Asking permission when permission isn’t required
Physicians acted appropriately when they removed Jesica Santillan from life support without the consent of her parents, according to advice offered by an attorney who says such situations can be difficult for risk managers to handle.
Following a series of tests, doctors at Duke University Hospital in Durham, NC, determined that Jesica Santillan, 17, met the criteria for the declaration of brain death. She was pronounced dead at 1:25 p.m. on Feb. 22, 15 days after an error led to her receiving a heart and lung transplant of the wrong blood type. Hospital spokesman Richard Puff tells Healthcare Risk Management that she was kept on life support until about 5 p.m. so family and friends could say goodbye.
Here is an excerpt from Duke’s statement explaining its decision to discontinue treatment: "Some have asked why other doctors were not brought in to provide a second opinion’ before Jesica was declared dead. In fact, a second pediatric neurologist from Duke was brought in to confirm death. And medical standards for brain death’ are clear. If a patient is in a deep coma, a decision about whether to maintain life support might require difficult medical judgments. But Jesica was not in a coma; multiple tests had determined that her brain would never again sustain life. We understand that it is extremely difficult for family and friends to accept the loss of a loved one, but the medical outcome was not a matter of interpretation."
Renee McCormick, a spokeswoman for a charity created to pay Jesica’s medical bills, released a statement saying the Santillan family didn’t know doctors were going to take the patient off life support and wanted to wait until a doctor outside the Duke system could verify she was brain dead. Though the conflict may have been exacerbated by the mistake that led to Jesica’s death, such disagreements are not uncommon.
Duke apparently handled the situation correctly, says Edmund Gronkiewicz, JD, a health care attorney with Hinshaw & Culbertson in Chicago. Gronkiewicz could not comment specifically about the Duke incident, but his advice for handling such termination-of-care disputes meshes with what Duke officials say they did. Once the patient meets all criteria for declaring death, the hospital should notify the family that support will be discontinued, rather than asking for permission, he says.
"This can become a problem when you attempt to get permission for something that you didn’t need permission for," he says. "If the patient is dead, and you’ve done everything you’re supposed to do to be certain of that, then you stop treating the patient and inform the family. When you go and ask them if you can stop treating the patient, the implication is that the patient isn’t really dead."
You’re on solid legal footing if you take that approach, he says. That situation is different from others in which the patient does not meet criteria for death but the family needs to decide whether to continue with extraordinary measures. In those cases, the family must be asked. Confusing that situation with one like Duke faced only burdens the family with unnecessary emotional trauma and increases the likelihood that the family will accuse the hospital of malfeasance.
Even when the facts back up your decision, doctors can be reluctant to fight the family’s wishes because the situation is so emotional and sensitive. But Gronkiewicz says risk managers should encourage physicians to approach these situations in the right way so as to avoid creating unnecessary problems with the family.
The manner in which you present the situation to the family can make all the difference. Once the patient is declared dead, the best strategy is to inform the family as firmly and clearly as you would in any other death situation, Gronkiewicz says. In other words, tell them the patient is dead, not that you’ve decided to stop trying to save her. Don’t try to couch the news in overly clinical terms that can confuse the family. State clearly that the patient has died, not that there is little hope for recovery.
However, you still should be as sensitive to the family’s emotional needs as you can be without backing down. Keeping the patient on life support for some time so family members can gather and say goodbye, as Duke did, is a good idea, Gronkiewicz says.
"There’s no harm in giving the family time to accept the situation," he says. "But don’t imply that you’re waiting for them to make a decision. You can make clear that the measures will be discontinued but you don’t mind accommodating the family’s needs."
Physicians acted appropriately when they removed Jesica Santillan from life support without the consent of her parents, according to advice offered by an attorney who says such situations can be difficult for risk managers to handle.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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