Disclosures I have no conflicts of interest or relevant financial - - PDF document

Hastening Death by VSED - 10-14-2016 Keynote Presentation - Legal - Pope - PowerPoint Handouts 1

Hastening Death by Voluntarily Stopping Eating and Drinking: Legal Perspective

Thaddeus Mason Pope, JD, PhD Mitchell Hamline School of Law Seattle University • Oct. 14, 2016

Disclosures

I have no conflicts

• f interest or relevant

financial interests.

Hastening Death by VSED - 10-14-2016 Keynote Presentation - Legal - Pope - PowerPoint Handouts 2

25 min

Learning Objectives

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Describe four legal foundations of a patient’s right to contemporaneous VSED Understand the challenges and risks for families and clinicians in implementing an advance VSED decision for a now incapacitated patient Compare legal distinctions between VSED,

• n the one hand, and medical aid in dying

and withholding or withdrawing life- sustaining treatments, on the other hand

Definition VSED

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Physiologically able to take food & fluid by mouth

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Voluntary, deliberate decision to stop Intent: death from dehydration

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>80% at 14d >50% at 8d

Legal concerns Legal analysis

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Legal concerns

Uncertainty & reluctance among providers

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Prohibited Permitted Unsure

Legal & ethical expert support nearly universal

Almost never: express prohibition

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RCWA specifically & expressly prohibits lots of things

Not VSED

BUT

Absence of a red light not good enough

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Clinicians want express permission

No green light from Olympia

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No green light anywhere

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Little precedent & not supportive

No red lights No green lights Lack of clarity & guidance

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Cinderalla pic again

neglected in academic & policy circles

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Providers still ask

Is VSED legal?

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Is VSED illegal?

Wrong questions

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Law is rarely binary

Risk assessment

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Measure Mitigate

Legal analysis

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case types

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VSED now with capacity

Ability to understand significant benefits, risks & alternatives Ability to make & communicate decision

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Advance directive for VSED later

(when lack capacity)

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Patient with capacity requests VSED now

Extremely low risk

• f sanctions – criminal, civil, regulatory

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Right to refuse medical interventions

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Right to refuse non-medical interventions

Not assisted suicide

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Not elder neglect

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Right to refuse medical interventions

Well established

> 3 decades

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“A competent patient may refuse treatment . . .”

Right to refuse medical

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Vent Dialysis CPR Antibiotics Feed tube

Vent Dialysis CPR Antibiotics Feed tube

VSED

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Cinderalla pic again

Vent Dialysis CPR Antibiotics Feed tube

ICD

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Vent Dialysis CPR Antibiotics Feed tube

VSED

Not DTC Not DIY

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Contrast VSED

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Part of a broader treatment plan Supervised by licensed healthcare professionals

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“the number of cases will

• increase. Since

the concept of fasting is not taught in medical schools, we will produce a guide to support doctors.”

Harvard CEC

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PAVSED

“Palliated and Assisted Voluntarily Stopping Eating and Drinking”

PAVSED

Highlights medical role in palliating symptoms Highlights the direct care staff role in providing assistance

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Medical b/c not “typical human”

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treatment

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unwanted

Does not matter whether food & fluid are “medical treatment”

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“The common law right to be free from bodily invasion is an alternative basis ...”

Battery

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Unwanted contact Even if clinically beneficial

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“Every human being of adult years and sound mind has a right to determine what shall be done with his own body . . . . ”

Mohr v. Williams (Minn. 1905)

Patient consented to left ear Physician

• perated
• n right ear

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Force feeding is a battery

“It seems odd that your bodily integrity is [not] violated . . . by sticking a spoon in your mouth.”

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Move now from legal bases, grounds for right

Responding to main objections

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VSED is not assisted suicide

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Alleged risk

RCWA 9A.36.060

(1) A person is guilty of promoting a suicide attempt when he or she knowingly causes or aids another person to attempt suicide. (2) Promoting a suicide attempt is a class C felony.

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Active Passive

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VSED is not abuse

• r neglect

Alleged risk

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“The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.”

42 C.F.R. 483.25(j) Tag F0327

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Tag 242

Over-treatment just as risky as under-treatment

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Bucilla Stephenson

Now leave

contemporaneous VSED

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Advance directive for VSED later

Trickier & more controversial

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What is this

Complete AD, today

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VSED in future when reach point you define as intolerable

But lack capacity at future time

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Can you leave VSED instructions in an AD?

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• Macbeth pic
• Call ghosts from deep

Glendower: I can call spirits from the vasty deep. Hotspur: Why, so can I, or so can any man; But will they come when you do call for them?

You can write anything you want in an AD But will it be honored

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No express permission

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• Oregon legislation planned

Sometimes prohibited

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Legal & ethical expert support nearly universal Autonomy

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Autonomy

Prospective autonomy

• Wis. Stat. 155.20

“A health care agent may not consent to the withholding or withdrawal

• f orally ingested

nutrition or hydration . . .”

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56

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“Health care directive may include . . . health care instructions . . . appoint . . . agent to make health care decisions.”

• Minn. Stat. 145C.02

“Health care means any care, treatment, service,

• r procedure to maintain .

. . or otherwise affect . . . physical . . . condition.”

• Minn. Stat. 145C.01(4)

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“Soft” hurdles

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Unusual Evidence

Be very specific on the when

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Be very specific on the what

Margot Bentley

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Probably meant this

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Trial court

“comfort care shall always be provided, and shall always include food and hydration, whether

• rally or artificially . . .

Appellate Division

Vacates that part of the order

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“incurable or irreversible condition . . . no artificial administered nourishment or liquids” “state of permanent unconsciousness or profound dementia, all nourishment or liquids”

Capacity

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Do later requests for water revoke the AD?

Maybe

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All patients presumed to have capacity Until rebutted

Decision specific

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Patient might have capacity to make some decisions but not others

Margot Bentley

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Risk ~ 0

Risk = 0

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19 months ago

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Selected References

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Medical Futility Blog

Since 2007, I have been blogging, almost daily, to medicalfutility.blogspot.com. This blog focuses on reporting and discussing legislative, judicial, regulatory, medical, and other developments concerning end-of-life medical treatment conflicts. The blog has received over 2 million direct visits. Plus, it is redistributed through WestlawNext, Bioethics.net, and others.

T.M. Pope, Narrative Symposium: Patient, Family, and Clinician Experiences with Voluntarily Stopping Eating and Drinking (VSED), 6(2) NARRATIVE INQUIRY IN BIOETHICS 75-126 (2016).

Hastening Death by VSED - 10-14-2016 Keynote Presentation - Legal - Pope - PowerPoint Handouts 78

T.M. Pope, Prospective Autonomy and Dementia: Ulysses Contracts for VSED, 12(3) JOURNAL OF BIOETHICAL INQUIRY 389-94 (2015). T.M. Pope, Legal Briefing: Voluntarily Stopping Eating and Drinking, 25(1) JOURNAL OF CLINICAL ETHICS 68- 80 (2014) (with Amanda West).

T.M. Pope, Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life, 17(2) WIDENER LAW REVIEW 363-428 (2011) (with Lindsey Anderson).

Hastening Death by VSED - 10-14-2016 Keynote Presentation - Legal - Pope - PowerPoint Handouts 79

Thaddeus Mason Pope, JD, PhD

Director, Health Law Institute Mitchell Hamline School of Law 875 Summit Avenue Saint Paul, Minnesota 55105 T 651‐695‐7661 C 310‐270‐3618 E Thaddeus.Pope@mitchellhamline.edu W www.thaddeuspope.com B medicalfutility.blogspot.com