End-of-life disputes go to court

We now have the technology to keep patients who are critically ill and near death alive for much longer than ever before. But some doctors say, just because a treatment is possible doesn’t mean it’s right.

Doctors say sometimes, the best–and kindest–care they can offer is to stop all life-sustaining treatment.

For 16 years, Dr. Karl Ahlswede worked in suburban Philadelphia caring for heart patients in intensive care. In one case, when surgeons couldn’t fix a 55-year-old woman’s lung disease, her kidneys, other organs and skin began to break down.

“Her daughter was adamant that we continue full-court, aggressive care under any and all circumstances,” Ahlswede said.

The patient couldn’t communicate, so her daughter became her medical decision maker.

“I was very clear that her mom was never going to leave the hospital. She was never going to be active again, she was never going to be able to live on her own,” Ahlswede said.

A breathing tube and dialysis kept the patient alive, but couldn’t make her better.

“It felt as though we were being asked to do something potentially painful,” Ahlswede said. “We were trying to keep the patient as comfortable as possible, but when we would turn this woman with these open wounds we were causing pain.”

More people do have advanced directives, but today’s life-sustaining technology makes terms such as “near death” and “terminal” harder to define. Disputes erupt over end-of-life care and can continue for months. Ahlswede says, in the meantime, some nurses and doctors are forced to give treatments they think are medically inappropriate.

“It takes a toll, and there is a great deal of moral distress whether or not we are doing the right thing,” Ahlswede said.

So what does the law say when the medical staff thinks it’s time to stop treatment and the family wants to keep going?

“We’ve come to a legal and ethical consensus that patients have the right to control their own medical care. It’s your body, it’s your life, you’re in the driver’s seat,” said Widener University Law Professor Thaddeus Pope.

He says the law is less clear about whether doctors have to offer treatment they consider unnecessarily aggressive or even cruel.

In 2008, when and an Elizabeth, N.J. hospital wanted to stop dialysis for Ruben Betancourt, his family took the case to court. Trinitas Regional Medical Center was ordered to continue treating the 73-year-old.

“This is a case that the hospital, and generally hospitals across New Jersey, don’t want on the books,” Pope said.

Pope says that lower-court decision gave a lot of power to patients and their surrogates. The hospital appealed the ruling. Attorney Todd Drayton represents the Betancourt’s against Trinitas.

“Their only, or at least their strongest argument in this matter is …’OK, our Hippocratic oath requires that we do no harm. We really believe that we are harming him, by prolonging his life we are actually harming him,'” Drayton said.

Ruben Betancourt suffered severe bed sores, and some say he was “slowing decomposing,” but his family argued that the New Jersey man was a “fighter” and would want his treatment to continue.

“They would tell the hospital: ‘Hey, listen my dad is awake, he’s arousable. He’s responding to pain, he’s responding to conversations. We don’t know that he’s all together gone like you guys claim'” Drayton said.

Trinitas countered that while the patient’s brain damage may have mimicked awareness, there was no hope for recovery.

Sam Germana is general counsel for the hospital.

“The family does get to decide in certain circumstances, one of them being to decide among treatments that are appropriate and offered to them. They don’t get to pick and choose like off the menu at McDonalds, things that aren’t even being offered to them,” Germana said.

Ruben Betancourt died before the question reached the higher court, and the appeals judges decided the case was moot.

Hospital attorney Sam Germana says the question lives on.

“Should doctors be forced by non physicians to perform medical care that they feel is inappropriate?” Germana said.

Family attorney Todd Drayton posed the question differently.

“Whether or not a hospital can unilaterally and over the objection of the family member terminate life-sustaining medical treatment, that’s really the issue,” Drayton said.

Widener professor Thaddeus Pope says health policy experts are studying these end-of-life cases, in part, to gauge our national to will cut health care costs.

“If we can’t say ‘no’ to providing millions of dollars of aggressive, medical interventions to somebody who has no prospects for recovery, no prospect for cure, then how can we say ‘no’ and start drawing lines with regard to other treatments,” Pope said.