Pregnant women in Texas and 11 states lose rights to DNR

[Stephanie66]

Yes, there's a "futile care" law in Texas that allows medical providers, under certain conditions, to withdraw care over the parent or representative's objections. No disagreement there.

But you claimed that Texas law requires life support to be discontinued. Not the case at all. Not in "futile care" cases and certainly not simply on the basis of ability to pay.

EDIT: For those who are interested in the futile care law, check out Chapter 166 of the Texas Health and Safety Code.

EDIT2: I've already used up my 10 free NYT articles for the month, so I can't comment on the last link.

EDIT3: Okay, I realize I might have phrased it ambiguously above. Stephanie66's comment implied that in Texas, hospitals are required to cut off life support for "uninsured and poor people who are terminally ill or have no chance of survival." While "required" may ring true in the sense that, under certain circumstances, the family can't do a damn thing about it, it is by no means required that the hospitals go about discontinuing care. Not even in all "futile care" cases.

"Under the Texas Futile Care Law, health care workers are allowed to remove expensive life support for terminally ill patients if the patient or family is unable to pay the medical bills."

If the family is not approving it, then it seems to be against their will, only because they are poor or uninsured. You do notice that people who can pay for it can stay on life support, even if futile, indefinitely. This law was aimed at poor people.

Automatic Invalidation of a Pregnant Woman's Advance Directive

12 state

statutes (

Alabama, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, South Carolina, Texas, Utah, Washington and Wisconsin

http://www.centerwomenpolicy.org/progra ... .Wolfe.pdf

Here's the NYT article. Interesting that it is the pro-lifers that are fighting it. Good for them.

Texas lawmakers have grappled year after year over whether families or medical professionals should decide when to end a terminally ill patient’s life-sustaining care. This year, they seem closer to a compromise.

The Texas Tribune

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

“If we were only making decisions based on medical facts, everything would be straightforward,†said Dr. Leigh Fredholm, the medical director of Seton palliative care at the University Medical Center Brackenridge in Austin. “But that’s not how we make decisions.†(Seton is a corporate sponsor of The Texas Tribune.)

State law allows physicians to discontinue treatment they deem medically futile. If a physician’s decision to end treatment contradicts the patient’s advance directive or the judgment of the patient’s surrogates, state law gives patients or their families 10 days to find another provider and appeal the doctor’s decision to a hospital ethics committee.

Advocacy groups that identify as “pro-life†say existing law does not go far enough to protect the interests of patients or their families. But they are divided on how legislators should change it. While support in the Legislature’s upper chamber seems to be coalescing around Senate Bill 303, which would tweak the process, some support bills that would bar doctors or hospital ethics committees from making the final decision to end treatment.

“There are times when medical treatment is inappropriate and death is inevitable,†said State Senator Robert Deuell, Republican of Greenville, a physician who filed S.B. 303. Prohibiting doctors or an ethics committee from participating in the process could “let a family subject a loved one to a lot of truly unnecessary, perhaps painful and harmful treatment,†he said.

The bill would alter the existing dispute process by extending the time frame for finding an alternate provider to 14 days, and by ensuring the patient or patient’s surrogate has assistance navigating the appeals process, access to free copies of medical records and adequate representation at an ethics committee hearing. The bill has the support of the Texas Medical Association, the Texas Hospital Association, two church-affiliated groups and the Texas Alliance for Life.

Notably missing from that list is Texas Right to Life. John Seago, the group’s legislative director, said Dr. Deuell’s bill would still allow an ethics committee to override a patient or surrogate’s desire to continue treatment and would not alleviate the burden put on families to find a new provider.

“An inmate on death row has more appeals and due process than a patient before an ethics committee,†Mr. Seago said.

Texas Right to Life supports two other measures, Senate Bill 675, which would prohibit a physician from withdrawing life-sustaining treatment based on a medical or value judgment, and House Bill 1464, which would eliminate the 10-day time frame and require the physician or hospital to continue life-sustaining treatment until the patient is transferred to another facility.

So far, none of the bills have advanced out of committee. Dr. Deuell said he planned to add additional protections to S.B. 303 based on input he has received.

