Withholding and withdrawal of Medical treatment decisions from Children and neonates - Case Study Example

1.Withholding and withdrawal of Medical treatment decisions from Children and neonates. Introduction Parents, doctors, the health care team havea common goal in ensuring good health and sustaining the life of children and neonates. Although advanced technology makes it possible to prolong life, prolonging life beyond a meaningful point in some neonatal and children's cases involves making difficult decisions on when and how life sustaining treatment is to be withheld or withdrawn. The Ethics Advisory Committee of the Royal College of Pediatrics and Child Health (EAC - RCPCH) has defined five categories in which the withholding or withdrawal of life sustaining medical treatment can be done. With holding or withdrawing does not even mean that the child will receive no care. Such a decision is followed by palliative care for the child. The withholding and withdrawing decisions is made by only experienced senior doctors. Clinical situations of these decisions include Non-resuscitation of a baby at birth with congenital abnormalities like anencephaly, making the child incompatible for survival; Non- resuscitation of a baby born with a gestational period of twenty three weeks or less making the baby neurologically impaired; withdrawal of ventilation from the baby with birth asphyxia leading to brain damage. The frequency of selective non treatment of extremely premature, critically or mal formed infants in Level III intensive care nursery (ICU) and the reasons documented by neonatologists for their decisions to withdraw or with hold life support has been well documented (Wall, 1997). They reviewed all the medical records of 165 infants who died at a level III (ICN) during 3 years. One hundred and eight infant deaths were found to be due to withdrawal of life support and thirteen deaths due to withhold of treatment. End of life decisions in new born with incurable diseases are difficult for pediatricians. In Netherlands, deliberate ending of life can be acceptable choice if a life full of severe and sustained suffering that cannot be relieved by any other means is expected of the child (Verhagen 2005). During a study for the period from January 1988 through December 1991, of 529 neonates admitted in Sophia Children's Hospital, Rotterdam, the Netherlands, 524 had been found dead of which 28 were due to the disease and 24 cases due to withdrawn or withheld treatment. In 15 of the 24, treatment was withdrawn due to severe congenital anomalies; in 9 of the 24, treatment was withdrawn because of serious complications. But in all the cases withdrawal was done unanimously after lengthy discussions between doctors, nurses and the parents (Hazebroek, 1993). Withdrawal of treatment in pediatric intensive care units accounts for between 43% and 72% of deaths in U.K (Mcmillan 2000). The Law:- All such professional decisions are done within the framework of law. The children Act (England and Wales 1989) safeguard the children's welfare. The Act also introduces the concept of parental responsibility. A number of judgments on withholding or withdrawing life sustaining treatment have proved that there is no obligation on part of the doctors to give treatment which is futile and burdensome and such a treatment could be treated as an assault. They have also given enough scope for the treatment goals to be changed in case of a dying child. These judgments have legalized the withdrawal of feeding and medical treatment In such cases in the best interests of the children. Withdrawal of life sustaining treatment in appropriate cases is not active killing, nor does it breach the article 2 of the European Convention on Human Rights. Decision Making: Initially the medical team must wait for enough information about the clinical status of the child. The decision making process involves all members of the Health Care Team and the parents. In practice, a decision to withdraw treatment is usually a matter of consensus. However such major decisions always require a second opinion, legal as well as clinical. The treatment can be withheld or withdrawn if the case in consideration is 1.Brain Dead Child: In such cases, brain stem death is confirmed and the patient by medical definition is dead. Brain death must be diagnosed in the usual practice by two medical practitioners. 2.Permanent Vegetative State (PVS):- In such cases the permanent Vegetative state occurs due to trauma or hypoxia and the child has no awareness. In such children feeding tubes can be removed as in the classic case of Bland (Airedale NHS Trust Vs Bland 1993) 3.The No Chance Situation:- In such cases, treatment just delays death with no cure. This is called futile treatment and may constitute an assault or inhuman and degrading treatment under Article 3 of the European Convention on Human Rights. Children with metastatic malignancy can be cited for these cases. 4.The No Purpose Situation:- In such cases, the child may survive with treatment, but the treatment may not be in the child's best interest as in the case of children with irreversible impairment. In such cases continuing treatment would worsen the condition. 