Bioethics on Call #4 The Need for an Advance Directive

Bioethicist David Lemberg discusses the need for a meaningful and practical advance directive and how to protect our financial assets in today’s health care system.

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Creating a New Doctor–Patient Relationship

I recently presented my talk, “Medical Ethics: Creating a New Doctor–Patient Relationship” at Jewish Family Service community group meetings at Temple Adat Shalom (Poway, CA) on 10/14/2015 and Temple Solel (Encinitas, CA) on 11/17/2015.

The talk focuses on

  • The history of medical ethics
  • How to create a mutually beneficial and effective partnership with your doctor
  • How to protect your future welfare and that of your family by creating a meaningful and practical advance directive

Today’s doctor–patient relationship requires new thinking on all sides. The Supreme Court long ago affirmed the principle of patient autonomy, that is, the patient’s right to choose or refuse medical treatment. It is no longer proper for the doctor merely to tell the patient what is to be done. Patient considerations regarding harms and benefits, as well as considerations of quality of life, must be part of the process. But such evaluations are complicated for both the patient and the doctor. The need for a new relationship, a partnership that involves shared decision-making, is now more important than ever, especially when considering end-of-life care.

I am available to present “Medical Ethics: Creating a New Doctor–Patient Relationship” at conferences and community groups.

  • Contact me via email
  • Contact me via phone: 619-540-9038

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Case Managers, Palliative Care, Advance Directives, MOLST

In our Bioethics On Call video conversation, Professor Kim Evanoski discusses topics in palliative care, training of care managers, use of advance directives, MOLST, and her work as Zelda Foster Palliative and End-of-Life Care Fellow at New York University. Additionally, Professor Evanoski discusses the upcoming Care Management Summit: Achieving Excellence conference on May 22-23, 2014 at Binghamton University, Binghamton, NY.

Kim Evanoski, MPA, LMSW, is Zelda Foster PELC Fellow at New York University and member of the Department of Social Work and Hartford Partnership Program in Aging Education at the College of Community and Public Affairs, Binghamton University.

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Medical Ethics, Living Wills, and End-of-Life Care

In our Bioethics On Call video conversation, Professor Wayne Shelton discusses medical ethics, end-of-life decision making, living wills, competency, and capacity. Dr. Shelton discusses the incorporation of ethics training in medical education and the use of ethics consultations in day-to-day interactions with patients, families, and medical staff. Medical ethicists at Albany Medical Center engage in 100 ethics consultation per year, providing incalculable benefits to patients and families at critical stages of care.

Wayne Shelton, Ph.D., is Professor of Medicine at Albany Medical College and Professor, Center for Biomedical Ethics, Education, and Research at Albany Medical Center.

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Your Health Care and the Affordable Care Act

Health Law Fails to Lower Prices for Rural Areas was the lead headline in the 10/24/13 New York Times. The article highlights the fact that in more than half of 2500 rural counties, health insurance plans are offered by only one or two carriers. The lack of competition has thus far failed to lower consumer costs.

But such an article diverts attention from the real issues. Yes, competition is severely limited in many regions across the U.S., particularly in the South. It will take time to redress the many inequities that persist from the pre–Affordable Care Act (ACA) era. Of course, the ACA rollout began only several weeks ago. Realistically, such a massive undertaking will be accompanied by numerous initial failures. The technical shortcomings, such as lack of ability to obtain coverage via the online systems, are still being hyped in every media outlet. But as the Nobel Prize–winning economist, Paul Krugman, observed in his 10/3/13 New York TimesOp-Ed column, Reform Turns Real, the glitches won’t matter in the long run.

Health care reform has been a very long time coming in the United States. Tremendously powerful special interests have been arrayed against such reform for decades. That we have any progress at all in this area is due to the vision and persistence of President Obama and his allies in the Cabinet and Congress. Enactment of the ACA is also due, in large part, to the efforts of President Clinton and his staff in the early 1990s. The ACA contains numerous policy errors and the act is extraordinarily complex. Compromises were effected on both sides of the aisle in order to obtain passage of the bill. Regardless, the ACA is law and will be of benefit to every American, not the least to those 50 million of us, predominantly women and children, who have been without health insurance coverage for many, many years.

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Bioethicist David Lemberg discusses how pharmaceutical marketing and lobbying costs impact your health care and the economy and what we can do about it.

Bibliography

Relman A, Angell M: America’s other drug problem. The New Republic, 12/16/2002, p 38

Big Pharma’s Stranglehold on Washington

Pharma Spending on Lobbyists

Drug Prices Jump Again While Other Costs Decline

DTC Advertising and Its History with the FDA

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Bioethics On Call #2 – The Right to Health Care

In today’s edition of Bioethics On Call, bioethicist David Lemberg discusses the right to health care, locating such a right in the U.S. Constitution’s Bill of Rights.

