Læknablaðið - 15.10.1989, Side 44

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LÆKNABLAÐIÐ
5. »Best interests« decisions. If the comparative
merits of the alternative futures, in the light of the
patient’s values, do not clearly indicate which
plan of care the patient would have preferred,
then the physician, in consultation with the
family, if available, and other direct care givers,
should identify the plan of care that would most
generally be thought to advance most such
patients’ interests; and, if family and direct
caregivers concur, it should be implemented.
Ordinarily, for example, persons would want to
preserve identity, be able to maintain
independence and control, be able to interact with
others, have pleasurable experiences, avoid pain
and suffering, and avoid being a severe burden
upon others. Normally treatment must be
justified in these terms (9).
6. Discord. If there is a conflict between the
responsible phycisian and an involved care giver
or family member as to which course of care
should be pursued, then procedures must be in
place to ensure adequate attention to resolving
this discord. Counseling, discussion,
consultation, and other informal interventions
may bring about significant degrees of agreement
(10). If the person(s) who disagree(s) with the
physician’s recommendation is emotionally and
socially distant and there are others who are
emotionally and socially close, then the physician
may disregard the claims of the more tangential
party. However, if the disagreement is with
someone close to the patient, the physician should
not generally override that view without resorting
to more formal conflict resolution processes.
These might include intrainstitutional authorities
(e.g., ethics committees or department heads or
administrators) or extra-institutional authorities
(e.g., the courts). Institutions and programs of
care should have available reliable and responsive
procedures that ensure that all relevant
considerations are given their due.
7. Socially isolated patients. If the
now-incompetent patient has no family or
friends, the physician has an especially weighty
obligation to ensure that decisions are made well.
Not all such patients need personal advocates
(e.g., guardianships, ombudspersons, public
officials), but the physician should consult widely
with other direct caregivers, consultants, and
relevant religious advisors. Some cases may merit
formal review either by intra-institutional or
extra-institutional authorities before the decision
is made by the physician. The need for this
prospective review should reflect the degree to
which the decision is one with serious and
irreversible effects, one with unavoidable
uncertainties, one concerning a patient of a group
with a history of being treated in a discriminatory
manner, or one which is without substantial
precedent.
8. Restoration of competence. When it is
reasonable to believe that a patient could regain
competence before a weighty decision must be
made, the decision should be delayed in order to
allow the patient the opportunity to make the
decision.
9. Futile treatment. A treatment that cannot
reasonably be expected to achieve even its
physiological objective is physiologically futile
and need not be offered nor provided if requested
(11).
10. Careplan considerations. Plans of care must
be resonably comprehensive, including
considerations of what treatments to utilize, how
long to employ them, and when and how to stop.
Planned trials of one or more courses of care for
indívidual patients are often very useful in
delineating the likely course of the patient’s
response to treatment and should be encouraged.
Withdrawing treatment already initiated should
not be regarded as any more problematic,
ethically speaking, than withholding such
treatment initially. Indeed, often, some medical
evidence is clearer after a trial of treatment, and
withdrawing ineffectual or harmful treatment
then has even more justification than would have
withholding the treatment originally.
11. Quality review. The decision-making process
must be documented and justified in writing to
facilitate regular audit by the profession and
others who may be involved in quality assurance
processes.
12. Active euthanasia. Intervention with the sole
intention of causing death (as distinguished from
forgoing treatment that is deemed inappropriate)
has no place in the treatment of permanently
incapacitated patients. However, vigorous
treatment to relieve pain and suffering may well
be justified, even if these interventions lead to an
earlier death.
13. Persistent vegative state. The patient who is
reliably diagnosed as being in the persistent
vegetative state (PVS) has no self-regarding
interests. Unless the patient in the past has
requested or the family or caregivers now can