Physicians' refusal of requested treatment: the case of baby L

Article Abstract:

This article concerns the refusal of a group of physicians to participate in the rendering of continued aid to an infant when the mother of the child and the court had requested life-prolonging medical treatment be given. To the knowledge of the authors, this is the first time that a team of physicians have denied such a request. The case involves a two-year-old child born prematurely at 36 weeks. The pregnancy had been complicated by fetal kidney disease and by a decreased amount of amniotic fluid (oligohydramnios) in the last three months of the pregnancy. At birth the infant required resuscitation and was placed on a mechanical ventilator. The infant's Apgar score, a measurement of vitality of the infant graded on 1 to 10 scale, was 1 at 1 minute following birth and improved to 5 at 10 minutes. Over the ensuing weeks the child's ability to breathe improved, but neurologic examinations showed severe retardation and damage. The infant required several operations, and she remained hospitalized for 14 months. Following her discharge, she required 24-hour-a-day nursing care, and experienced several bouts of pneumonia, which required her again to be admitted to the hospital. After 23 months of recurrent difficulties, pneumonia and four cardiac arrests, a meeting of the hospital ethics committee was convened to discuss the case. Because the child was considered capable of feeling pain, but had no long-term hope of survival, the committee decided to refuse to make mechanical ventilation available to the child if she should require it. The mother took the issue to the court and the judge indicated a willingness to mandate the provision of service by the hospital, and asked the physicians whether they would now provide mechanical ventilation if ordered by the court. The physicians said that they would be unable to provide it on ethical grounds. The court appointed a consultant, who ultimately took responsibility for the child and made the court case moot. At this time the child remains alive, but is blind, deaf, quadriplegic and is fed by a tube placed in her stomach. She has improved but continues to receive 16-hour-a-day nursing home care, and her intellectual ability is at the three-month level. (Consumer Summary produced by Reliance Medical Information, Inc.)

Case studies, Medical ethics

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Informed demand for ''non-beneficial'' medical treatment

Article Abstract:

A conflict arose recently between a patient's family and a medical center regarding the provision of life-sustaining treatment. The 85-year-old patient, Helga Wanglie, had been in a persistent vegetative state for more than one year, and the medical center had asked permission to discontinue medical treatment (a respirator) because it was not beneficial to the patient. The family refused, stating they believed Mrs. Wanglie would not have wanted treatment stopped. The hospital then asked permission of its board of directors to go to court. The court allowed the patient's husband, an attorney, to be appointed conservator, letting him decide whether the respirator should be continued. However, the patient died three days after the appointment, with the respirator still in place. This situation was one in which the family wanted medical treatment that physicians did not consider beneficial to the patient. The majority of older people do not want to live with respirator support for long periods of time after they have become irreversibly unconscious. Physicians are not obligated to deliver whatever care patients demand: they cannot heed requests for mutilation, inappropriate drugs, or useless treatments. Other health care providers involved in the Wanglie case had refused to support the continued use of a respirator. Payment for this treatment was provided by Medicare and a private insurance company. This case differed from other right-to-die cases because it brought into question the patient's right to choose a particular treatment against professional advise, rather than the right to refuse a treatment. Another issue brought up by this case is the right of one patient to receive expensive treatment paid for by others, who do not want to support medically inappropriate care. Deciding what is best in cases where treatments of questionable value are involved necessitates attention to legal, social, and professional issues. Ultimately, each case must be resolved individually. (Consumer Summary produced by Reliance Medical Information, Inc.)

Right to die, editorial

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Overriding a patient's refusal of treatment after an iatrogenic complication

Article Abstract:

Physicians should discuss the potential complications of any treatment with the patient and be prepared to follow the patient's wishes if those complications arise. A good example of this moral dilemma occurs when a patient has a cardiac arrest caused by a complication from treatment. Most doctors are trained to correct their mistakes and to do no harm. However, the treatment to correct the complication may do more harm than good. And the patient may have requested a Do-Not-Resuscitate (DNR) order. The best policy in these cases is to clear any treatment decisions with the patient, a family member or to follow the patient's advance directive.

Health aspects, Care and treatment, Medical errors, Iatrogenic diseases

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