In 2012, the Texas Hospital Association surveyed 202 private hospitals — a third of all hospitals in the state — and found the end-of-life dispute process had been used 30 times between 2007 and 2012. Of those cases, a third of the patients died during the appeals process, six patients were transferred to another provider and four continued treatment past the 10-day period. The ethics committees agreed with the physician’s decision to end treatment in 7 of the 10 cases that got that far.

“Legislating the end of life is tricky,†Dr. Fredholm said, “but for us, how you prepare for the end of life is much more important, because we all have to die.â€

baaronson@texastribune.org

[GawkingToo]

So, since Texas also has a lw requiring uninsured and poor people who are terminally ill or have no chance of survival to be removed from life support, I second othe question of who is paying for it?

After going through all our posts back and forth and the articles posted, I think we're probably just understanding "requiring" to mean two different things.

I'm guessing you mean it in the sense that removing the life support is "required" by the hospitals over the family's objection. However your post, standing alone (meaning without the followup posts and articles, but still with the above sentence in its original context), can also be read as saying that Texas has a law requiring hospitals to withdraw support in the case of indigent or futile care patients. Do you see why I'd object to that being presented as the state of Texas law?

I think we've really just been talking in circles all along here.

[jean70]

What are the other 11 states?

If I'm reading this report right, Alabama, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, South Carolina,Texas, Utah, Washington, and

Wisconsin all have directives that invalidate an advance directive if a woman is pregnant. The source is from here: (centerwomenpolicy.org/programs/health/statepolicy/documents/REPRO_PregnancyExclusionsinStateLivingWillandMedicalProxyStatutesMeganGreeneandLeslieR.Wolfe.pdf) and is dated August 2012

[salex]

Yes, there's a "futile care" law in Texas that allows medical providers, under certain conditions, to withdraw care over the parent or representative's objections. No disagreement there.

But you claimed that Texas law requires life support to be discontinued. Not the case at all. Not in "futile care" cases and certainly not simply on the basis of ability to pay.

EDIT: For those who are interested in the futile care law, check out Chapter 166 of the Texas Health and Safety Code.

EDIT2: I've already used up my 10 free NYT articles for the month, so I can't comment on the last link.

EDIT3: Okay, I realize I might have phrased it ambiguously above. Stephanie66's comment implied that in Texas, hospitals are required to cut off life support for "uninsured and poor people who are terminally ill or have no chance of survival." While "required" may ring true in the sense that, under certain circumstances, the family can't do a damn thing about it, it is by no means required that the hospitals go about discontinuing care. Not even in all "futile care" cases.

That case brings to mind the ongoing case in Oakland CA right now.

http://www.latimes.com/local/lanow/la-m ... z2oWMfSdFC

[Stephanie66]

I probably did use required incorrectly. It was from memory at the time.

It still seems wrong that money plays into it. If a person is terminally ill and has money, then there is no ethical issue, apparently, with leaving them on life support. If they can't pay, however, then it becomes an ethical issue. I mostly found it ironic, since W made much ado about the Schiavo case and her "right to life" while the law he signed can deny the right to life if you are poor.'

I guess this law won't come in to play in this case.

ETA: The case in Oakland is heartbreaking. The mom and uncle seem to be a little misinformed, as well. They believe she can't be dead "if her heart is beating" and that she is breathing on her own. I wish them a miracle, but I think they also just needed time to accept that their baby is dead. I am glad the judge allowed them Christmas together.

[GawkingToo]

I probably did use required incorrectly. It was from memory at the time.

It still seems wrong that money plays into it. If a person is terminally ill and has money, then there is no ethical issue, apparently, with leaving them on life support. If they can't pay, however, then it becomes an ethical issue. I mostly found it ironic, since W made much ado about the Schiavo case and her "right to life" while the law he signed can deny the right to life if you are poor.'

I guess this law won't come in to play in this case.

ETA: The case in Oakland is heartbreaking. The mom and uncle seem to be a little misinformed, as well. They believe she can't be dead "if her heart is beating" and that she is breathing on her own. I wish them a miracle, but I think they also just needed time to accept that their baby is dead. I am glad the judge allowed them Christmas together.

