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Tuesday, June 1, 2010

Windows of Opportunity: Scary Thoughts

I had a great Memorial Day weekend. While I Was happy without access to the news or internet my son went through what appeared to be withdrawl symptoms. On the drive home he asked me "How do people live without the internet?" A question asked with great sincerity and curiosity. After a depressing morning of catching up on disability related news stories my answer to my son's question today might be "happily". What disturbed me the most was a subject I was following up on via Thadeus Pope and his thought provoking blog Medical Futility. I disagree with much of what Pope writes but respect his scholarship and do not question the factual basis of what he writes. We may disagree but he does not mislead readers. Pope referred to current debates on "informed consent"--specifically an article by Alexander Kon (Informed Nondissent Rather than Informed Consent). Kon's article led me to read another article he had written, "The Window of Opportunity: Helping Parents Make the Most of Difficult Decision They Will Ever Face Using an Informed Non-Dissent Model" in the American Journal of Bioethics (94, #4:55-62). Kon believes we have been moving toward a shared decision making strategy between doctors and patients. He also thinks doctors can "unburden some parents" as they face an agonizing decision--deciding whether a child should live or die when they face end of life decisions. In Kon's estimation between days 2 and 5 of the event that indicates there is certainty a child will not experience meaningful neurological recovery a window of opportunity exists--when it is considered appropriate to withdraw life support. Kon argues, and read this direct quote very closely:

I advocate for an informed non-dissent approach to decision making. Under such a model, the physician, with the help of other members of the healthcare team, informs the parents of the dismal prognosis and that unless life-support is withdrawn within a short period of time, the child will regain sufficient brainstem function to maintain minimal, but inadequate, respiratory function off the ventilator. After extensive discussion, the physician can ascertain to what extent the parents wish to bear the burden of decision making. When the parent appears to agree that life in a persistent vegetative or minimally conscious state is not acceptable for their child but cannot bring themselves to verbally agree with withdrawing life-support, the physician informs the parents that he will make the decision to withdraw life-support, but that the parents have veto authority over this decision.

If Kon's "non-dissent model" comes into vogue I fear many will die--that is die needlessly and before their time. Anyone that has spent time around doctors and within a hospital setting know many physicians do not communicate well (I am being very polite here). In my experience, few physicians are socially skilled, that is people I would trust to understand what my wishes are. Add in the inherent power and knowledge imbalance and a physicians words and opinion carry great weight. Indeed, many patients and their loved ones do not question what a physician states and even fewer would question what a healthcare team believes. Given this, problems abound with the non-dissent model. Parents are not passive recipients of bad news as Kon would have the reader to believe. Parents with a critically ill child find themselves in a different world--a profoundly different cultural setting where they are unfamiliar with the rules and the environmental setting. Most parents are woefully unprepared for such an experience. Now Kon wants to step up the pressure on these people, tell them they have a window of opportunity and need to make a decision now. However, if they have second thoughts, veto authority, they can inform the physician or healthcare team. Sure, they do. If you believe this I have a pink elephant for sale too--at a great price I may add.

I do not understand the medical industrial complex. The experiences I had as a child were radically different. I am not referring to the advances in science--they are revolutionary and significant, life saving in fact. What I do not get is the lack of humanity in contemporary medicine. We have great technology that can extend and enhance life but we have a gross failure to communicate. End of life issues, and by extension disability, magnify the failure to communicate. Today quality of life, autonomy and end of life decisions all require patients, parents, children and doctors to work together. This does not happen and people are too often pressed into making decisions or conversely left on their own. Kon is pressing parents or at minimum enabling them to avoid making a decision. I for one do not trust Kon or most doctors to make anything but the most basic decisions. I surely do not trust them or anyone else for that matter to make life and death decisions. But that is exactly what Kon wants--the power to make a life and death decision. He does not want this power for himself of course but for the medical industrial complex. This is not about releasing parents from making a choice as Kon argues but the assertion of power. Power is a subject I know a good bit about. I lack power as do most people with a disability. I know this for a fact as we, that is the American government, decided inequities existed and needed a law to protect the civil rights of people with disabilities--the ADA. I believe patients and parents of children have rights too. One of those rights to make the decisions for themselves and their children. They should do so without being pressured and told about windows of opportunity.

After reading Kon's paper I thought of my parents and what they experienced with me. Luckily we had an unusual physician in charge of my care--a man that empowered me even as a child into believing I was an integral part of the decision making process. He did not making decisions for me or for my parents. We did that together. No power games were played or employed. What I wonder has taken place in the medical industrial complex that has led us to where we are today. I think of Barbara Farlow and the death of her child. I think of other children and their parents that have horrific experiences with physicians making decisions for them. I think of the elderly and their loved one pondering under what circumstances will one live and die. I think of people with life altering and disabling injuries who are reliant on the expertise of those providing care. Too may are given bad advice, rendered powerless, exploited, or flat out lied to. The irony here is that we can do so much with science but as a people we are failing socially. Thus I think I was lucky to get sick when I did in the 1970s. Modern science had not taken over the medical industrial complex as we were on the cusp of technological change. Too bad that technological change has not been matched by a similar social change.

2 comments:

Claire said...

"Under such a model, the physician, with the help of other members of the healthcare team, informs the parents of the dismal prognosis and that unless life-support is withdrawn within a short period of time, the child will regain sufficient brainstem function to maintain minimal, but inadequate, respiratory function off the ventilator".

The scary thing about this is that we were **exactly** in this position with Sophie 10 years ago. Exactly, Bill. They told us that...PVS. Look at the kid now...so far from that! You are "dead" on...many children will die before their time. The physicians' confidence in predicting the future for injured or disabled children far outstrips their actual ability to do so accurately.

william Peace said...

Claire, The human brain is not static and predicting future cognition is uncertain at best. Some children may indeed be in PVS but this diagnosis is not always correct. To me this emphasizes the overwhelming need for parents and MDs to establish not only excellent communication but a close rapport with one another. This does not happen often and the result is miscommunication and in some cases an untimely death. This of course is very wrong and a specific population is at risk.