Withholding and withdrawing life-sustaining therapy

Article Abstract:

In life-threatening situations, decisions regarding the institution or the withholding of life-sustaining therapy must be made. Adult patients who are mentally competent, and who have been thoroughly informed of the consequences of their decision, have the right to refuse life-sustaining treatment. They also have the right to request that life-sustaining treatment that is already in place be withdrawn. This right is protected by the concept of autonomy or self-determination. A patient's request for withdrawal of life-sustaining therapy should be honored by the physician; furthermore, the physician should see that appropriate pain relief and sedation are provided if needed. An important adjunct to making these decisions is the advance directive, in which the patient prepares a written statement, sometimes called a living will, in which he delineates what treatments he desires to have or forgo, and under what circumstances. The patient's physician should be informed of the existence of the advance directive, and indeed, should ensure that it addresses medical situations that might be unique to that particular patient. A patient should also appoint a surrogate to make medical decisions for him in the event of incapacitation. The surrogate should make every endeavor to make decisions that are consistent with the patient's known wishes and values. Furthermore, a surrogate should not have the power to override a previously stated preference of the patient. Certain life-sustaining measures might be judged to be of temporary benefit, but ultimately futile, and a physician is under no ethical obligation to provide a therapy he believes to be futile. If a patient or his surrogate disagrees with the withholding of treatment because of its futility, then he may ask for transfer to another physician or institution that will provide the desired treatment. Institutions such as hospitals and nursing homes have an ethical responsibility to address the issues of life-sustaining care and its withdrawal, and should have professionals available to assist the decision-making in disputed cases. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Social policy, Life-saving apparatus, Lifesaving equipment, American Thoracic Society

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Health care reform: who will lead?

Article Abstract:

Currently, there is a crisis in the practice of internal medicine that has resulted from dramatic changes in patients' needs, including the increasing numbers of patients with chronic disease combined with restricted access to health care for many. Managed care is but one example of a range of attempts to intrude into the practice of medicine. Two cycles of activity by policymakers can be described: the first began when budget projections concerning the costs of Medicare were vastly exceeded. The second began when, threatened with cost control, physicians used inadequate data to state that cost control threatened quality. The problem of access to health care is presented. Although most Americans state that everyone should have access, few are willing to pay more so that can happen. Furthermore, many people who need access are considered 'unworthy', according to traditional American values. However, the access problem can be solved, as it has been in many other countries in the world. Understanding costs and developing better reimbursement systems are less important than clarifying the nature of effective, appropriate care. Leadership to promote constructive change is needed, and physicians should provide it. The medical profession is in the best position to answer certain questions concerning the type of health care to which all Americans deserve universal access. Physicians can be effective leaders in health care improvements where the federal government, state governments, the business sector, labor, and insurance companies cannot. Leadership by physicians is deemed optimal. To effect this, they must work together and not be dissuaded from their role by other concerns. Physicians will not decide who will pay for health care; they will only participate in making political decisions. Using professional organizations, physicians can begin to act. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Medical care, Political aspects, Medical policy, Health policy, editorial

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Physicians as leaders in the improvement of health care systems

Article Abstract:

Tips on leadership are described for physicians who agree to be leaders. Leaders take an overall look at a process to see how it is working and whether it needs to be changed. They then initiate and test the changes, listening carefully to all who are affected by the change. In the health care arena, the most important customers are patients, employers and taxpayers because these are the groups who pay for services. Their input should be included when making changes to processes. Tips are also included for physicians who are followers.

Analysis, Leadership

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