the patient, if possible, and/or the patient’s surrogate decision maker; (2) "immediately make all reasonable efforts to assist in the transfer the patient to another provider or institution that is willing to comply with the instruction or decision" unless such assistance is refused; and, (3) provide continuing care to the patient until a transfer is complete or it appears that a transfer cannot be accomplished (Cal. Probate Code § 4736). Appropriate pain relief and palliative care must be continued (Cal. Probate Code § 4736(c)). A healthcare provider who, acting in good faith, declines to comply with an individual healthcare instruction or healthcare decision under § 4735 and § 4736 is immune from civil or criminal liability and from disciplinary action for unprofessional conduct (Cal. Probate Code § 4740(c)).

Purpose

To provide guidelines and a process for attending physicians caring for patients at the end of life to promote a positive atmosphere of comfort care, to alleviate pain and suffering, and to avoid unnecessary prolongation of the dying process. Respect and dignity is guaranteed to all patients, and to their families and friends.

Policy Statement

It is the policy of This Hospital to promote a positive atmosphere of comfort care for patients nearing the end of life. Pain and suffering must be relieved to the greatest extent possible. The dying process must not be unnecessarily prolonged.

Specifically, comfort care and relief of pain and suffering will be provided and oral nutrition and hydration will be offered to all patients regardless of condition, diagnosis, or prognosis.

The patient, surrogate, family, and friends must be given respect and treated with dignity at all times.

If requested, a patient or surrogate will receive a review of the physician's decision not to comply with an individual healthcare instruction or healthcare decision that the physician has determined to be medically ineffective or contrary to generally accepted healthcare standards.

Guiding Principles

1. Beneficence - The physician will always have the patient's best interest at heart. The patient should never be or feel abandoned by his/her health care providers. The physician should offer treatment that provides medical benefit to the patient, but not offer treatment that has no medical benefit.
2. Autonomy - The patient (or surrogate) will have the right to choose between offered intervention options, and the right to refuse medical intervention. This does not infer that the patient has the right to demand interventions that in the patient's case are considered to be of no medical benefit.
3. Nonmaleficence - The physician must not knowingly subject patients to avoidable harm, nor put patients in harm's way.
4. Truth-telling - The patient or surrogate must have access to all information needed to reach reasonably informed consent or refusal. The physician has the legal responsibility for obtaining informed consent from the patient or legal representative. The physician must inform the patient and/or surrogate about recommended intervention and procedures in a way that allows the patient or legal representative to make informed, meaningful decisions about treatment.
5. Proportionate means - Those interventions and procedures "that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community" (ERD, # 56). A patient is morally obligated "to use ordinary or proportionate means of preserving his or her life” (ERD, # 56).
6. Disproportionate means - Those interventions and procedures "that in the judgment of the patient do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community" (ERD, # 57). A patient "may forego extraordinary or disproportionate means of preserving life" (ERD, # 57).
7. Professional integrity - A physician or other health care professional cannot be required to provide intervention that goes against his/her beliefs or values.
8. Institutional support - In order to provide optimal care to the patient, hospital resources will not be arbitrarily withheld. These resources include nursing care, pastoral care, social services, and patient care representatives.
9. Comfort care - Comfort care is directed toward relief of pain and suffering and not toward the prolongation of life. Patients will be "kept as free of pain as possible so that they may die comfortably and with dignity" (ERD # 61). Hydration and nutrition are not always required for patient comfort and may worsen suffering near the end of life. Consideration of artificial nutrition and hydration should therefore be made on a case by case basis, and the patients families and designated decision makers should be informed of the risk and/or lack of efficacy of artificial nutritional support. Appropriate hydration and nutrition will be provided "as long as this is of sufficient benefit to outweigh the burdens involved to the patient" (ERD # 58). Even if a patient cannot experience "comfort", care is directed to preserve respect and dignity and will always be provided.
10. Appropriate end of life care - Appropriate care at the end of life always includes comfort care and relief of pain and suffering to whatever extent possible. Medicines that alleviate or suppress pain may be given to   a dying person even if they indirectly shorten life as long as the intent is not to hasten death (ERD #61). Care may also include specific interventions available to achieve a particular palliative or patient goal.
11. Medically ineffective intervention - An intervention is considered medically ineffective as determined by the treating physician(s) when: (1) it has not or will not reasonably be expected to meet a patient goal; (2) the burden or harm outweighs any expected benefit; (3) it is ineffective or harmful; (4) it is a "disproportionate means" as defined above. At this institution, medically ineffective intervention includes but is not limited to the following:
    1. The provision of any intervention other than comfort care when a patient or surrogate requests only comfort care;
    2. The provision of any intervention to patients in irreversible coma or permanent (persistent) vegetative state or with anencephaly that does not recognize the dignity of the patient and grant a peaceful death;
    3. The provision of intervention other than comfort care to patients who are permanently dependent on intensive care to sustain life;
    4. The provision of intervention other than comfort care to patients at the end of life, which can include cardiopulmonary resuscitation and hydration and nutrition "when they bring no comfort to the person who is imminently dying or when they cannot be assimilated by a person's body" (ERD p. 30);

Procedure

1. The attending physician will consult with the patient and/or surrogate regarding diagnosis, prognosis, and the lack of available treatment modalities that would either meet the goals of care for the patient or provide the patient with a reasonable quality of life. During this consultation, the physician should make an effort to understand patient values, beliefs, and preferences and those values, beliefs, and preferences that guide the patient or surrogate's decision making. The physician will also explain diagnosis, prognosis, and the plan of care to the patient, surrogate, family, and other healthcare providers as appropriate. A family conference should be convened when appropriate.
   
   Physicians are to consult with chaplains, social workers, Palliative Care Services and the Bioethics Committee, who may be able to clarify patient (surrogate) and family values and goals and improve the understanding of intervention options together with the benefits and burdens associated with each. Sufficient time must be allowed for the appropriate parties to understand what is being decided and to participate in the decision making process.
   
   
2. The attending physician should seek the consensus of the healthcare team regarding the plan of care.
   
   
3. If the patient (or surrogate) is in agreement with the plan of care, the patient is eligible for maximized comfort care in an appropriate setting; e.g., hospice, home care, nursing home, or palliative care unit.
   
   
4. If the physician declines, or intends to decline, to comply with a patient's or surrogate's healthcare instruction or decision on the grounds that it is medically ineffective, the physician will: 
   1. promptly inform the patient, if possible, and surrogate;
   2. document why the intervention is medically ineffective or contrary to generally accepted healthcare standards;
   3. immediately make all reasonable efforts to assist in transferring the patient to another physician or institution that will comply with the intervention request;
   4. provide medically indicated and ethically appropriate care to the patient until a transfer is complete or determined to be impossible;
   5. always, continue appropriate pain relief and other forms of palliative care; and,
   6. refer the issue to the Bioethics Committee for case review, if appropriate.
5. The attending physician may request a second opinion and/or request assistance from social services, palliative care and/or chaplaincy. The physician may also request a case review with the Chief Medical Officer and/or the Bioethics Committee.
6. Providers should seek to accommodate the emotional and spiritual needs of the survivors.

Resources Consulted

California Probate Code

Ethical and Religious Directives for Catholic Health Care Services