Why Do Doctors Ignore Living Wills?

In the reading for today, the author cites a survey which concluded that 65% of physicians "would not follow a living will if the instructions conflicted with the doctor's own view of the prognosis or expected quality of life." (Colby p. 142) My first reaction to this statement is: Who do those doctors think they are, substituting their judgement for my wishes!!!

But then I begin to wonder how this situation arises. The living will seemingly can only "respond" to specific scenarios. Who is defining that scenario that the living will is responding to? Who beyond the physician is outlining the prognosis or expected quality of life? Who is the doctor disagreeing with? Is this statistic saying that physicians substitute their judgement if they think the patient didn't really mean what they said in their living will or that they would feel differently about their life (say as a quadraplegic) if only they had a chance to live that life?

Other thoughts about what this statistic is really indicating?

Laws About Death

This week we will be talking about issues related to death and resuscitation. There are two legal and political issues that are important in this discussion: DNR orders and I-1000. Hopefully you have already taken a look at the Physicians Orders for Life Sustaining Treatment (POLST) form linked at the course readings webpage and have had a chance to read the chapter from Bill Colby's book about living wills. I'd encourage everyone to post some thoughts on the blog about DNR and living wills by clicking "New Post" in the upper right corner of the page. (You need to be signed in first.)

There is one other topic that you should be aware of if you think you will practice medicine in Washington or Oregon. The Washington Death with Dignity Act passed by initiative in November 2008. Sometimes it's an interesting challenge to read the original text, but its always helpful to have a digest. I've pasted in information about safeguards of the law from the pro-I-1000 website, below.

There are multiple safeguards in Washington’s death with dignity law. These safeguards include independently witnessed oral and written requests, two waiting periods, mental competency and prognosis confirmed by two physicians, and self-administration of the medication. Only the patient – and no one else – may administer the medication.

Washington’s Death with Dignity safeguards:

1. The patient must be at least 18 years old
2. The patient must be a resident of the state of Washington
3. The patient must be terminally ill - not disabled, but diagnosed as terminally ill
4. The terminally ill patient must have 6 months or less to live, as verified by two physicians
5. Three requests for Death with Dignity must be made (two verbal and one written)
6. Two physicians must verify the mental competence of the terminally ill patient
7. The request must be made voluntarily, without coercion, as verified by two physicians
8. The terminally ill patient must be informed of all other options, including palliative care, pain management and hospice care
9. There is a 15 day waiting period between the first oral request and the written request
10. There is a 48 hour waiting period between the written request and the writing of the prescription
11. The terminally ill patient's written request must be independently witnessed, by two people, at least one of whom is not related to the patient or employed by the health care facility
12. The terminally ill patient is encouraged to discuss their decision with family (not required because of confidentiality laws)
13. Only the terminally ill patient may self-administer the medication
14. The patient may change their mind at any time

The safeguards in Washington's Death with Dignity Act ensure that terminally ill patients are making a voluntary and informed decision. These same safeguards have worked in Oregon for over 10 years. Patients must be terminally ill, must have less than 6 months to live, the patient must make two independently witnessed requests, and every step of the process must be approved by two doctors.

Because this is a political issue (it passed with 58% of the vote), it's important to include the position of the sizable minority. A comprehensive opinion of the opposition is available at noassistedsuicide.com. Specifically, there are lengthy arguments centered on the:

• text of the initiative
• claims of the initiative's supporters and
• a critique of Oregon's law
  

I take the position that when health care issues come up in elections, it's my social obligation as a care provider to become informed about the issue. For one reason or another, there are very few physicians in politics, and only slightly more who advise policy makers. The least we can do as future docs is to be able to provide facts about the issues to patients and our opinions to friends.

Psychiatric Holds

In the next class, we will be talking about issues in autonomy and consent. One really big issue within these topics is how to approach dilemmas that involve patients with mental illness. You may know that the Harborview ER has its own psych ward and psychiatrist (plus a resident) in house 24 hours a day. Not every emergency department will have such a resource. In fact, few do. Emergency providers must be familiar with the law, or at least with hospital procedures relevant to detaining a person.

Dr. Cooper will be giving a lecture on Wednesday about what is needed to establish consent. Needless to say, the mentally ill fall short on several accounts. (Can you name which?) The interesting thing is that each state defines autonomy differently. "5150" for example, refers to California's involuntary detainment statutes. We live in a state that is among the most protective of individual autonomy. It is very difficult to detain someone in Washington.

There are three ways to learn about Washington's system.

1. Read the law. Start here and here, and focus on this section and the laws referenced. Make sure you are caffeinated.
   
2. Look at a description not written in legalese. (This description of Washington's Involuntary Treatment Act is published by Snohomish County)
   
3. Have someone explain it to you. We can go over it in class.

One or two of our cases on Wednesday may deal with this issue, so if you have a chance to read about it, you'll be one step ahead.