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Læknablaðið - 15.10.1989, Blaðsíða 45

Læknablaðið - 15.10.1989, Blaðsíða 45
LÆKNABLAÐIÐ 307 justify continuing life-sustaining medical treatments, thers is no reason to use those treatments (*12). PART III: FOR DECISIONS INVOLVING PATIENTS WHO ARE NOT NOW AND NEVER HAVE BEEN COMPETENT These guidelines address patients who now lack and have always lacked the capacity to choose for themselves with regard to life-prolonging medical treatment. They are patients for whom no »substituted judgment« can be rendered, as their present or previous wishes and desires cannot be known. Within this group two further distinctions may be useful: 1. Between those who, due to anomaly, illness, or injury, will never develop decisional capacity in the future (such as anencephalics, the permanently unconscious, and the severely and permanently incapacitated) and those who can be anticipated, if they survive, to develop that capacity to varying degrees; 2. Between those who have a natural or agreed surrogate (e.g., parents or guardian) and those who lack such a surrogate. Guidelines 1. Regard for the value of life does not imply an absolute duty to employ life-prolonging treatment for non-competent patients. In setting reasonable limits for such treatment, third person judgments about quality of life, (13) are inevitable. Responsible third person quality of life judgments consider, insofar as possible, how the options must appear from the perspective of one in the patient’s condition and determine what would most generally be thought to count as quality for most such patients (14). 2. Assessing quality of life of these patients for purposes of medical decisions involves weighing the ratio of benefits and burdens (15). 3. In most decisions involving patients in this category, at least five sets of interests may be discerned: a) the patient’s; b) the surrogate’s or family’s; c) the physician’s and those of other care givers; d) the health care institution’s (where continuing or withholding treatment may have religious, financial, and legal implications and may expose it to local or national publicity); e) society’s (including both the use of economic resources and the need for research to help future patients). Normally, the patient’s interests should be regarded as paramount. However, difficult moral dilemmas arise when the patient’s interests are unclear or clearly conflict with a number of other interests. Societies differ in their preferences for mechanisms for arbitrating conflicts in these difficult cases (e.g., institutional ethics committee, courts). It is important to remember, however, that in the cases most commonly encountered, the various interests are not necessarily in conflict. Often the patient’s own interest is integrally interwoven with the interest of the family and the community. Part of the physician’s clinical wisdom consists of responsibly weighing interests and creatively resolving apparently irreconcilable conflicts. 4. When the patient has a surrogate, the physician’s obligation to the patient also requires certain duties toward the surrogate. These include: a) providing accurate information about the specific clinical problems; b) being honest; c) applying skills in effective communication; d) being willing to answer any questions that are asked; e) being aware of broader social and moral implications. To act in a way that recognizes these duties to the surrogate is to be worthy of the trust that one hopes the surrogate will place in the physician, so that a policy of mutual and shared decision making may be fostered. When the patient is a child with an emerging capacity to participate in the decision-making process, both physician and surrogate demonstrate respect by responding to questions and concerns at a level consistent with the child’s cognitive and moral development. 5. While the physician is required to act in a trustworthy manner toward the patient and surrogate, the range of interests that could conflict (see Part II, 3 above) demands that that same standard of trustworthiness be translated to the level of social review and professional peer relationships. Whatever patterns an individual medical culture may employ to achieve that translation of standards, the process will be enhanced by careful documentation of medical care to facilitate thoughtful audit. This careful documentation should include both the careful recording of management plans and the internal reasoning that led to them. It should routinely include both medical evidence and the applications of principles which logically lead to
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