Premium ContentClick on Premium Content on the Featured navigation bar for information.A loved one's desire to keep a patient on life support is not always enough.
Many hospitals have policies, or at least standard practices, to handle cases in which a patient's family continues to hope that a miracle will happen while physicians recognize that continued life support is futile.
Standoffs are rare between family members and health care providers on removal of life support. Even when a family initially resists having its loved one removed from life support, reality usually sets in and consent comes.
But when agreement can't be reached, hospitals typically consult ethics committees and acquire second opinions before pulling the plug in defiance of a family's wishes.
Nebraska Medical Center physicians and officials last month ultimately overrode a father's desire to keep his son on a ventilator after the young man had spent 17 months on life support at the hospital. The medical center asked its ethics panel to analyze the case and also sought a second opinion from a physician outside the hospital.
The son, Irvin Madrid, 22, died last month after he was removed from the ventilator. He had long been in a vegetative state from a brain malady that baffled physicians.
"He wasn't going to recover," said Dr. Stephen Smith, the Nebraska Medical Center's chief medical officer.
Life support is treatment that maintains a patient while he heals, Smith said. It isn't intended to keep a patient alive indefinitely, he said.
"And the line is blurry, I understand," Smith said.
Dr. William Shiffermiller, vice president of medical affairs at Methodist Hospital, said family members usually accept that a miracle won't occur for a patient in a persistent vegetative state.
"It's hard to put yourself in the position of a family member who really, genuinely feels" that a miracle will happen, Shiffermiller said. But for those who work in intensive care units and observe patients in long-term comas, the decision to remove life support is understandable.
"The honest truth is, usually it's pretty straightforward," he said.
Two patients who made national news had very different advocates for keeping them on life support. Karen Ann Quinlan, a young New Jersey woman, suffered respiratory failure and fell into a vegetative state in 1975.
Although her parents argued for her to be taken off a ventilator, her doctor disagreed. A judge ordered that the ventilator be removed, and Quinlan lived about 10 more years on a feeding tube and in a vegetative condition.
The Quinlan case compelled a judge to recommend that hospital ethics committees be formed to deal with disagreements over whether life support should continue. The American Medical Association and other health care organizations now encourage hospitals to have those committees in place.
Terri Schiavo, a Florida woman, entered a vegetative state after suffering cardiac arrest in 1990. Her husband asked eight years later that she be taken off a feeding tube, while her parents wanted her to stay on it. Considerable intervention by politicians occurred, including President George W. Bush, who sought another review of the case in the hope that life support would continue. Judges ruled in favor of the husband, Michael Schiavo, and Terri Schiavo died in 2005, about two weeks after her feeding tube was removed.
Dr. Anne O'Keefe, Douglas County Health Department senior epidemiologist, experienced a different situation while a resident at a Georgia hospital about 20 years ago. A middle-aged patient suffering heart failure begged her to stop giving him the drugs that kept his heart pumping. He was in misery and knew he wouldn't improve.
But his main physician didn't want to withhold medication, and his family members feared they would feel guilty if they insisted that treatment end, O'Keefe said. And so he lived a month or two in pain before dying.
O'Keefe said it's important that people have "advance directives," or directions for how they will be treated and what measures be taken when the end is near.
"Make sure your family knows your wishes," O'Keefe said. "And make sure your family understands."
Creighton University Medical Center, tied to the Catholic-sponsored university, has an ethics committee that helps doctors, patients and families reach consensus on life-support questions, a spokeswoman said.
The Nebraska Catholic Conference says in a paper about treatment decisions that choosing to withdraw or withhold extraordinary medical intervention "is not suicide or euthanasia." The paper says a medical intervention's burdens, including pain, anxiety, excessive expense and risks, should be compared with the benefits anticipated.
The analysis, the paper says, may consider the burdens experienced by family members and the community as a whole.
A medical journal three years ago said a patient's or relative's acceptance that treatment will bring no improvement comes with two difficulties. One, the article in Critical Care Medicine said, is that doctors can't predict the future or give a precise time when death will come. The other is "the widespread and deeply held desire not to be dead."
Smith, of the Nebraska Medical Center, said the hospital's representatives judged that keeping the young man on life support indefinitely was inhumane.
"We gave him great care with great respect throughout the entire hospitalization," Smith said.
Contact the writer:
402-444-1123, rick.ruggles@owh.com
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