I agree 100%. I'm not sure what the relationship with money is--I recall coming across a couple cases involving kids where there was in fact insurance coverage (but maybe not enough?)--but the money aspect does look shady. A common criticism has also been the lack of procedural oversight. We're talking about a decision made by a hospital ethics committee. Not even a judge, unless the family files legal action in time. (And it makes no sense that the burden of filing the legal action should fall on the family resisting the decision to withdraw care, not the facility seeking the drastic action.) I like this article that I came across: http://www.nejm.org/doi/full/10.1056/NE ... 3444cf1cd1

EDIT: Some more links:

http://www.chron.com/news/houston-texas ... 136586.php

http://www.chron.com/news/houston-texas ... 474998.php

http://www.washingtonpost.com/wp-dyn/co ... 01620.html

http://lawprofessors.typepad.com/health ... t_sto.html

EDIT2: Removed the info about the committee makeup, because I couldn't find the sources for that.

[tigerchild]

The Terri Schaivo case is what motivated me to draw up notarized end of life/advanced care directives and update all my legal information/will. I'm pretty sure it would hold up in court (I used a lawyer who has had the experience of a contested wills and won) but I wanted to protect my husband from my parents--my mom in particular I could see would love to strut and morally masturbate and try to take over control of my dead body if she could, to hold up her image in the extended family. I made sure to leave explicit instructions with her sister that I'm closest to (conservative, but not fundie anymore) and well as in multiple locations.

For years after my great uncle decided to go to hospice and turn down further chemo care she would rant and rail about how "selfish" he was and cowardly and "not willing to fight like he should". And during the case she would go on and on about how if the husband didn't want Terri anymore then she should "belong to the parents so that she can go back to who she belongs to." The minute those words passed her lips, I ran to my lawyer friend. :/ Chilling.

I'm upset that my state apparently is one of the few that has that provision. Once the holidays are over, I think I'm contacting my state representatives.

[Lillybee]

I assume that since this woman and her husband are paramedics that they might have decent health insurance but I have to wonder if they had no insurance would the result be the same.

[Stephanie66]

I assume that since this woman and her husband are paramedics that they might have decent health insurance but I have to wonder if they had no insurance would the result be the same.

Well, there would be one law that would say to keep her alive and another that would say the hospital can terminate life support because they can't pay. Indeed, that would be interesting.

As it is, I wonder how much the husband is going to have to pay? He likely will hit the out of pocket maximums for two different years. Maybe the pro-life folks can help with those bills.

[Lillybee]

Well, there would be one law that would say to keep her alive and another that would say the hospital can terminate life support because they can't pay. Indeed, that would be interesting.

As it is, I wonder how much the husband is going to have to pay? He likely will hit the out of pocket maximums for two different years. Maybe the pro-life folks can help with those bills.

You do know that the pro-life peeps never put their money where their beliefs land.

[starfish]

Yes, there's a "futile care" law in Texas that allows medical providers, under certain conditions, to withdraw care over the parent or representative's objections. No disagreement there.

But you claimed that Texas law requires life support to be discontinued. Not the case at all. Not in "futile care" cases and certainly not simply on the basis of ability to pay.

EDIT: For those who are interested in the futile care law, check out Chapter 166 of the Texas Health and Safety Code.

EDIT2: I've already used up my 10 free NYT articles for the month, so I can't comment on the last link.

EDIT3: Okay, I realize I might have phrased it ambiguously above. Stephanie66's comment implied that in Texas, hospitals are required to cut off life support for "uninsured and poor people who are terminally ill or have no chance of survival." While "required" may ring true in the sense that, under certain circumstances, the family can't do a damn thing about it, it is by no means required that the hospitals go about discontinuing care. Not even in all "futile care" cases.

I'm familar with the Sun Hudson case in Texas. The baby had congential dwarfism, among other issues, and would not live. The medical professionals at the hospital were of the opinion that he was greatly suffering, and it was sheer cruelty to prolong his life. They were not cheapskates, and they did not act upon a whim. The mother was clearly mentally ill, and claimed her child was fathered by the "Sun" who would heal him. No facility would take him and he was removed from life support by the hospital. I believe it was the first time the legislation sometimes called the "Futile Care Act" signed by then-Gov George Bush was used to overturn a parent's wishes. It is interesting that the hospital lobby, when trying to craft the "Futile Care Act", sought the input of Pro Life groups, none of the groups were interested in helping shape the legislation. (probably b/c they are really on interested in fetuses).

