AARC Times September 2010 : Page 30

General Counsel First, Do No Harm by Anthony L. DeWitt, JD, RRT, FAARC I t was one of those defining moments as a therapist, and it occurred early in my career.I was working at a hos-pital in Northeast Missouri when we heard a code called. I went to the room, bagged the patient, and eventually a heartbeat was restored. The patient required ventilation, so I transported her to the ICU, and only then did we learn that the patient was one of the hospital family — a lovely older nurse whom everyone admired. Within moments of arriving in the ICU, the woman’s two daughters demanded that their mother be taken off the ventilator. “She wouldn’t want to live like this,” they said. The resident physician informed them that their mother would come off the ventilator soon, but she wasn’t ready yet. The women were upset and left the ICU. Fif-teen minutes later the attending physi-cian, who had told the resident to “handle it” when the code was called, called back to tell the ICU staff to re-move the ventilator. Everyone’s mouth dropped open. The patient was viable, and would likely survive the heart attack with proper definitive therapy. But extubat-ing her and placing her on a mask was tantamount to a death sentence. The resident refused to follow the order. He told the attending if he wanted that order given, he could come extubate her himself. A few moments later, the attending directed the nurses to extu-bate, and the nurses refused. No one in the ICU missed hearing the language the physician used before he hung up. Twenty minutes later the physician about the author… the mask on her, and within 30 minutes the woman, whose family wanted her designated as a “Do Not Re-suscitate,” expired after spending most of that time struggling for air. I very nearly resigned that night. In 1993, Judge Edward D. “Chip” Robertson of the Mis-souri Supreme Court gave a law school lecture and de-scribed the legal analysis that went into the sentinel case of Nancy Beth Cruzan, a Missouri woman who was ulti-mately removed from life support after the U.S. Supreme Court upheld the Missouri Supreme Court’s opinion in her case. Judge Robertson had ended his opinion in the state case in this way: We find no principled legal basis which permits the coguardians in this case to choose the death of their ward. In the ab-sence of such a legal basis for that decision and in the face of this State’s strongly stated policy in favor of life, we choose to err on the side of life, respecting the rights of incompetent persons who may wish to live despite a severely diminished quality of life. Anthony L. DeWitt, JD, RRT, FAARC, is an attorney and a partner in the firm Bartimus, Frickleton, Robertson & Gorny, PC, and resides in Jefferson City, MO. He has also authored two books and numerous legal journal came in,and I was the only therapist in the ICU. He directed me to extubate the woman, and I politely declined.He told me to get an oxy-gen mask, which I did. He then extubated the patient, whose first words were “Oh my God, I need air!” I placed articles. This article is not a substitute for legal advice. I wrote to Judge Robertson and told him the story of the woman who had died after being removed from life sup-port, and told him that had the opinion been in place in 1981, when I had been involved in the case above, it might have made a difference. Judge Robert-son hired me as his clerk in 1993, and I continue to work for him today as we both practice in the same firm. The therapist’s choice A therapist has a right to refuse to perform any procedure that the thera-pist has a moral or legal objection to performing. In this case, I believed that extubation was tantamount to mur-der. I did not wish to carry that on my conscience. No 30 AARC Times September 2010

