These are situations where "clinicians withhold advanced cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest despite objections of patients or their surrogates."
Patients allowed to die against their or their surrogates' will is news, right? Let's see if anyone in the press cares. (
Here is the presentation description found at the conference's web site (search here on "unilateral" to replicate):
According to a 2007 CHEST Journal article ("The Ethics of Unilateral 'Do Not Resuscitate' Orders: The Role of “Informed Assent'"), there are "three categories of decisions to withhold or withdraw life-sustaining therapies that clinicians believe are clearly not indicated," and "the concept of informed assent is not equally relevant for all three categories" (bolds are mine throughout the rest of this post):
The first category is withholding treatments that patients or family members are not likely to expect for the patients’ specific condition (for example an exploratory laparotomy or activated protein C for a moribund patient with severe septic shock and multiple organ failure); and, accordingly, clinicians need not discuss each treatment withheld if they do not regard it as medically indicated (although clinicians would be obliged to discuss such treatment if a patient or family member takes the initiative to inquire). In this category, decisions about medical futility are commonly made unilaterally ...
The second category is withholding treatments or procedures that are clearly not indicated but that most patients or families have come to expect. We believe clinicians are obliged to discuss such interventions on their own initiative. Cardiopulmonary resuscitation is currently in this category. It may be that specific patients or families do not in fact expect this intervention. But the expectation is so widespread in our contemporary culture that clinicians should assume that the intervention is expected unless the patient or family indicates otherwise.
The third category is withdrawing a therapy that has already been started but which due to the patient’s clinical course is no longer indicated. Although many medical ethicists conclude that withholding and withdrawing life-sustaining treatments are ethically and legally equivalent, decisions about withdrawing interventions that clinicians have previously viewed as potentially beneficial often have a different and more powerful impact on patients and families than decisions not to initiate therapies in the first place. Accordingly, communication with families about withdrawal decisions should take account of those differences. As in the second category, clinicians should assume that patients or families expect interventions to be continued, once they are begun, unless the patient or family indicates otherwise.
For these second and third categories, we believe that obtaining informed assent to withhold or withdraw interventions is an ethically acceptable alternative to insisting that patients or families always bear the full burden of explicit consent.
Note the clear statement that cardiopulmonary resuscitation is currently something "most patients or families have come to expect." Of course it is. Therefore, Mass General's claimed unilateral decisions NOT to attempt it in certain instances without informing patients or their families clearly crosses the line of medical practitioners secretly deciding who will live and who will die, i.e., a death panel.
I wonder if unilateral DNRs are covered in the "Critical Care Handbook of the Massachussetts General Hospital"?
Smith's reaction:
If I read this correctly, thirty-eight percent of those upon whom the unilateral DNRs appear not to have been at the end stage of a terminal disease:
Patients for whom unilateral DNR was recommended were more likely to have conditions judged to be endstage rather than potentially reversible (62% versus 41%, p=0.05).
And who can be surprised that non whites were more likely to have an involuntary DNR imposed?
This is medical tyranny.
So there's even a potential "minorities most affected" aspect to all of this. So I'm sure the establishment press will be all over this.
Well, let's hope for the best, but don't hold your breath. The press's performance in chronicling the culture of death's forward march has been abysmal for many years. They may see the likelihood that such arbitrary and secret decisions might be even more strongly insulated from scrutiny in the future under Obamacare as a feature and not a bug.
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Premier hospital, high angioplasty death rate
Updated 2/10/2009 5:32 PM
By Steve Sternberg, USA TODAY
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The death rate for angioplasty in critically ill patients at one of the world's best-known hospitals, Massachusetts General, was more than twice the state average, according to an analysis released Monday.
A Harvard Medical School teaching hospital, Massachusetts General is legendary for the care it provides to the critically ill. But the revelation that a premier hospital suffered such a big spike in its death rates suggests that it is just as important to monitor performance at the best institutions as all the rest, experts say.
Just because you're famous, doesn't mean you're good," says Yale University cardiologist Harlan Krumholz, an expert in performance measurement who has helped craft a method of tracking hospital death rates for Medicare.
The analysis, carried out at Harvard as part of an exhaustive process that involved doctors throughout the state, found that the angioplasty death rate for patients suffering from a heart attack or shock hit 12.6% in 2007 at Massachusetts General, the most recent year available, vs. 5.5% for 22 hospitals statewide.
The rate for Massachusetts General represents the midpoint of a range that could be as low as 8% or as high as 20%, according to researchers at the Harvard Medical School Department of Health Care Policy.
"Even the lower limit is higher than the state's average," says Sharon-Lise Normand, who led the analysis under contract to the Massachusetts Department of Public Health. The death rate for all other angioplasty patients at Massachusettes General ranged from about 50% to 300% higher than expected for the hospital's mix of patients, the report showed.
The head of the hospital's angioplasty program, Michael Fifer, confirmed the state's analysis and noted that an internal audit raised the same concerns. "We've known for about a year our mortality was higher than average," he says.
Hospital officials studied all 43 deaths that occurred among 1,543 angioplasty patients treated in 2007. They concluded that the 27 excess deaths among 213 heart attack and shock patients resulted from a willingness to treat patients with a slim chance of survival, rather than technical mishaps, poor medical care or poor performance by "an individual physician or group of physicians."
"In spite of technically successful procedures, the great many of the patients died due to underlying disease," Fifer says, adding that the conclusion was borne out by an independent audit.
The finding presented Fifer with a dilemma: Should the hospital stop treating the sickest patients to reduce its death rates and keep is mortality low? Or should it continue trying to bring those patients back from the brink?
"Patients and families and referring cardiologists want to do everything possible to give patients that glimmer of hope," Fifer says. "The challenge is to figure out which patient you're giving a reasonable chance of survival and for which patients you should take a step back and say, it's probably a bridge too far."
He says the hospital has decided to encourage heart specialists to ask their colleagues for second opinions in the riskiest of cases. In some cases, the doctors have decided that the procedure's risks were too great, which has already brought down the hospital's death rates.
Krumholz says the hospital's death rates were also higher for elective angioplasty. "There's a consistency in both kinds of patients. Patients in shock are higher and the other patients are also higher," he says. "Although it's possible it's due to other things, quality remains the most likely concern."
Paul Dreyer, head of the state agency that commissioned the report, concurred that the spike in death
rates signaled a "quality problem," adding that you have to look at the meaning of the signal. "We've looked as best we can, and we've determined that mortality rates have returned to pretty much the statewide average at both institutions."
The second institution, Saint Vincent in Worcester, also topped the state average, with an angioplasty
death rate of 11% for patients having heart attacks or those in shock. Massachusetts state reported death rates for bypass surgery since 2002 and angioplasty since 2003.
Angioplasty is a minimally invasive way of using a tiny inflatable balloon to clear blocked arteries supplying the heart. It is the most effective way to stop a heart attack from destroying heart muscle.
All of the hospitals providing bypass surgery in Massachusetts were within average limits, the report found.
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