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Editorial Note: Readers of the Journal will recall that in the July/August issue of 2004 (Volume 65, Number 4), we chose the topical theme of “New Directions in End-of-Life and Palliative Care.” Reaction to this issue has been very positive, but a number of additional issues have been raised in North Carolina and around the country, which are worthy of our consideration. The commentary that follows summarizes an effort by some of the leadership in our state’s medical profession to address one of these matters and is presented here as a policy change proposal for further discussion and debate. ntractable conflicts sometimes develop among patients or their surrogates and clinicians where protracted negotiations and discussions fail to result in a course of action tolerable to everyone. In 1999, Texas passed the first legislation to deal with such disputes. The legislation tries to honor patients’ or their surrogates’ rights and values, but is also based upon a notion of professional integrity, respecting the fact that physicians are the most skilled in determining appropriateness and inappropriateness in medical care. Individual physicians or institutions do not have immunity from civil or criminal liability in making decisions against the patients’ or surrogates’ wishes unless they go through multi-stepped procedures involving a medical staff or ethics committee. Patients or their surrogates may avoid or abort this process by seeking other caregivers or turning to the courts. This due process policy has proved successful in helping to solve entrenched disputes among clinicians, patients, and families. North Carolina should adopt a policy using this portion of the Texas law as a model. The Problem Conflicts sometimes develop among patients or their surrogates and clinicians about the appropriate medical course to follow. Many conflicts are resolved with patience, better communication, and education. Nurses, social workers, patient representatives, chaplains, and other representatives along with physicians can help clarify options and prognoses in a way that fosters general agreement about what courses of action are acceptable for the patient. There are times, however, when protracted negotiations and discussions end in irreconcilable differences, and no course of action seems tolerable to everyone. At times these disagreements may reflect deep-seated views about the meaning of life or duties to vulnerable people. In what follows, we focus on the subset of these intractable disputes where requests by families or patients are judged to be inappropriate by all, or almost all, clinicians. |
