Let me preface this by saying that I’m a liberal Democrat who voted for Obama, so keep the flames turned down. Here’s the thing. The part of the Health Care bill in question (Section One Thousand Two Hundred and Thirty Three, I kid you not) ADVANCE CARE PLANNING CONSULTATION is available here.
My problem is in this part:
Now, call me crazy, but to me that part says that an “Order” can be (reasonably) issued by an MD, an NP, or a PA … but there is absolutely no requirement that it be agreed to, or signed by, the patient. It can also incorporate an “advance directive” if it is “executed by the individual”, but there’s no requirement that any other part of the “Order” has to be “executed by the individual”. And there is no limitation on what kind of treatment can be denied under the “Order.”
Now I’d bet money that this was an oversight on the writer’s part (a not uncommon occurrence with foolishly trying to craft a thousand page bill in three weeks … but I digress).
But unless someone can point to some part that says that the patient has to sign or at least clearly OK the “Order”, I’d have to say that (hides his face and whispers) Sarah Palin is kinda right …
Yikes! Can’t have that … fight my ignorance, what am I missing here?
It seems clear to me that the Order in question is one originating from the patient him/herself, since the Order is a direct result of the consultation as listed in #4–and presumably that consultation involves the voluntary participation of the patient.
Everything else as described proceeds from this premise. The “order” may be underwritten by a physician or other figure to give it the weight of additional authority, but I don’t see anywhere where it suggests that the order is imposed externally and potentially counter to the wishes of the individual in question.
You appear to be right regarding the intention of the section. But laws don’t run by intention. They run by exactly what is written, exactly what is required, exactly what is forbidden. If it doesn’t require the patient’s agreement, what’s to stop a Doc from ordering a DNR order?
Again, my point is that there is no requirement that the individual signs the order. A doctor could write up anything, and might even sincerely believe it is a statement of the individual’s preferences … but it might also just be a statement of the doctor’s preferences. Without requiring that the individual read and sign the order, anything is possible.
Like I said above, I think that this is merely an oversight on the part of whoever wrote the bill. But laws don’t run on anything but what is actually written … and as written, there is absolutely nothing stopping a Physician’s Assistant from writing up anything he pleases. When he does so, it becomes a legally enforceable order. Which brings up a separate issue … what if the person finds out that the order doesn’t exactly reflect their preferences? There’s no mechanism to protest, or to change the order?
Look, I’m not saying that those are reasonable interpretations, they’re not. But they are most definitely possible interpretations, and as written, the bill gives the docs, NPs, and PAs huge and unchecked power. I don’t think they’d use it … but what I think is meaningless.
What counts is what the bill says. As written, it says a PA can write and sign an order without the patient agreeing or signing the order. That’s a big hole …
The bill requires the advanced directive be an accurate effective communication of the individual’s preferences regarding life sustaining treatment and that it be signed by a physician. That specifically precludes the legality of an order that isn`t the individual’s preference. Nothin in what you quoted suggests the death idiots are remotely right.
You’re not “crazy” but you dont know what youre talking about here.
I realize that people already think that dozens of professional legislative staffers and their congressman bosses working for months in consultation with major stakeholders couldn’t possibly understand, know or comprehend everything written in the 1000 page bills they themselves write. But in reality, as big as they are, they’re just the beginning. Legislators dont try to cover absolutely every minor detail in their bills an they're still that big. They cover the broad strokes and then some executive branch department is able to detail every tiny little detail. For instance, the bill mandates that the advanced directive must be the patient's accurate and clear preference, but that doesnt mean that ultimately, in order to get reimbursement for the consultation, a copy signed by the patient won’t be required. It’s not ALL supposed to be in the legislation - they don`t work that way.
Fuzzy, you’re not reading what I’m saying. It may well be as you say, that if a patient takes the order to court, or back to the doctor, and states and proves that it does not reflect their preferences, it will then be illegal.
But until then, it is legal. The burden of proof is on the person to show that it is not legal. It has all the signatures required, from all of the officals required. It’s legal until proven otherwise.
For example. Doctor X creates and signs such a “Do Not Resuscitate” order, seriously believing that’s what the patient wants … but in fact although the patient can read English, he doesn’t speak English all that well and doesn’t even want that. But the order can legally be created and become official without the patient signing it, or even reading it.
The patient comes in, unconscious, to another hospital. Are you seriously claiming that the doc’s order is somehow illegal, and would not be followed?
Now the patient may wake up and say “Hey, that’s not what I wanted!” And he may get the DNR order rescinded. But until then … the DNR order is legal.
Remember that this document follows the patient, and can be used (even without the patient’s knowledge) to make decisions on their treatment.
Once again, I don’t think that’s what the bill intends … but I can sure see how someone who doesn’t trust the Government could say “Hey, the Doc can write and sign an order I may not even agree with”. And from what I read in the bill … the Doc can in fact do that.
The key is that the order must reflect the individual’s preference. There are many circumstances in which the individual’s signature would not be possible even if the individual could clearly express a preference and a signature requirement would prevent the individual’s preference being respected. (Various injuries, paralysis, motor impairment, etc.)
Signatures are one way to document an individual’s preference but not the only way, not enough in and of itself in any case (we docs are taught that a signature on a consent form is not enough, for example, you also need to document the conversation and the understanding expressed), and sometimes not possible.
And in any case right now orders for Do Not Resuscitate (DNR) are signed by the doctor, not the patient, reflective of the patient’s wishes and of the conversation and the understanding of the meaning of the order. The patient signature is not legally required for DNR right now. This is no change from current practice.
Willing to bet the doctor’s signature is to make it good for the government to pay for it. If an individual just writes one on their own they cannot get reimbursed.
I cannot imagine such a document is legal and a protection from lawsuit to healthcare professionals if the patient has not signed it.
Fight my ignorance here … can you just get up in the morning and sign a DNR for me that will follow me for the rest of my life, without me ever seeing the document?
Right, but there’s nothing that follows to indicate that they must follow the individual’s stated preferences, is there? The word “preferences” is an alarmingly loaded one given there must be multiple treatment options under consideration if one is to prefer any.