Help Physicians Honor Patients’ End-of-Life Wishes

Testimony by Ray Callas, MD

House Committee on State Affairs
House Bill 2063 by Rep. Greg Bonnen, MD 

April 5, 2017

Thank you, Chairman Cook and committee members, for the opportunity to speak with you today. 

My name is Dr. Ray Callas. I am a practicing anesthesiologist from Beaumont. I am speaking today for the Texas Medical Association and our more than 50,000 physician and medical student members. I speak on behalf of our patients, and that is why we are opposed to House Bill 2063 as filed.

As physicians, Dr. Bonnen and I have a unique perspective of and role with you, our patients. Both of us, and every colleague I know, want to help the people who entrust themselves to our care.

As physicians, we have a moral obligation to put the best interests of each individual patient above those of our own, above those of any hospital or health care system, and above any insurance company or other outside party. 

End-of-life decisions cannot always be made in a contemplative fashion with adequate time to consider options, collect the needed witnesses, and draft and sign the proper documents. All too often, they must be made in the emergency department. We are seriously concerned that the bill as filed does not account for the realities that patients, families, and physicians face in emergency care. 

Patient Wishes

TMA strongly encourages all patients to execute legal advance directive documents, including a medical power of attorney; a directive to physicians that specifies any preference for or against care; and, if desired, an out-of-hospital “do not resuscitate” order, or DNR. Unfortunately, about two-thirds of adult Americans have not done so.  Even when patients have executed these documents, very few of them arrive in the emergency department with the relevant papers in hand. 

We are seriously concerned that HB 2063 as filed does not permit physicians to honor patients’ wishes if they are communicated privately to the physician in a setting where paper documents are not available or have not been executed. The current bill interferes with our ethical duty to act in accordance with patients’ wishes and best interest. We note that it is not unusual for a patient’s own wishes to be different from a family member’s wishes for the patient. Thus, if a patient orally expressed his or her directive, this bill language might permit a surrogate to override those wishes.

Medical Judgement

When physicians make treatment decisions in an emergency, we must consider many factors and act on them almost instantaneously. Medical teams often must act rapidly on verbal orders and directions, as there is no time to ensure proper documentation. We must consider and balance the patient’s known and possible unknown conditions and the likelihood that any particular procedure or treatment will be helpful or harmful in the specific circumstances. 

In this setting, orders for cardiac resuscitation are similar to other orders like prescribing antibiotics or providing certain treatments. There are circumstances in which they are appropriate and circumstances in which they may not be. The factors we must considered must always include the patients’ wishes when they are known, but as with other medical orders, a myriad of other medical factors also guide physician decisionmaking. Two of these are:

 

  • Effectiveness: Whether CPR is likely to be effective depends on medical conditions and circumstances subject to medical decisionmaking. The physician must consider the patient’s age, the circumstances in which the patient’s cardiac arrest occurred, and the patient’s other medical conditions. Some injuries or illnesses are simply not survivable. However, even in the best of circumstances, CPR is effective in only about 12 percent of cases when performed outside the hospital and in less than 25 percent of the time in a hospital setting.
  • Possible Harm: Even when the medical circumstances are optimal and the results are good, CPR can cause pain, damage, and distress to patients. For example, chest compressions commonly result in broken ribs, and repeated attempts can cause those broken rib fragments to puncture lungs and damage other body tissues. These problems can become particularly acute when patients are elderly and frail. When there is no ultimate benefit to a patient, CPR can turn a tragic death into prolonged suffering or even torture. 

 

HB 2063 greatly restricts reasonable medical judgment in application of a DNR order on behalf of a patient. The language is vague and would permit physician judgment only if death were expected within 24 hours. But time of death can almost never be predicted that accurately. Physicians and providers need to be allowed to do what is in the patient’s best interest based on our experience and training. 

When patients are dying due to the terminal stages of disease or the expected effects of advanced age, sometimes the best possible medical care is to take measures to relieve suffering but allow a natural death.

Our goal should be to encourage and educate patients to use advance directives. The medical and legal professions should work together to develop new and better pathways for patients to communicate their own wishes.  

Alternative Language

TMA has developed alternative language that addresses the concerns we have raised and that we believe many of the other interested parties can support. Depending on the wishes of the chair, the committee members, and the author, our staff will be happy to work with you on that language.

Thank you for your attention, and we look forward to working with the committee on this important and complicated issue.

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Last Updated On

May 09, 2017