Cruzan v. Director, Missouri Department of Health

Cruzan v. Director, Missouri Department of Health

Substituted Judgement Doctrine

Recommendations

Enhanced Policies on Advance Directives

• The legal principle that a court should make a decision on behalf of an incompetent person by trying to determine what he/she would have decided (Harris, 2014).

• 2 types of SJD cases (Rouse, 1986):

(1) those in which the patient's specific wishes are known and can be conveyed by a family member

(2) those in which the patient's specific wishes are not known, but a family member, because of his/her closeness to the patient, is considered a reliable spokesperson for the patient

• Substituted judgement doctrine (Tonelli, 1997)

• Enhanced policies on advance directives

• Objective balance test (Quinn, 1988)

Health Reform

• PSDA requires written information about advance directives to be given to patients, but no regulation on how often paperwork is filled out and turned back in

• Information about advance directives should be given in inpatient and outpatient settings

Cruzan v. Director, Missouri Department of Health

Meghan Whitebread

HCM515: Health Law and Ethics

Colorado State University- Global Campus

Prof Andrea Rea

November 05, 2017

Legal & Ethical

Dilemmas

Patient Self- Determination Act:

• Hospitals and nursing homes that receive Medicaid or Medicare funds must give patients written information about treatment options, advance directives, and the right to die (Galambos, 1998).

• Physicians also have a responsibility to inform patients on the right to refuse treatment, make ADs a prominent part of a patient's medical records, ensure compliance with state laws, maintain organizational policies and procedures, and provide community and staff education on advance directives (Galambos, 1998).

Objective Balance Test

Ethical Assessment

• There are times were clear and convincing evidence is not present and the patient's wishes are not known

• A balance test can be used to prove whether or not the burdens of continued life outweighs the benefits in order to determine of life-sustaining treatment should be withheld ( Quinn, 1988)

Action Plan

Ethical principles present in this case:

• autonomy
• beneficence
• non-maleficence

• Implementing policies and procedures regarding subjective judgement doctrine, advance directives, and objective balance tests

• Education at all levels
• Lunch and learns
• Workshops
• Written information such as flyers and brochures

Regulatory Compliance

Assessment of Case:

Who was Affected?

• Hospital would not terminate AN&H without a court order

• Missouri requires clear and convincing evidence

• Ethical Assessment

• Legal Assessment

• Regulatory Compliance

• Health Reform

• Nancy Beth Cruzan

• Cruzan's Parents

• State and Federal Courts

What Happened?

Legal Assessment

• Nancy Beth Cruzan was injured in a car accident and left in a persistent vegetative state

• Cruzan was not terminally ill and was breathing on her own

• Parents asked hospital employees to terminate AN&H, but hospital refused to do so without a court order

• Missouri court refused to order the termination of treatment because there was no clear and convincing evidence of the patient's desire to to terminate AN&H

Legal Assessment (cont'd.)

• Right to Refuse Treatment

covered under 14th Amendment

• Supreme Court allows states to determine how the right to refuse medical treatment should be exercised if the patient is mentally incapacitated
• Missouri requires clear and convincing evidence

Rationale:

Introduction

Introduction and Description

Advance Directives (AD):

• Legal documents that allow patients to put their healthcare wishes into writing, or to appoint someone to make decision for them, if they become incapacitated (Miller, 2017)
• Two parts to an AD: living will and durable power of attorney

• Absence of AD is root cause of this case

• AD are not just for the elderly

• Life and crises are unpredictable

The courts were not denying Nancy Beth Cruzan's right to die. Rather, they were requiring clear and convincing evidence to show that Ms. Cruzan would have wanted to have her AN&H terminated.

• Case study regarding the termination of artificial nutrition and hydration (AN&H) for a patient in a persistent vegetative state.

• Persistent vegetative state is one in which the body’s internal functions operate to maintain temperature, heart beat, pulmonary ventilation, digestive activity, and conditional reflex activity (Gaudin, 1991).

• Introduction: brief overview of case

• Description:
• What Occurred
• Who was Affected
• Rationale

Conclusion

• It’s not the first time something like this happened, and it wasn’t the last time.
• take her situation and learn from it in order to prevent this from happening in the future.

• Due to the absence of an advance directive, Cruzan was artificially fed while her parents fought their way through the courts.

• Using subjective judgement doctrine, enhance policies on the completion of advance directives, and objective balance tests will help guide health care facilities through these tough situations

References

Darr, K. (1991). After Cruzan, hospitals and the right to die. Hospital Topics, 69(4), 4.

Galambos, C. M. (1998). Preserving end-of-life autonomy: The Patient Self-Determination Act and the Uniform Health

Care Decisions Act. Health & Social Work, 23(4), 275-281.

Gaudin, A.M. (1991). Cruzan v. director, Missouri department of health: To die or not to die: That is the question- but

who decides. Louisiana Law Review, 51(6), 1308-1345

Hampson, L.A. & Emanuel, E.J. (2005). The prognosis for changes in end-of-life care after the Schiavo case. Health

Affairs, 24(4), 972-975. doi: 10.1377/hlthaff.24.4.972

Harris, D. M. (2014). Contemporary issues in healthcare law & ethics. Chicago, IL: Health Administration Press.

Kleinman, I. (1991). The right to refuse treatment: ethical considerations for the competent patient. CMAJ: Canadian

Medical Association Journal, 144(10), 1219–1222.

Lewin, T. (1990). Nancy Cruzan dies, outlived by a debate over the right to die. The New York Times. Retrieved

from http://www.nytimes.com/1990/12/27/us/nancy-cruzan-dies- outlived-by-a-debate-over-the-right-to-die.html

National Center for Life and Liberty. How the “right to die” came to America. Retrieved from http://www.ncll.org/

liberty-centers/center-for-life-defense/cld-articles/57-how-the-right- to-die-came-to-america

Miller, B. (2017). Nurses in the know: The history and future of advance directives. Online Journal of Issues in

Nursing, 22(3), 1. doi:10.3912/OJIN.Vol22No03PPT57

Quinn, K. (1988). The best interests of incompetent patients: The capacity for interpersonal relationships as a

standard for decision making. California Law Review, 76(4), 897-937.

Tonelli, M. R. (1997). Substituted judgment in medical practice: Evidentiary standards on a sliding scale. Journal of

Law, Medicine & Ethics, 25(1), 22.

Rouse, F. (1986). Question and answers about the right to die. Nursing, 16(11).