By Sen. Robert Deuell and Rep. Susan King
From the beginning of life until the end — and for all the days in between — physicians are bound by our oath and professional Code of Ethics to put our patients first. We are morally and professionally required to put each patient’s own, individual best interests above our own, above those of any hospital or health care system, above those who pay for their care.
As physicians, we entered this great profession to heal the sick and injured, keep the healthy well, relieve pain, and provide comfort. Despite tremendous technological advances, sometimes only comfort care — physical and emotional — is all we have to offer. At the end of life, comfort is a powerful and compassionate form of treatment — one that supports a patient’s dignity.
The Texas Advance Directives Act (TADA) helps patients, family members, physicians, and other health care professionals in those days and hours when comfort treatment is the best medicine we have to give.
TADA was landmark law when written in 1999. It was adopted by unanimous consent and signed by then-Gov. George W. Bush. The most important goals of the law — then and now — are to encourage patients to discuss their end-of-life wishes with their families well before needed, and to provide families a reasonable process to resolve differences of opinion if difficult treatment decisions occur.
Texas physicians join authors Sen. Robert Deuell, MD, and Rep. Susan King along with colleagues at the Texas Catholic Conference, Texas Hospital Association, Texas Alliance for Life, and Texas Baptist’s Christian Life Commission to improve TADA. Changes to this law should be made only with support from patients and their families — as well as by the entire community of physicians, nurses, hospitals, nursing homes, and hospices who take care of patients near the end of life.
Reasons to support SB 303/HB 1444
Protects the patient-physician relationship.
Patients and families have autonomy, including the right to request a particular treatment and the right to refuse a particular treatment. They also have the right to seek second opinions or different care providers.
However, they do not have an unlimited right to require the physician to do anything the patient or family requests. A physician exercises independent medical judgment to ensure that a treatment is medically appropriate and effective for a patient. When a patient asks a physician to do something the physician believes is medically inappropriate, the physician can refuse to do so, and the patient may choose to seek another physician or provider. In the case of a patient who cannot make his or her wishes known, the law permits a surrogate to make treatment decisions based on what the patient would have wanted. If a physician believes the treatment decision is harmful, medically inappropriate, or unethical, current law provides a rational process for resolving such disputes without arbitrarily forcing physicians to abandon their moral conscience. SB 303 improves on that process by providing families more information sooner, more time for the process, and a liaison to shepherd the family through the process.
Protects patients from unnecessary suffering.
Senate Bill 303/House Bill 1444 will strengthen current law that ensures patients will not physically suffer unnecessarily. Proposed new laws in 2009 and 2011 would have prolonged the process of dying for many patients indefinitely, without regard for whether it harmed the patient or caused substantial pain and suffering. SB 303/HB 1444 increases the time for the disagreement resolution process, improves communication in the process, and ensures artificially provided nutrition and hydration is not withheld.
Protects against the provision of potentially unethical, medically inappropriate, outside-the-standard-of-care treatment.
Government should not interfere in the patient-physician relationship or legislate the standard of care. Just as a physician should not be forced to perform an abortion, so a physician should not be required to provide harmful or medically ineffective treatment to a dying patient. Just as surgeons should not be required to perform surgery they believe to be medically inappropriate, physicians should not be required to use their skills and technologies if they believe doing so is unethical, not in the best interest of the patient, or medically inappropriate.
Bolsters patient confidence on use of Do Not Attempt Resuscitation (DNAR) order.
Physicians are bound by medical ethics to discuss the issuance of DNAR orders with their patients and, if the patient is incompetent, with the patient’s family. SB 303/ HB 1444 actually provides patients and family members more protections than existing state law.
Current law treats a DNAR the same as any other medical order, which includes the reality that all medical acts must be performed in compliance with the standard of care and the principles of medical ethics. Many treatments and procedures could significantly affect the life of the patient, such as chemotherapy for cancer, administration of a significant medication to treat a stroke, or antibiotics. Consent forms are not required for these procedures, but physicians speak with their patients about the care they will receive, including potential risks.
SB 303/HB 1444 would take this one step further for a DNAR order, requiring notification when it is issued and an appeals process if the patient or family members disagree.
Expands families’ rights during the rarely used dispute-resolution process of TADA.
TADA recognizes disagreements can arise, in the setting of terminal illness, between health care providers and families in which families request the premature termination of treatment or request treatment that promotes suffering and prolongs dying. TADA provides a reasonable process to resolve any such disagreement. SB 303/HB 1444 improves on this concept by ensuring both parties can initiate an ethics review process, allowing more time and information for the process, providing a liaison for the family, and permitting numerous members of the family to participate.
Protects the professional ethics of physicians and protects against unreasonable emotional burdens for those who care for a dying patient.
This bill would maintain physician protections against forcing them to violate their own moral conscience or professional ethics. Forcing physicians to violate their own beliefs creates undue emotional burdens and increases the likelihood of professional burnout. Likewise, nurses and other health care providers are protected against the emotional trauma that results from being required to provide harmful, medically inappropriate, or substantially painful treatment to their patient indefinitely.