[bookgirl14]

This is horrible. It does remind me a little bit of Terri Schaivo only without the bickering between the family and husband. If both the husband and family are in agreement and its what the woman would have wanted, why keep making her suffer? I just hope that the husband and family doesn't get stuck with the medical bills.

[bionicmlle]

I need to read more about this but the term "brain death" is just that - when the second brain death exam is done, a death certificate is filled out. There's a fucked up case in California abt this now but the way I was taught is that brain death is dead body and we don't "treat" dead bodies.

[Mama Mia]

This is horrible. It does remind me a little bit of Terri Schaivo only without the bickering between the family and husband. If both the husband and family are in agreement and its what the woman would have wanted, why keep making her suffer? I just hope that the husband and family doesn't get stuck with the medical bills.

Completely agree. If all the parties involved are against it it's horrific to subject them to this. There isn't even the ambiguity of not knowing her wishes, or her parents or husband disagreeing on what she would want.

Personally, I would want to be kept alive in the same situation, and I know one of my daughters definitely would, but some of the others I don't think would want them for themselves....and that should be their choice.

[starfish]

I need to read more about this but the term "brain death" is just that - when the second brain death exam is done, a death certificate is filled out. There's a fucked up case in California abt this now but the way I was taught is that brain death is dead body and we don't "treat" dead bodies.

If you are talking about the Jahi McMath case, I am of the opinion that is just gruesome. Let the lawsuits fall where they may, and I recognize that the family is suffering a degree to which I cannot comprehend, but the poor child is dead.

[starfish]

I think it's also important to note that there is a difference between "brain dead" which is the condition of the pregnant lady in Texas and Jahi McMath case in California, and a PVS (persistent vegatative state) which was Terri Schiavo's condition. Schiavo had enough brain stem activity to breathe on her own.

But pregnant lady in Tx and McMath are powered by ventilators. That's why I used the word "gruesome" in an earlier post. They are dead, and I feel like

there's a Dr. Frankenstein element going on. I know folks are trying to be compassionate to the McMath family by saying they will help move her to a nursing home, but at the same time, I think it's cruel.

And we've been talking about the money aspect of it, and it does not really come into play in the McMath case as the girl has insurance who is willing to pay. (again, not helping; but I'm sure they don't want the bad publicity if they refuse to pay). The hospital wants to remove the venilator b/c they say she's dead, and they don't treat dead people.

[RosyDaisy]

These are private family issues and should be decided by the family. Everybody else, including the government needs to STFU and butt out.

[starfish]

I read it costs around $4000 a day to keep a brain dead person on life support.

[bionicmlle]

If you are talking about the Jahi McMath case, I am of the opinion that is just gruesome. Let the lawsuits fall where they may, and I recognize that the family is suffering a degree to which I cannot comprehend, but the poor child is dead.

Yes have been following this more closely this week and am disgusted that a judge "gave her a stay of execution" as the supporters say. I know the family is suffering but they need to grieve the loss of their daughter. If I was the physician caring for this body, I think I'd have to refuse to continue providing support for a corpse. It's morbid and gruesome, as you say. It does not fit with medical ethics to essentially mutilate a dead body in this way.

ETA: I wonder if the judge would compel the physicians/hospital to provide "care" and hold them in contempt if they refused.

[Coconut Flan]

Perhaps at some point soon the insurance company will get involved and refuse to pay for care.

[GawkingToo]

Some additional commentary regarding the pregnant Texas woman:

http://abcnews.go.com/US/wireStory/preg ... e-21416685

Journalists are taking the husband's word for it that the wife is brain dead, because they can't get the hospital to confirm or deny it. (I'm guessing it's a HIPAA issue?):

Hospital spokeswoman J.R. Labbe said she isn't permitted to confirm that Marlise Munoz had been declared brain-dead, only that she was pregnant and hospitalized in serious condition.

However if she is in fact brain dead, the hospital might be misinterpreting the statute:

But three experts interviewed by The Associated Press, including two who helped draft the law, said a brain-dead patient's case wouldn't be covered by the law.

"This patient is neither terminally nor irreversibly ill," said Dr. Robert Fine, clinical director of the office of clinical ethics and palliative care for Baylor Health Care System. "Under Texas law, this patient is legally dead."

