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MedicalFu+lityDisputeResolu+onOp+onsintheUnitedStates:Law&EthicsFundamentals
ICEL2(HalifaxNS),Sept.15,2017
ThaddeusMasonPope,JD,PhD MitchellHamlineHealthLawIns5tute
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Whatisamedicalfu+litydispute
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SurrogatewillnotconsentwhenMDthinkstheyshould
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Fu5lityisaboutlinedrawing
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Inappropriate Appropriate
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Inadvisable Advisable
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Disproportionate Proportionate
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Non-beneficial
Beneficial
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Outside the standard of care
Inside the standard of care
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Therapeutic obstinacy
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Surrogatedrivenovertreatment
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Surrogate
LSMT
Clinician
CMO
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SurrogatewillnotconsenttoCMOrecommenda5on
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Whenmay/should/mustaclinicianstopLSMTwithoutconsent?
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Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
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Categoriesoutlinedinanewmul5-societypolicystatement
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Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
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Interven5onscannotaccomplishphysiologicalgoals
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Scien5fic
impossibility
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An5fungalsastreatmentformyocardialinfarc5on
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• Cptrigormor5s
CPRwhenshowrigormor5sordependentlividity
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Valuefree
objec5ve
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MaytheclinicianstopLSMT?
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Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
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LegallyProscribed
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Treatmentsthatmayaccomplisheffectdesiredbythepa5ent
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Prohibitedbyapplicablelaws,judicialprecedent,orwidelyacceptedpublicpolicies
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Might“work”
Butillegal
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Iftreatmentrequestislegallyproscribedà
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Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
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LegallyDiscre+onary
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Laws,judicialprecedent,orpoliciesthatgivephysicianspermissiontorefusetoadministerthem.
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Appropriatemedicine
Surrogate
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• Pics5nson• PicothersSFKYetc• Clickclickclick
IsraelS+nson
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Trisomy18/23
22-weekgesta5on
ECMO
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Not5-societystatement“fu5lity”
MightrestoreCPfunc5on
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“imminentdeath”
3daysh^p://healthvermont.gov/regs/ad/dnr_colst_instruc5ons.pdf
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MaytheclinicianstopLSMT?
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Legallydiscre5onary
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Fu5le
LegallyProscribed
LegallyDiscre5onary
Poten5allyinappropriate
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Poten+allyInappropriate
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Somechanceofaccomplishingtheeffectsoughtbythepa5entorsurrogate
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Not“fu5le”becausemight“work”
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E.g.dialysisforpermanentlyunconsciouspa5ent
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E.g.ventforpa5entw/widelymetasta5ccancer
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Wecallthem“fu5litydisputes”
...BUT...
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Disputedtreatmentmightkeeppa5entalive.
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But...isthatchanceorthatoutcomeworthwhile
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Notamedicaljudgment
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MaytheclinicianstopLSMT?
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Still no consent
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Lastresort
Notresponsiveinanycase
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Op+onswhenintractablePITconflicts
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199
Replacesurrogate
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SDMstepsintoshoesofpa+ent
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Hierarchy1. Subjec5ve2. Subs5tuted
judgment3. Bestinterests
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2105
Greenlights
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StopLSMTwithoutconsent
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PhysicianmaystopLSTwithoutconsentforanyreason,ifreviewcommi^eeagrees
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Givethesurrogate
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48hrno5ceRC
Wri^endecisionRC
10daystotransfer
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A^emptstoCOPYTexas
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NotchangenatureNarrowscope
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H.B.3074(2015)
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ar5ficiallyadministerednutri5on&hydra5on
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S.B.11(2017)
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Consentalways
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Nondiscrimina5oninTreatmentAct
November2013
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“healthcareprovidershallnotdeny...life-preservinghealthcare...directedbythepa5entor[surrogate]”
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MedicalTreatmentLawsInforma5onAct
November2014
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“Ifsurrogatedirects[LST]...providerthatdoesnotwishtoprovide...shallnonethelesscomply....”
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Discrimina+on
inDenialof
LifePreserving
TreatmentAct
132
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“Healthcare...maynotbe...deniedif...directedby...surrogate” 133
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DNRwithoutparents’consentorknowledge
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“Nohealthcare...staffshallwithhold,withdraworplaceanyrestric5onsonlife-sustainingmeasuresforany...under18yearsofagewithoutthewrifenpermission....”
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ThaddeusMasonPope,JD,PhDDirector,HealthLawIns5tuteMitchellHamlineSchoolofLaw875SummitAvenueSaintPaul,Minnesota55105T651-695-7661C310-270-3618EThaddeus.Pope@mitchellhamline.eduWwww.thaddeuspope.comBmedicalfu5lity.blogspot.com