Government Death Care -- When Doctors Pull the Plug

This comes from my blog, The Mercenary's Cookbook.

The Houston Press does a story on what a family claims is the hospital’s efforts to end their daughter’s life. Fourteen-year-old Sabrina Martin went to the hospital for what doctors at first thought was a brain tumor, then determined was a abscess from a sinus infection. After a surgery to drain some fluid from her brain, she went into cardiac arrest from two strokes that left her in a coma. The family was then told that if she ever came out of it, she would be a mental vegetable, and immediately started getting pressure, they claim, to end her life.

This is not as clear cut as it might at first seem. I come at this issue with some personal experience, as I have a sister on disability and a niece who has lost 60% of her brain due to a severe seizure. Legally, once you put in a feeding tube, it becomes very hard to end a person’s life – it is deeply imbedded in our genes and our law that not intervening to save a person is more acceptable than intervening to end a person’s life. In my experience, however, despite the fact that my sister is on disability and Medicaid, the powers that be in Arizona have done nothing to try to circumvent my sister's wishes. Yet, I can see why it would be better for everyone involved if they had.

In my case, my niece is not quite as bad off as Terri Schiavo, yet it is beyond doubt that my niece will never have any quality of life, let alone even be able to swallow by herself. Even if her brain were fully functional, she has been unconscious for the most important period of child development, that recent research shows can only be patched, not repaired. She could live as a vegetable for decades, at taxpayer’s expense. And I don't feel I have the right to make that decision for her.

No matter how you feel about situations like these, the laws in Texas are terrifying:

Memorial Hermann was one of a host of hospitals across the state that along with doctors and right-to-life groups endorsed the Texas Advance Directives Act, which the Legislature passed in 1999 and which was signed into law by then-Governor George W. Bush. (The right-to-life groups have now backed off their support of the Advance Directives Act and say the law is unfair and gives too much power to ­doctors.)

In essence, the law gives doctors the ability to either continue or withhold life-sustaining treatment against the wishes of the patient or the patient's legal guardian. To do so, the doctor presents his case before the family and an ethics committee, and if the committee agrees with the doctor's decision, the family is given ten days to find another facility that will comply with their wishes before treatment is either continued or withdrawn. Families are given a list of lawyers and organizations to help facilitate a transfer.

Now I can totally empathize with Michael Schiavo’s decision to end Terri’s life, and I found the smear campaigns against him (alleging attempted murder, among other things) disgusting and invasive. There is little that offends me more than politicians grand standing and bringing their considerable power and media manipulation to bear on average citizens.

To this day, I think nothing defines the character of President Bush more than the fact that after signing the above law, it was not receiving a memo on “Bin Laden determined to Strike U.S.”, or Katrina, but Terri Schiavo that got Bush to cut his vacation short for the first time of his Presidency, to prevent a family from making the decision he placed in the hands of Insurance companies and hospital administration.

The family claims that after the surgery, they started finding DNR orders (Do Not Resuscitate) orders clandestinely slipped into Sabrina’s file.

"Hospitals routinely do that," says. "In another case at Memorial Hermann, we were participating in an ethics committee process and the neurologist who had done brain surgery... he said that he put a DNR in the file. We asked, 'Did you consult with the patient's mother? Did you have any indication this is what the patient wanted?' And he said, "No, we do it all the time.' The doctor just decided to put a DNR on this patient. And I can think of two others right off the top of my head. And mind you, for all of this, these are only the ones who call us for help. There could be countless others."

Fine says that orders not to attempt resuscitation are almost always done in collaboration and with consent of the patient's family.

"I'd say it's that way 99.999 percent of the time," he says. However, "A doctor can write a order on a patient if they feel that it is appropriate for the patient. No law prohibits that."

The head reels. Again, in my case (Arizona is apparently sane in comparison) the family was consulted and their wishes adhered to. Let’s remember, though, that Texas is the model from which conservatives would like to base national healthcare “reform”. What’s more, because of tort "reform", medical malpractice is not profitable, and typically only desperate lawyers would attempt to bring such a case. There’s simply no money in it, which means there’s no consequence for hospitals who do this.

Sabrina’s immediate family also claims the doctors in this case pulled other family members aside and convinced them to pull the plug. This doesn’t offend me. Terri Schiavo is not atypical (Tom DeLay decided to pull the plug on his father). Loved ones often understandably want to hold on longer than what most anyone else would find is reasonable. Which again, is why I had such sympathy for Michael Schiavo, who had held out hope for years. When a loved one decides to let go, you better believe all avenues have closed down.

That doesn’t mean a doctor can’t give advice. What I found most infuriating is that the doctors I dealt with saw their job as providing comfort without imparting information. As they showed me X-rays of the black void showing dead tissue where my niece’s brain used to be, you’d ask if it was possible to recover, or want percentages, or some idea of what sort of life was possible in this situation. The doctor would parry, “I don’t like to use percentages”, “You never know, each case is different”, “She will improve, we don’t know how much”. Finally, I just asked, “Should I be investing in a college fund for her?” He refused to speculate.

The doctor does have a better idea of a patient’s chances, and the family unrealistic expectations of recovery. But slipping in DNRs? You can’t blame the family for suspecting this might be used as a way around convening the ethics board to cover up malpractice.

When there’s no accountability, and profit becomes the one factor determining decisions like this, we know how discretion gets used by the cynical. I see no reason why doctors would be immune. This doctor, responding in comments, does offend me:

As a practicing physician I can assure you that convening an ethics board (containing physicians, nurses and laypeople) to review every aspect of a case in great detail is the last thing a physician who had made a mistake would want to do.