John Peter Smith Hospital in Fort Worth is pointing to a provision of the Texas Advance Directives Act that reads:

Tom Mayo, a Southern Methodist University law professor, said he did not believe the law applied in this case. He said the hospital would not have absolute immunity from a civil or criminal case if it went outside the subchapter referenced by the law, but noted that "most medical decisions" are made without immunity.

Not sure what to make of it all. The term "brain dead" gets thrown around a lot, so maybe she isn't actually? (Then again the husband is medical professional, so I'd imagine he'd know the difference, right?) On the other hand, lawyers tend to be a cautious bunch, so it may very well be that she's brain dead but the lawyers have advised the hospital to take the safest possible approach, especially since the husband isn't actively suing to get life support removed.

[starfish]

Some additional commentary regarding the pregnant Texas woman:

http://abcnews.go.com/US/wireStory/preg ... e-21416685

Journalists are taking the husband's word for it that the wife is brain dead, because they can't get the hospital to confirm or deny it. (I'm guessing it's a HIPAA issue?):

However if she is in fact brain dead, the hospital might be misinterpreting the statute:

Not sure what to make of it all. The term "brain dead" gets thrown around a lot, so maybe she isn't actually? (Then again the husband is medical professional, so I'd imagine he'd know the difference, right?) On the other hand, lawyers tend to be a cautious bunch, so it may very well be that she's brain dead but the lawyers have advised the hospital to take the safest possible approach, especially since the husband isn't actively suing to get life support removed.

The hospital clearly thinks they have no choice. Interesting that her family has joined in with husband.

[doggie]

a update on this poor woman's case.

DALLAS (AP) - The pregnant, brain-dead Texas woman being kept on life support over her family's protests is carrying a fetus that is "distinctly abnormal," attorneys for the woman's husband said Wednesday.

Marlise Munoz remains hooked up to machines in a Fort Worth hospital, while her husband and the hospital are locked in a court battle about whether to retain life support.

The case has raised questions about end-of-life care and whether a pregnant woman who is considered legally and medically dead should be kept on life support for the sake of a fetus. The case has gotten the attention of groups on either side of the abortion debate, as anti-abortion groups argue Munoz's fetus deserves a chance to be born.

Erick Munoz said his wife, a fellow paramedic, was clear with him before he found her unconscious on Nov. 26: If she ever fell into this kind of condition, pull life support. But John Peter Smith Hospital says it's bound by state law that prohibits the withdrawal of treatment from a pregnant patient, although several experts interviewed by The Associated Press have said the hospital is misapplying the law.

Munoz's attorneys, Heather King and Jessica Hall Janicek, issued a statement Wednesday describing the condition of the fetus, now believed to be at about 22 weeks' gestation. King and Janicek based their statement on medical records they received from the hospital.

"According to the medical records we have been provided, the fetus is distinctly abnormal," the attorneys said. "Even at this early stage, the lower extremities are deformed to the extent that the gender cannot be determined."

The attorneys said the fetus also has fluid building up inside the skull and possibly has a heart problem.

"Quite sadly, this information is not surprising due to the fact that the fetus, after being deprived of oxygen for an indeterminate length of time, is gestating within a dead and deteriorating body, as a horrified family looks on in absolute anguish, distress and sadness," the attorneys said.

Spokeswomen for the hospital and the Tarrant County District Attorney's office, which is representing the hospital in the lawsuit, declined to comment Wednesday.

A hearing in the case is scheduled for Friday. Munoz's lawsuit asks a judge to order the hospital to pull life support and return Marlise Munoz's body to her family.

Several experts have said the Texas Advance Directives Act doesn't apply in this case because Marlise Munoz, having suffered brain death, is legally and medically dead - a key argument in Erick Munoz's lawsuit.

Munoz previously told the AP he wasn't confident about the health of the fetus. His wife was 14 weeks pregnant when he found her unconscious in November, possibly from a blood clot.

[PurpleSheepleEater]

I hope to God they let this man bury his wife and baby in peace now. The entire story is so disturbing and so unfair to everyone involved.

[sparkles]

And if/when this child is born with profound medical problems requiring constant and prohibitively expense care, do you think any of the same people who are forcing a corpse to incubate the fetus will step up to provide assistance? Not a fucking chance. Sorry bud, we've done our part. You're on your own now!