5. The Unbearable Situation:- The situation occurs when the child and the family of the child feel that the treatment cannot be clinically borne anymore. Palliative care has to be offered after withdrawing or with holding treatment respecting the child's dignity. A full record of communication with the family should be written in the clinical record on all occasions. Do not attempt resuscitation orders and decisions to withhold or withdraw life sustaining treatment must be recorded in the clinical notes. The death of a child is one to the most devastating experiences fro a parent and the quality of care at the end of life and at death has an impact on the grief. There are situations where medical attempts to cure are futile or inflict suffering on the child. Appropriate withdrawal or withhold decisions depends on the accuracy of knowledge of the condition and inter-relationships with and around the child. Total = 974 words 2.Incompetent patients and the law : This is a classic example of a person who has become incompetent not clearly making his treatment options clear by proper documentation. There is no proxy consent for an adult in UK. Thus, no close relative of an adult can influence the treatment options. The treatment options are decided on the Best Interests of the patient by doctors. The doctor under such circumstances should judge the options clearly and be prepared to defend his decisions. In case of litigations on account of such medical decisions , the court will decide based on the findings whether the treatment was given in the best interests of the patient. The Bolam test is used to determine the best interest standards which confirms if a responsible body of medical opinion would affirm that the treatment was in the best interests. Although In Scotland , the Adults with Incapacity (Scotland) Act 2000 says that competent individuals over 16 can appoint someone to make decisions about medical treatment on their behalf if they become unable to do so, the English law demands that no-one can consent to medical treatment on behalf of an incompetent adult patient and the patient's relatives cannot demand treatment they consider is in the best interests of the patient. When a patient is temporarily incompetent, following an accident or medical event like being unconscious the healthcare professional should do only what is necessary in the circumstances. Patrick Hoyte, in his publication Consent may not be needed to save life opines that in case of such adults who will not allow a blood transfusion in all circumstances , giving a blood transfusion under such a restriction would lay the doctors open to legal charges of battery. When a patient is incapacitated or incompetent, the Law Commission recommends careful consideration of "the ascertainable past and present wishes and feelings of the person concerned, and the factors that person would consider if able to do so to decide on a treatment ( Patrick Hoyte,1997). According to Hoyte, when a patient temporarily, or permanently, lacks the capacity to give or to express consent to treatment, it is axiomatic that treatment necessary to preserve the life, health or well-being of the patient, may be given without consent. This is not only lawful for doctors to provide such necessary treatment to incapacitated patients, but it is also their duty to do so as medical professionals. According to English Law, no one can give consent on behalf of an incompetent adult.-but , treatment can be still be given in the Best interests of the patient. The patient's close relatives are reliable sources who can help in this regard. But, in case the patient when competent issues an advance refusal of treatment under certain circumstances, the doctors should abide by the same. A code of practice under the new Mental Capacity Act for doctors and others who deal with people who cannot take decisions for themselves was issued recently in draft for consultation. The draft code applies to England and Wales. It sets out how patient capacity should be evaluated and how these advance directives on treatment will function and how treatment modes should be decided. The act is expected to be in force from 1 April 2007. Living wills are already binding on doctors even under common law (Dyer,2006). These advance directives helps sort out two types of legal situations.1.These directives help a competent adult to choose his treatment and 2.These helps a competent adult to choose his treatment options when he becomes incompetent under circumstances of a disease or accidents. These advance directives can also serve the purpose of a living will of a competent adult who can also direct how his organs could be utilized for research study. Before any terminally ill person receives his chemotherapy or an invasive procedure, he/she should give a well-documented consent. Informed consent means that tests, treatments and medications have been explained to the person, as well as outcomes, possible complications and alternative procedures. The doctor in this case is liable for prosecution because he has not taken the consent of the person before taking his samples for research. Taking the organs, parts of tissues without patient's consent is illegal in UK. This includes Kidney, Liver and other organs and tissues including blood samples for genetic tests. This is as per the recommendations of Joint Committee on Medical Genetics of the Royal College of Pathologists and British Society for Human Genetics. But if a tissue is taken in the larger interests of the population, where the incompetent patient is also a beneficiary, the doctor should be able to prove the best interests in the court of law. Total words=780 3.Euthanasia Case 1 Karen yanoch who was terminally ill with liver cancer decided to end her life by drinking a bitter solution of a lethal barbiturate. She took several small sips and a final gulp of the solution, slipped into a coma three minutes later before dying shortly afterwards. This happened in Oregon, U.S.A., which has a law which provides for assisted suicide or Euthanasia. The Oregon law allows adult with terminal diseases who are likely to die within six months to obtain lethal doses of drugs from their doctors. Case 2 Madison County authorities charged Dr. James Bischoff with murder because he gave 85 year old Kathryn Dvarishkis a lethal drug to let her die. She was administered two doses of fentanyl in a 10 minute interval and she died moments later. Case 3 Nancy Curzon met with a car accident and from then on remained in a persistent vegetative state. The U.S. Supreme court refused to allow her feeding tubes to be removed to let her die because there was no concrete evidence to that regard from Nancy herself. The first case is of a patient who has been allowed to die as per the "Death with Dignity Act" passed in 1994 in the State of Oregon, U.S.A. The second case is a Direct Euthanasia, where the doctor has been an agent in inducing a patient's