General Counsel

Anthony L. DeWitt, JD, RRT, FAARC

<b>First, Do No Harm</b><br /> <br /> It was one of those defining moments as a therapist, and it occurred early in my career. I was working at a hospital in Northeast Missouri when we heard a code called.I went to the room, bagged the patient, and eventually a heartbeat was restored. The patient required ventilation, so I transported her to the ICU, and only then did we learn that the patient was one of the hospital family — a lovely older nurse whom everyone admired.<br /> <br /> Within moments of arriving in the ICU, the woman’s two daughters demanded that their mother be taken off the ventilator. “She wouldn’t want to live like this,” they said. The resident physician informed them that their mother would come off the ventilator soon, but she wasn’t ready yet. The women were upset and left the ICU. Fifteen minutes later the attending physician, who had told the resident to “handle it” when the code was called, called back to tell the ICU staff to remove the ventilator.<br /> <br /> Everyone’s mouth dropped open.The patient was viable, and would likely survive the heart attack with proper definitive therapy. But extubating her and placing her on a mask was tantamount to a death sentence. The resident refused to follow the order. He told the attending if he wanted that order given, he could come extubate her himself. A few moments later, the attending directed the nurses to extubate, and the nurses refused. No one in the ICU missed hearing the language the physician used before he hung up.<br /> <br /> Twenty minutes later the physician came in, and I was the only therapist in the ICU. He directed me to extubate the woman, and I politely declined. He told me to get an oxygen mask, which I did. He then extubated the patient, whose first words were “Oh my God, I need air!” I placed the mask on her, and within 30 minutes the woman, whose family wanted her designated as a “Do Not Resuscitate,” expired after spending most of that time struggling for air. I very nearly resigned that night.<br /> <br /> In 1993, Judge Edward D. “Chip” Robertson of the Missouri Supreme Court gave a law school lecture and described the legal analysis that went into the sentinel case of Nancy Beth Cruzan, a Missouri woman who was ultimately removed from life support after the U.S. Supreme Court upheld the Missouri Supreme Court’s opinion in her case. Judge Robertson had ended his opinion in the state case in this way: <br /> <br /> We find no principled legal basis which permits the coguardians in this case to choose the death of their ward. In the absence of such a legal basis for that decision and in the face of this State’s strongly stated policy in favor of life, we choose to err on the side of life, respecting the rights of incompetent persons who may wish to live despite a severely diminished quality of life.<br /> <br /> I wrote to Judge Robertson and told him the story of the woman who had died after being removed from life support, and told him that had the opinion been in place in 1981, when I had been involved in the case above, it might have made a difference. Judge Robertson hired me as his clerk in 1993, and I continue to work for him today as we both practice in the same firm.<br /> <br /> <b>The therapist’s choice</b> <br /> <br /> A therapist has a right to refuse to perform any procedure that the therapist has a moral or legal objection to performing. In this case, I believed that extubation was tantamount to murder.I did not wish to carry that on my conscience. No administrator ever questioned my decision. If the hospital had disciplined me, I would have gone on to find another job. No job is worth being forced to do that which you find morally repugnant.<br /> <br /> To the extent that a therapist — any therapist — is asked to do something unlawful (in violation of the civil law) or illegal (in violation of the criminal law), they not only have the right, but also the obligation to object and not to carry out the order. The defense of “I was just following orders” didn’t work at the Nuremburg war crimes trials and is unlikely to work before a criminal court or state board. Importantly, if the order comes from a supervisory health care provider, like a physician, a therapist must respectfully refuse. If such a request comes from family, it must also be refused. That’s especially true when someone manifests an interest in equipment and alarms.<br /> <br /> Late in my career as a therapist, when I worked at one of the truly great hospitals in America, The Toledo Hospital, I had a stroke patient who had been ventilated from admission. The patient’s husband had demanded that everything be done, even though much of the care being provided was medically futile. The patient’s son one night asked me what would happen if their mother came off the ventilator. I told them that the alarms would sound and that someone would come to the room and fix the problem. He then asked me what controlled the alarms and if they could be turned off. I told him no, they could not be turned off. I then asked him why he wanted to know. Without answering, he asked me to take his mother off the ventilator and let her die. There were tears in his eyes. “Let her go,” he pleaded. It was a heartbreaking situation. I compassionately refused the request. I also reported his request to the nurses.<br /> <br /> Therapists have a duty to protect patients and to respect the orders that they’re given even when they disagree with them, so long as they do not cause patient harm. It is never proper to choose sides where a family disagrees about a course of therapy at the end of life. The only safe thing to do is follow the directives of the person legally appointed to represent the patient. If a therapist feels a compulsion to intervene or act against those wishes, the only safe thing to do is to withdraw from the case and abstain from further treatment. The license you save may be your own.

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