Thursday, March 29, 2012

When Legislators Do Harm


Has Idaho just become the worst place in the country to be an ICU nurse?
Both of Idaho’s legislative bodies have now approved a measure that supporters say is necessary to assure respect for dying patients. Once signed by the governor, doctors and nurses in the state will be strictly limited, in the words of the Idaho Statesman, “on when they can withhold care to dying patients without the patient's consent.”
Sounds reasonable -- so long as you accept that what the medical team intends to do is “withhold care.” But is “care” being withheld, or is the treatment insisted upon by the patient’s family (because the patient is sadly beyond communicating more than an occasional wince or agonized sigh) of no therapeutic value to a dying patient?
Has the care in question become futile at best, harmful at worst? And who, in all of this, is actually looking out for the patient’s best interests?
When dying is in process, it’s hard enough on all concerned -- family, patient, care team -- that there are no more therapeutic options. But for Idaho to create a situation that devalues medical judgement, and forces provision of futile care, is to turn non-maleficence on its head: the state is essentially insisting that the doctors and nurses do harm. 
It’s essential to good medical practice that the benefit to the patient outweighs any potential harm. To be ordered to deliver harm without benefit leaves the ICU nurse with a choice: either refuse to provide treatment that goes against your patient’s best interests, and leave it to a colleague; or suck it up and try not to think about what the patient is feeling.
One vote against the bill came from House Minority Leader John Rusche, who was concerned at the impact on medical staff making difficult decisions about dying patients. Rusche is also a physician.

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