Life-support guidelines can help risk managers deal with minors
Los Angeles guidelines provide framework for any facility
The withdrawal of life support often raises a myriad of ethical and legal questions, and the problem only gets worse when the patient is a minor. New guidelines from a Los Angeles group of physicians and lawyers may help clear up many of the dilemmas, or at least provide a framework for you to develop your own facility’s policies and make decisions about individual patients.
The guidelines represent the best available consensus on how medical ethicists and legal experts advise handling withdrawal of life support with minor patients, says Robyn Meinhardt, RN, JD, the lawyer who co-chairs the Joint Commission on Biomedical Ethics of the Los Angeles County Bar and Medical Association. She is a partner in Foley, Lardner, Weissburg & Aronson. The guidelines consist mainly of a summary of the existing case law and ethical considerations, rather than a specific set of instructions on how to handle such cases.
"This is a collection of current thought," she explains. "We were responding to what we perceived as a need from health care professionals. They had very little out there to tell them how to act when considering the withdrawal of life support from a minor patient."
Meinhardt suggests that risk managers across the country will find the guidelines useful as a resource when making decisions about individual patients or formulating an overall policy for your facility. (See insert for full guidelines.) That idea is endorsed by Joan Hajny-Leeds, RN, FASHRM, BSN, director of risk management at Cedars-Sinai Medical Center in Los Angeles.
"This might be especially helpful for institutions that have not confronted this issue enough to have a policy of their own and some familiarity with handling the situation," Hajny-Leeds says. "As the public becomes more knowledgeable about these situations, the family is more likely to make a request that creates a dilemma for the health care providers. These guidelines can help you work through that." (For more on the guidelines, see story, p. 99.)
Because the guidelines were developed jointly by health care providers and legal professionals, they cover both the ethical and legal questions involved with the withdrawal of life support. The same Los Angeles committee has developed guidelines in the past, including guidelines on the withdrawal of life support in adults, that have been widely adopted or used as a resource across the country. Meinhardt hopes risk managers will look at the guidelines as a way to jump-start their own facility’s discussion of the issue. If nothing else, the guidelines can be seen as an excellent source of background material on the case law that affects withdrawal of life-support decisions.
"These guidelines represent the thinking of a committee whose former guidelines on life-sustaining treatment have been accepted in courts across the nation, and have been relied upon in many cases," Meinhardt says. "If you rely on these guidelines when a treatment decision arises in your own hospital, you will have a good argument that you were doing the right thing."
The guidelines include information on situations in which the parents want to continue treatment but the providers don’t. However, the guidelines focus much more on cases in which the parents don’t want to continue treatment but the providers do. That area was considered more firmly rooted in case law, allowing for more specific advice on those situations.
But in addition to the explanation of case law, the guidelines provide a system for trying to get parents and health care providers to reach an agreement. The guidelines establish some assumptions about parental authority and where certain lines must be drawn, which gives all involved parties some basis for knowing when to stand their ground and when to pull back. That is an important benefit, Meinhardt says.
"Many will be pleasantly surprised to see that the process is very workable," she says. "A lot of risk managers and providers feel that the area is such a morass that they don’t even know where to begin. These guidelines will help them structure the discussion with parents and providers and bring some order to the process."
The guidelines also may provide some uniformity in decisions regarding the withdrawal of life support, Hajny-Leeds says. She notes that health care facilities have quite varied policies on the issue. Many facilities have no policy at all and just deal with each case as it arises. That can create difficult situations, she says, such as when a minor patient receives some treatment at one hospital but later returns to his or her primary place of treatment. If the first hospital has a policy that would encourage the withdrawal of life support in that situation, it may be difficult for providers to return the patient to a hospital where they believe unreasonable support will be provided.
And it works the other way, too. Staffers at one hospital may be reluctant to send a child to a facility with a policy that encourages the withdrawal of life support. Widespread adoption of the Los Angeles guidelines, or at least their consideration in forming your own policy, could help alleviate much of that disparity, she says. And in doing so, hospitals will be left on firmer legal ground because everyone will be working with similar policies or assumptions.
Hajny-Leeds says she finds the Los Angeles guidelines to be sound and reliable. She advises other risk managers to take a close look at them.
"If you have an ethics committee, pass the guidelines by the committee and see if they are in keeping with your institution’s thinking regarding withdrawal of life support," she says. "You may get some conflict, and that’s okay. The point is that you’ll have something to start with and you can get your institution to develop its own policy."
Meinhardt also suggests getting the guidelines to the front-line health care providers who will encounter the real-world life-support dilemmas. Though the guidelines are aimed primarily at physicians, they can be used by the entire health care team. "Get the word out to the providers, social workers, chaplains, anyone who might have a role in these cases," she says. "Let them know that these guidelines exist and what position your facility has taken with them. You may want to say, These are the guidelines we will follow,’ or These are a resource we will consult when making decisions.’"
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