death by giving a lethal drug in a state euthanasia is not legal. The third case is of a situation where there is no request of the patient to die based on his/her own will. Thus, decisions at the end of life are always difficult ones to make creating a conflict of morality, Ethics, and the law. Another example of a patient with a terminal illness in U.K. fighting for her right to die is Diana Pretty with a motor neuron disease. Her request was turned down by the Government and she then went to the British Courts and the European Court of Human Rights to fight for this right. All the Courts refused her request. A survey in the Pulse magazine (Nov 1997) proved this point and showed an alarming 46.5% of GPs helping assisted suicide. This is against the law in U.K and medical staff face prosecution on such acts. In Countries and States where Euthanasia has a legal validity, it is an act on purpose, performed by a third person, in order to end life of a person who has requested for this act. Only a physician can perform this act. The doctor can perform euthanasia only when the patient is of major age or an emancipated minor. The patient is of full legal capacity and conscious; the request is voluntary, well considered and repeated; the patient is dealing with unbearable and consistent physical or psychological pain or suffering as a result of an illness or an accident and cannot be cured. The doctors are allowed to perform Euthanasia when the following rules are followed: The patient needs to be informed about his health situation and life expectancy. The doctor is obliged to discuss the possible therapies, palliative care and the consequences. Based on the discussion, the doctor has to clear that there is no other alternative than euthanasia and the request of the patient is based on his own will. A second opinion has to be obtained from another doctor. The doctor has to wait for a period of at least on month between the written request of the patient and euthanasia. However, in all cases a written request is an essential component. A written request is composed, dated and signed by the patient requesting for euthanasia. In cases, where the concerned patient is not physically in a state to communicate, a living will regarding euthanasia valid for a maximum of five years can be taken after adding it to the Medical file record. After performing euthanasia, the doctor has to report to the Legal governing bodies. Euthanasia has been found to acceptable to two thirds of Oncology patients in U.S.A (Emanuel 1996). But Euthanasia is illegal in U.K. Recently investigations have been ordered into deaths of 11 patients at a psychiatric hospital in the mid 1990s after allegations of euthanasia. The 250 bed hospital is part of the South Derbyshire Mental Health Trust. A U.K nursing home in Birmingham has been closed after reported deaths of twenty eight patients in 2002-2003. Critical Analysis A law currently proposed by Lord Joff, debated in the House of Lords, gives a framework for euthanasia in U.K. His proposal states that only patients who are terminally ill and judged to have less than six months to live would be eligible for an assisted death. In most of the countries removing or denying treatment without consent from the patient is seen as clear murder . Euthanasia may be direct or indirect. Indirect methods of euthanasia are defined by an individual himself/herself taking the final step of inducing death. Direct methods are defined by the involvement of clinicians and is legal in Netherlands, Columbia, Japan and Belgium. Voluntary Euthanasia is carried out with the fully informed request of an adult patient or his proxy. In Britain, a High Court Judge recently cleared the legal hurdles for an euthanasia case. The judge permitted the husband of Mrs. Z to accompany her to Switzerland to help her die. Mrs.Z (her anonymity protected by a court ruling) suffered from an incurable brain disease and wanted to go to 'Dignitas' an organization in Switzerland which helps people to die. After the court ruling the women flew to Zurich where she took a lethal dose of barbiturates in a home accompanied by a doctor nurses and a lawyer. The British Court had said that the law should not interfere with her rights to die weakening the barriers that prevent assisted suicide in English Law, under which it is an offence that could take the doctor up to 14 years in prison. .Total=970 words. Works cited .Emanuel et. Al; 'Euthanasia and physician assisted suicide: attitudes and experiences of oncology patients, oncologists and the public', 'Lancet', 347 (9018):1805, June 29, 1996. Hazebroek et al; 'Withholding and withdrawal of life support from Surgical neonates with life threatening congenital anomalies', 'I pediatr Surg', 28(9) 1093-7, Sept 1993. Karen Street et al; 'The decision making process regarding the withdrawal or withholding of potential life saving treatments in a children's hospital', J .Med Ethics, 26:346-52; 2000. Kubler - Ross E, "On death and dying", Macmillan New York, 1969. .Michel Fertleman, 'The law of Consent in England as applied to the sick neonate', The interned journal of Pediatrics and Neonatology, Vol 3, (1), 2003. Mc Skimming S.A, Super, A., Driever, M.J, Schoessler, M., Franey S.G & Fonner E, "Living and Healing during life-threatening illness"; Portland, 1997. Mulcahy, L., "Disputing Doctors - The socio-legal dynamics of disputes between doctors and patients", Open University press, Milton Keynes, 2003. Neil H.Baum, "Support your decisions with Evidence based Medicine", "Urology Times" Feb 1, 2003. Patrick Hoyte, BMJ 315:1531-1532 , 'December 1997; Stephen N Wall, 'Death in the Intensive Care Nursery Physician Practice of withdrawing and withholding Life Support', 'PEDIATRICS' Vol 99(1) 64-70, Jan 1997 Verhagen, et al; 'End of life decisions in new born: An approach from the Netherlands', PEDIATRICS, Vol 116; No.3, 736-39, Sept 2005. .Withholding or Withdrawing life sustaining treatment in children. A Framework for practice, second Edn May 2004. Royal college of Pediatrics and child Health U.K. Read More