Opinion – Life Support

Texas’ 10-day rule regarding life support works to prevent harm.

by Stuart Pickell, MD, FACP, FAAP

We have monitored the scenario surrounding infant Tinslee Lewis at Cook Children’s Medical Center for the last two months as it has moved the issue of the Texas Advance Directives Act in general, and the 10-day rule in particular, back onto the front burner.

While we agree with the Fort Worth Star-Telegram Editorial Board’s assertion that the law is imperfect, we do not agree that extending the 10-day period that hospitals have to find an alternative facility is the solution.

As technology has advanced, so have the options available to treat critically ill patients. For many patients, aggressive medical intervention is a life-saving bridge until their bodies can recover. But there is a point at which no amount of medical intervention will help. In fact, it may hurt.

For the last 40 years, healthcare facilities have increasingly relied upon ethics committees to aid them with the unenviable task of examining clinical situations in which medical technology contributes to a moral conundrum with no good options. The typical ethics committee consists of an interdisciplinary team of healthcare workers. The members are often employees of the institution but the panels also usually include community members who have no official relationship with the facility.

Families rarely insist on aggressive treatment that the medical team believes is non-beneficial or even harmful, but when they do, either party may request a formal hearing before the ethics committee. The committee’s objective is to hear the concerns of both and discern the ethical thing to do for the patient. If the panel decides to withdraw aggressive interventions that the family wants continued, the facility may invoke the advance directives law.

Texas’ law leverages the expertise of healthcare and ethics professionals to promote a deliberative process at the bedside, carefully considering the family’s desires for treatment in light of the medical realities to discern the best treatment options available for the patient. As medical professionals we have an imperative to honor our patients’ treatment desires.

While we sympathize with the Lewis family, their desire to continue aggressive interventions does not give them — or anyone — the right to demand treatment that violates the norms of the medical profession, the caregivers’ moral integrity or the long-standing ethical precept of “do no harm.”

Much of the criticism of the directives law focuses on the section that allows a health-care facility to discontinue life-sustaining treatment 10 days after giving written notice. During this time, the treating facility and the family seek to identify another facility willing to assume care. Despite opponents’ claims, 10 days is long enough.

Every case that gets to the point of invoking the law has been thoroughly vetted by the medical team in consultation with the family. When it becomes clear that an impasse is imminent, the search for an alternative facility begins, usually weeks before any formal hearing of the ethics committee.

The law allows a judge to grant an extension if more time makes it likely that another facility would be willing to accept the patient. It’s rare for a medical team elsewhere to disagree that care is futile. Even so, judges often grant extensions, especially in high profile cases.

But many families have not dealt with the gravity of their loved one’s condition, a reality they can no longer ignore once the 10-day rule is invoked. Extending the 10-day period will not lessen their grief or increase the likelihood of finding a facility willing to assume the patient’s care.

The Texas Advance Directives Act is imperfect, but this law, including the 10-day rule, is better than what we had before: actively dying patients with no hope of recovery subjected to indefinite pain and suffering because well-meaning loved ones were unwilling to let them go.

A longer waiting period will not bring hope to a hopeless situation; it will only prolong suffering. So, while we strongly advocate for initiatives to improve the health and well-being of Texans, extending the 10-day rule is not one of them.

Stuart Pickell, MD is chairman of the TCMS Ethics Consortium, a group that seeks to ensure the application of ethical principles in health care. He wrote this piece on the group’s behalf. Dr. Pickell is a member of Cook Children’s Medical Center’s ethics committee; this piece does not necessarily reflect that committee’s views.

This article was originally printed in the Fort Worth Star-Telegram.
Reprinted with permission.