The laws in Texas are a blessing and exist so that physicians and nurses have the right to NOT continue painful and unnessesary treatments even if the family wants to continue. This is to protect the patient from unrealistic family members and the staff from doing things they find morally and profesionally wrong. They must continue full treatment until an independent group makes a decision.

A DNR order is usually approved by the family, but is a decision made by a physician that advanced recusitation on a patient would not be benificial and would cause suffering for no reason.

Crickey. The point made in the article is that DNRs can be used by doctors, at their discretion, to circumvent the ethics board that might determine if “advanced resuscitation on a patient would not be beneficial.” A blessing, indeed. For the hospital.

I hate to ask what the staff finds “morally and professionally wrong”. From this statement, it appears to be allowing a family to keep a loved one alive, based on their moral principles, which apparently may be overridden by moral judgment of the staff, without oversight. If someone really has a moral problem, they don’t have to be compelled to change the IV bags. Let someone on staff do it who is not going to object to complying with the family’s wishes.

Here’s another comment, which I feel encapsulates the whole rationale for the conservative approach to healthcare

Many people are patients at Hermann hospital and never pay their bills. It is a huge place that handles most of the local trauma . Many lives are saved at Hermann. For the ones that will not make it, the DNR is a kind way to let nature take its place. The story of that child is a sad one but things happen that are out of the control of all parties concerned. A reality check is needed here. The child appears to be in a vegetative state and no doubt, if she were able to communicate she would prefer to be set free. Often times parents suffer from guilt, selfishness in terms of wanting to hold on to their children even though they should let go. In this case, these people are determined to get money to satisfy their point of view and greed. They are wrong for doing so. They will not win. Hospitals try their best and not all will end up satisfied. We have to face reality that all things do not end up the way we expect.

I am empathetic to those who say it is a waste of resources to keep some of these patients alive, with no chance of any quality of life. And Terri’s parents (and my sister) certainly demonstrate how love can blind us, and how easy it is to convince yourself random facial expressions or ticks are conscious responses. But if the abortion and euthanasia debate have taught us nothing, it is that life – when it begins, and when it ends – is a very personal, spiritual question that ought not to be answered by anyone but the families.

I’m pro-choice, but I couldn’t, in good conscience, support a law that forced a mother to have an abortion to save her life. I couldn’t force a Christian Scientist to get medical treatment (for their children – a more difficult call). The point is, these are matters of the soul, and as such belong to the most personal, religious beliefs a person can have. If we are to save money, why not save it by allowing those like Michael to make the decision without the Federal government staging a media event on the outside lawn?

In fact, Bush is being consistent here, not in matters of life, but matters of power: the decision of when life ends should be left up to hospital bureaucracies and the government, based on dollars and cents rather than God and family. All they need to know is the hospital pulled the plug, and they assume the family will not pay, and the hospital, given total discretion, will make the best moral decision. This is the rationale used for an imperial Presidency as well – our leader needs no checks, no balances, no accountability, only the freedom to decide what he feels is best. Selfishness is not possible. They are good. The victims of those decisions deserve it.

The articlesays Sabrina remembers everything up until her second surgery and helps her younger sister with math now, and is in special ed. The perceptions of the family are highly suspect, but this is a few steps beyond following a balloon with your eyes on videotape. In my case, my niece is unable to swallow, bed ridden, in foster care, having cost millions of dollars. What is true about the Schiavo case and Sabrina’s – and mine – is that it was not the families who made the decision. And in all these cases, I see no evidence that the government and hospital bureaucrats are making better decisions than the families.

I know that these issues are complex, and I am very sorry that this is personal with you, and with your niece. All of this is just heartbreaking........ personal circumstances are just bound to affect perceptions in these issues. I imagine that a lot of doctors have a difficult time......

I don't know what else to say. Much of it has to do with limits on state resources, and how best to spend them. There is no perfect answer, unfortunately. But your niece is still alive, and I believe that all things are possible.

In our case, the doctors got in the way. In the Houston Press case, the doctors pulled the plug.

In both cases, I think the family had the right idea. It ought to be up to us, our religious beliefs, etc. if we want to be kept on life support. What bothers me is when the government steps in and forces a family to keep someone under this condition (like Schiavo) or slips in a DNR without informing you, like here.

...he was age 49, in a skilled nursing facility for therapy on a badly broken shoulder. He also had high functioning autism /aspergers and type 1 diabetes.

Well, his sugar started going off the chart time and time again... check him for infection I said!

No, he's fine, I was repeatedly assured.

Well, after his blood sugar went to 1700 (NOT a misprint) and he took a non-recoverable brain stem hemorrhage I was asked did I want life support.

YES, I did, because I needed time to prepare my mother age 89 who was in another Skilled Nursing for stroke therapy. We got a week and then (I was told) nature took it's course and he died even though on life support. It was OK, enough time that I was able to let my mother know that he was "very ill" so she wasn't shocked into another stroke losing her only son.

Anyway, the cause of death was listed as BOTH the brain stem bleed AND septicemia -- TWO concurrent drug-resistant infections.

IS THERE NO PROTECTION FROM THIS CRAP and our barbaric, for-profit healthcare system??

but the skilled facility was negligent for not getting cultures done when his blood sugars started going up. That's a cardinal sign of infection!

Due to the brainstem bleed being one immediate cause of death, you probably don't have a case for medical negligence, although a nasty letter from a lawyer might be in order so that they don't put another family through this.

As for the infection, itself, it is always a risk with any surgery, which is why the informed consent form lists it. Diabetics are at a far greater risk for developing post operative infections. Sterility protocols have reduced the risk but it is always present for anyone undergoing surgery.

I am very sorry for your loss.