The ACOFP Ethics Committee is offering this column to provide a forum for medical ethical discussion.

By David A. Plundo, DO, FACOFP

Low back pain is a very common problem and occurs in 15 to 45 percent of Americans yearly. Various treatment strategies There was a time when death was looked at as a natural part of life. Most dying persons remained at home surrounded by loved ones. Now death is viewed as a disease to be treated and conquered. Advances in medical technology and life sustaining efforts make it almost impossible for a patient to die without implementation or discussion of “extraordinary measures.”

Advanced directives provide patients a means to decide how they would like the end-of-life to proceed if they become unable to make their wishes known. The Patient Self-Determination Act was passed in 1990 as part of the Omnibus Budget Reconciliation Act to uphold the principle of personal autonomy in healthcare decision-making.

Advanced directives have achieved substantial acceptance in the United States since this bill became law. Patients have the right not only to
refuse initial treatment, but also to refuse treatment at any time during the course of care. All 50 states and the District of Columbia have some type of advanced directive legislation, although the specifics can vary greatly.

Advanced Directives Types
There are two basic types of advanced directives: living wills and durable powers of attorney for healthcare. A living will is a document drafted at a time when the patient was presumed to have been able to comprehend the information, consider the options, evaluate the risks and make informed decisions directing potential future treatments.

Unfortunately, the interpretation of living wills by healthcare providers can be difficult. Physicians argue that they are not clinically specific enough to cover unforeseen circumstances and there is no guarantee that the patient’s wishes are fully known and that appropriate clinical action will be taken.

Durable powers of attorney for healthcare (also called healthcare proxy or medical power of attorney) designate a spokesperson to represent the patient in decision-making. These designated individuals should base all decisions on the patient’s known or probable wishes under the circumstances and not their own preferences. Durable powers of attorney for healthcare can supersede living wills when disputes arise.

Family Dynamics
The family dynamics involved in end-of-life decisions are often unsettled and conflicting. The complexity of a severe illness or disability can often lead to ambiguity in the interpretation of a living will leading to requests for interventions that may be in conflict with the intent of the living will.

Physicians often become concerned about their legal obligations to continue care when family members disagree with the advanced directives especially when their requests violate the personal values and ethical beliefs of the physician.

Clinicians, however, do have an ethical obligation to recommend a course of action and may legitimately use their clinical skills to persuade patients that it is in their best interest. But they must recognize the limits of their authority when patients decide the burdens of their disease and/or treatments outweigh the potential benefits. Respect for personal autonomy is among the highest values in the ethical practice of medicine.

Basic Ethical Principles
It may be helpful to review four basic ethical principles involved in advanced directives. Autonomy (or self-determination) assures the freedom of choice or free will. This is a fundamental principle when discussing patient decision-making.

Nonmaleficence is an obligation not to inflict harm intentionally and includes the prevention of harm or the removal of harmful conditions. Controversy exists surrounding the definition of harm as it is applied to the withdrawal of treatment.

Beneficence is the provision of benefits. Offering treatment or removing a harmful treatment can accomplish this.

Fidelity is the obligation to live up to the patient’s reasonable expectations and trust. Patients trust their physicians to do what is best for them and respect their decisions. In extraordinarily difficult cases physicians must be compelled by ethical duty to apply these principles consistently and fairly, regardless of whether or not the clinician agrees with the decision.

Physician Obligations
Physicians are under no obligation to act in ways they find personally objectionable or outside of their own ethical beliefs. When physicians cannot reconcile personal beliefs with professional duty they must remove themselves from the case. Transfer of care must be achieved so as not to abandon the patient and family in their greatest time of need. Palliative care services or hospice can often facilitate these transitions.

Simple solutions are often difficult in cases involving ethical issues. Those involving advanced directives are no exception. Difficult or conflicting decisions may be reviewed by a hospital or nursing home ethics committee, which will enable a multidisciplinary approach to the problem.

The support, knowledge base and experience of others represent invaluable collegial benefit, as well as a readily available option for ethical patient
care decision-making.

Dr Plundo is a member of the ACOFP Ethics Committee. He is the director of the Osteopathic Family Practice Residency Program at St Vincent Mercy Medical Center in Toledo Ohio.