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Monday, November 24, 1997

Doctors discuss ethics of pulling the plug

By MARK BABINECK Associated Press Writer

LUBBOCK, Texas (AP) - An 83-year-old man lies motionless in a hospital bed, his brain and kidneys having deserted him. It's a matter of time until his other organs follow suit.

Because he hadn't made any plans for this vegetative state, the man's family forces doctors to keep him alive with tube feedings, a breathing machine and dialysis.

As doctors and the family debate, the man finally succumbs to heart failure.

"At least we do not feel guilty, because our father died with everything being done for him," said the daughter in the hypothetical case presented by West Virginia University lecturer Dr. Alvin H. Moss last week.

Texas Tech panelist Dr. Thomas McGovern questioned the daughter's conclusion: "I'd like to argue their father died with everything being done for his family."

Moss, a kidney specialist and bioethicist who addressed a Texas Tech ethics forum Thursday, said doctors still aren't as adept at dealing with such situations as they should be. He emphasized that communication is key, especially before a patient endures such dire straits.

"Many patients want their families to make the decisions," Moss told an audience of medical personnel Thursday. He said advanced care planning is the key, and it doesn't have to involve a lengthy legal document, just a "good talk."

"More important isn't what a patient would want, it is what a patient would not want," he said.

Forum attendees described their struggle between family demands to keep patients alive and their oath to "do no harm." Many of them construed artificially maintaining a shell of a body as doing more harm than good.

When patients make it clear they want to be kept alive under any circumstances, case law still supports their right to live no matter the cost.

Doctors are charged with determining whether the burden-to-benefit ratio is "proportionate" or "disproportionate." Then, more importantly, they must clearly and fully inform the patient or his family the situation.

"In the scenario there was a $300,000 bill. About $200,000 could have been saved," if the family had stopped heroic treatments when doctors diagnosed the man brain-dead. "Isn't it a happy scenario when doing the right thing costs us less?"

Whether patients detail their critical care wishes in writing or simply discuss their beliefs with family, physicians or clergy, Texas Tech associate law professor Elizabeth Schneider said, preparation is crucial.

"The time you enter the hospital is not the time to be drafting these agreements," she said.

In the forefront of Moss' ethics talks is dialysis, the exhausting method whereby patients in renal failure get their blood cleaned by a machine three times weekly.

A majority of the United States' approximately 250,000 dialysis patients are elderly, many of whom aren't candidates for transplantation. About 10,000 either voluntarily stop treatments or are taken off when it's decided that burdens on quality of life outweigh the benefits of staying alive, Moss said.

Moss and other kidney specialists are formulating standards by which dialysis should be discontinued, a task he hopes other disciplines will mimic.

The biggest challenge for bioethicists, however, occurs when patients can't make their own decisions. One Tech doctor said "do not resuscitate" orders signed by patients often aren't immediately to doctors faced with split-second decisions.

Moss supports the availability of a wallet-sized card to instruct doctors not to perform heroic lifesaving measures in certain situations. Send a Letter to the Editor about This Story | Start or Join A Discussion about This Story
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