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Introducing Bioethics On Call, a new audio blog focusing on health care policy, end-of-life decision making, health disparities, social justice, and biomedical ethics. In today’s edition, bioethicist David Lemberg discusses health care delivery in the United States and the need for the Affordable Care Act.

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The Need for a Living Will

Before the early 1960s, there was no particular need for a living will or advance directive. Back then, if a person’s heart stopped, that was it. Cardiac arrest rapidly led to death. But in 1960, a method of “closed-chest cardiac massage” was described in an article in the Journal of the American Medical Association.1 The article reported on 14 patients who survived cardiac arrest via application of the new technique. The innovative procedure was refined over the next few years and became known by the term with which we’re familiar, cardiopulmonary resuscitation (CPR). Guidelines for the use of CPR were developed and continue to be updated.2

CPR provided the possibility of a return from death under certain circumstances. The primary concern with CPR, of course, is the amount of time that the person’s brain has been deprived of oxygen. MedlinePlus, a service of the U.S. National Library of Medicine and the National Institutes of Health, states that permanent brain damage begins after 4 minutes without oxygen and death may occur as soon as 4 to 6 minutes later.3 Problematically, fewer than 50% of persons in cardiac arrest receive CPR from bystanders, and emergency responders have no accurate means of determining how long it has been since the victim’s heart stopped beating. As a result, many of those who survive CPR have some degree of brain damage, often serious or severe. Given a choice, at least some of these persons might have desired not to be resuscitated if the circumstances were not optimal.

Similarly, terminally ill patients or those suffering a catastrophic injury may require artificial hydration and artificial nutrition (ANH) to sustain life. But some persons, given a choice, might not choose such means of survival if they were able to state their preferences and desires. ANH might be viewed as unacceptably onerous. The quality of life obtained might be viewed as insufficient. These persons would prefer to permit natural processes to determine whether they live or die.

But if one has not enacted a formal living will, one’s medical treatment is determined by the medical standards of the community. Typically, any and all available life-saving measures will be utilized when needed, based on the presumption that saving a life is always better than the alternative. A living will is required in the event that one is not able to speak on one’s own behalf. With respect to medical treatment, a living will provides the opportunity for having one’s desires and preferences honored and implemented.

1Kouwenhoven WB, et al: Closed-chest cardiac massage. JAMA 173:1064-1067, 1960
2Field JM, et al: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation 122:S640-S656, 2010
3MedlinePlus

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What Is a Living Will?

A living will or advance directive is a legal document by which one can specify his or her personal preferences and desires regarding health care decision-making in circumstances in which one is not able to speak on one’s own behalf. In other words, a living will provides a formal record of a person’s wishes in situations requiring medical decision-making, in the case in which that person, who previously had the cognitive capacity to make her preferences known, has lost such capacity, temporarily or permanently.

For example, a 55-year-old man suffers a stroke (cardiovascular accident; CVA) and loses consciousness. EMTs are called and the man is taken to the local hospital. The man (we’ll call him Joe) is able to breathe on his own, but requires life-saving support measures including delivery of fluids and nutrients (artificial hydration and nutrition). Joe never enacted a living will, and these measures are undertaken. After 72 hours Joe regains consciousness, but it is apparent that the CVA has caused severe brain damage. He is unable to understand what is said to him and he is unable to articulate recognizable words. Such a condition is known as global aphasia. He also has suffered a deterioration of skilled movements (apraxia) and is unable to feed himself. Thus, Joe requires full-time nursing care and may require such care for months or years. Although functional improvement is possible, the potential for improvement is typically unknown and the possibility exists that Joe will be permanently severely impaired in terms of cognitive function and the ability to perform activities of daily living.

Of course, these circumstances are very difficult to think about and speak about. Most of us have loved ones, family members or friends, who have suffered such an illness. Our critical question is what would Joe have wanted in the immediate aftermath of his stroke, had he been able to speak on his own behalf. Would Joe have desired live-saving measures to be used, regardless of the outcome? Would he have desired to continue living despite the long-term, possibly permanent, loss of his cognitive abilities? Many people would respond affirmatively, desiring that all life-saving measures be used to preserve life at any cost. Others would wish to decline such measures in medically life-threatening circumstances, being concerned about an unacceptably untoward outcome, based on their beliefs and values of what constitutes a happy life. For these people, a living will provides a formal, clear statement, of what medical services they would wish to have done to preserve life and what they would wish not to have done.

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