Protecting the Patient-Physician Relationship at the End of Life

TMA Testimony by Arlo Weltge, MD

Senate Health and Human Services Committee
Senate Bill 303
March 19, 2013
 

Good morning Madame Chair, Senator Deuell, and members of the Committee. Thank you for hearing my comments today.

My name is Dr. Arlo Weltge. I am an emergency medicine physician in Houston. I am here today testifying on behalf of the 47,000-plus physician and medical student members of the Texas Medical Association. I strongly believe that I am also here today to speak on behalf of our patients.

As physicians, Doctor Deuell, Doctor Schwertner, and I have a unique perspective and role with you, our patients. Each of us and every colleague I know genuinely wants to help the people who entrust themselves to our care.

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, insurance company, Government bureaucrat or even a personal injury trial lawyer.

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 comfort care – physical and emotional – is the best treatment I have to offer. You cannot imagine some of the horrific situations that I as an emergency physician must face in the status of patients who are wheeled through our doors and out of the back of ambulances.

We encounter patients at all stages of life. The beginning, the accidents in between, the maladies of the body, and unfortunately the reality of death for each and every one of us.

There has been so much rhetoric and accusation over the past few years in discussing this part of Texas law. My hope is that those behind language of hate do not truly view physicians as the enemy. Today, I represent my organization in attempt to be a part of the solution. It is because of our value and respect for patients that we gladly sat down with patients, Texas Catholics, Baptists and the Alliance for Life as well as THA to peacefully discuss how each of us should be treated and honored during the dying process.

Senate Bill 303 and many of the other bills on this topic, alter the Texas Advanced Directives Act, which was written to provide families a reasonable process to resolve differences of opinion if difficult treatment decisions occur.

Part of the reason I believe it has taken so long to present an agreed-upon bill is because this subject is so sensitive and thus must handled delicately and thoughtfully. 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.

Here are just a few reasons to support SB 303

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. When a patient asks a physician to do something that the physician believes is medically inappropriate, the physician can refuse to do so, and the patient may choose to seek another physician or provider. If a physician believes the treatment decision is medically inappropriate, harmful, or unethical, the current law provides a rational process for resolving such disputes without arbitrarily forcing physicians to abandon their moral consciences. SB 303 improves on that process by providing families with more information sooner, more time for the process, and a liaison to shepherd the family through the process.

Protects patients from unnecessary suffering.
SB 303 will strengthen current law that ensures patients will not physically suffer unnecessarily. Proposed 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 increases the time, improves communication for the disagreement resolution 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. 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 is medically inappropriate no matter who is demanding it.

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 or the patient’s family. SB 303 actually provides patients and family members with more protections than existing state law.
 
Current law treats a DNAR the same as any other medical order, which includes the reality all medical acts must be performed in compliance with the standard of care and 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, antibiotics, etc. 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 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. This is a significant change in law, one we are willing to make in order to achieve solutions for both sides

Expands families’ rights during the rarely used dispute-resolution process of the 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. SB 303 improves on the reasonable process to resolve any such disagreement by ensuring both parties can initiate an ethics review process, allows more time and information for the process, provides a liaison for the family, and permits 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 consciences or professional ethics. Forcing physicians to violate their own beliefs creates undue emotional burdens and increases the likelihood of professional burnout I know of entire medical teams who go through counseling for some of the cases and trauma they encounter. Under SB 303 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.

Thank you very much for your time. I would be pleased to answer any questions. 

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