determination of death by neurological criteria: what is reasonable accommodation? are we doing it?...
TRANSCRIPT
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Determination of Death by Neurological Criteria: What Is Reasonable Accommodation? Are We Doing It?
Southern California Bioethics Committee Consortium
January 18, 2015 ● Los Angeles
Thaddeus Mason Pope, J.D., Ph.D. Hamline University Health Law Institute
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2
Prefatory Remarks
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6
Roadmap
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7
1. Legal duties after DDNC
2. History of 2008 CA accommodation statute
3. Meaning of 2008 statute
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8
Determination of Death by Neurological Criteria
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11
Wrong
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1970s
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An individual . . . . . is dead . . . who has sustained either
(1) irreversible cessation of circulatory and respiratory functions, or
(2) irreversible cessation of all functions of the entire brain
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total brain failure
= death
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Legally settled since 1980s
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Remains settled (legally)
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All 56 US jurisdictions (narrow NJ exception)
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“durable worldwide consensus”
Bernat 2013
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Consent not required to stop LSMT
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Not a patient
Dead
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Not a patient
No duty to treat
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“After a patient . . . brain dead . . . medical support should be discontinued.”
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“Once death has been pronounced, all medical interventions should be withdrawn.”
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The rule almost everywhere
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California rule for 34 years
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DDNC in California
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1974
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California Health & Safety Code § 7180
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1982
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California Health & Safety Code § 7180
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35
History of DDNC Accommodation Laws: NY, NJ, IL
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NY, NJ, IL have laws
But custom & practice of accommodation in other states
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1986
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Sheldon Silver bill -----Religious exemption from DDNC
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An individual . . . . . is dead . . . who has sustained either
(1) irreversible cessation of circulatory and respiratory functions, or
(2) irreversible cessation of all functions of the entire brain
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Mario Cuomo
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“Each hospital shall establish and implement a written policy . . . a procedure for the reasonable accommodation of the individual's religious or moral objection to the determination . . . .”
10 N.Y.C.R.R. § 400.16(e)(3)
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No duty treat
Dead
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No duty treat
Dead
NY changes this
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NY Changes duties to treat after DDNC
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1. Hospital discretion to write policy
2. Only for objections that are religious or moral
3. Only “reasonable” accommodation
Limits
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1991
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Did what NY originally planned:
Religious exemption
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New York
Accommodation Dead but ongoing rights
New Jersey
Exemption Not dead
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“The death of an individual shall not be declared upon the basis of neurological criteria . . . when the licensed physician . . . has reason to believe . . . that such a declaration would violate the personal religious beliefs of the individual.”
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No duty treat
Dead
NJ changes this
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NJ
Changes definition itself
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Assures paymentAlso directly required
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Shewmon80% < 4 weeks20% > 4 weeks10% > 8 weeks5% > 6 months
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1. Only religious objections
2. Only objections of the individual
Limits
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Barnert Hospital v. Moreno (NJ. Sup. 1998)
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2007
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“Every hospital must adopt policies and procedures to . . . take into account the patient's religious beliefs concerning the patient's time of death.”
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2008 -2015
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62
MA Cho Fook Cheng
DC Motl Brody
MI Shahida Virk
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RFRA
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Religious objectors may demand exemptions from generally applicable laws that substantially burden the objectors’ religious practice
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67
Diagnostic Mistrust
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Close call in death ruling of potential organ donor(April 12, 2007)John Foster at Fresno Community
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Maria de Jesus Arroyo
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Hootan Roozrokh
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Not in NY, NJ, IL
Only moral & religious
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Orthodox Jews
Japanese Shinto
Native Americans
Buddhists
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84
History of DDNC Accommodation Laws in CA
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1983
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Dority v. Superior Court, 145 Cal. App. 3d 273
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DDNC “does not mean the hospital or the doctors are given the green light to disconnect a life-support device from a brain-dead individual without consultation . . . .”
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“We are in accord with . . . deferring to parental wishes until the initial shock of the diagnosis dissipates; and would encourage other health care providers to adopt a similar policy.”
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Obiter dictum“by the way”“said in passing”
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1986
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Richard Katz
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Would have made CA = NJ
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1987
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2008
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2007 “there out to be a law contest in Eng’s district
Mike Eng
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California Health & Safety Code § 1254.4
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102
1254.4
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Made CA like NY
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CA broader duty accommodation
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NY & NJ: moral & religious
objections
CA: other objections too
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Examine accommodation duties separately
1. Non-moral2. Moral, cultural
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Non-moral
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What does 1254.4 require of hospitals?
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1. Text (plain language)
2. Legislative history
3. Custom & practice
4. Judicial construction
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110
Plain language
1254.4 on non-moral objections
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Accommodation What (type)
How long (duration)
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What
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“hospital is required to continue only previously ordered cardiopulmonary support. No other medical intervention is required.”
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How long
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“reasonably brief period”
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“amount of time afforded to gather family or next of kin at the patient's bedside”
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“in determining what is reasonable, a hospital shall consider the needs of other patients and prospective patients in urgent need of care.”
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“hospital shall adopt a policy for providing family or next of kin with a reasonably brief period”
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Delegation
Deference
Discretion
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120
Legislative history
1254.4 on non-moral objections
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2007 “there out to be a law” contest
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Constituent's mother experienced a severe stroke
Patient eventually diagnosed as neurologically dead.
Physician took 15 hours to notify the family
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Family was given 3 hours to pay their final respects
1 family member out of town
Family's spiritual leader could not be reached.
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Early versions of the bill suggested 2 days
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Annual cost per hospital = $78,000
Based on 1 patient per month at $6500 for 24 hours
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126
Custom, Practice1254.4 on
non-moral objections
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Irvine v. California Employment Commission (Cal. 1946)
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Delegation
Deference
Discretion
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“hospital shall adopt a policy for providing family or next of kin with a reasonably brief period”
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<24 x x x x24 x x x x x x3648 x72 x x x
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CHO Usual: 2-3 days
Actual: 8 days
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Hiram LawrenceCHO
> 1 week
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134
1254.4
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Examine accommodation duties separately
1. Non-moral2. Moral, cultural
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4 types of sources
Plain languageLegislative historyCustom & practiceCourt rulings
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137
Plain language
1254.4 on moral & cultural objections
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“reasonable efforts to accommodate . . . special religious or cultural practices and concerns”
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practice and concerns “of the patient or the patient's family”
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Not drafted as exemption (indefinite) but as accommodation (definite)
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Perverse if mandated to continue DDNC but not for PVS
Dead have more rights than the living?
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“A health care provider . . . may decline to comply . . . medically ineffective health care or . . . contrary to generally accepted health care standards . . . .”
Cal. Prob. Code 4735
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Delegation
Deference
Discretion
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Requires more than “reasonably brief period” to gather family
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“give meaning to every word in a statute and to avoid constructions that render words, phrases, or clauses superfluous.”
Klein v US (Cal. 2010)
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Separate sections
(a) “reasonably brief period of accommodation”
(c) “reasonable efforts to accommodate”
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(d) “in determining what is reasonable, a hospital shall consider the needs of other patients and prospective patients in urgent need of care.”
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148
Legislative history
1254.4 on moral & cultural objections
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1986 bill failed
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“special religious or cultural practices and concerns”
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• Pic ritual
“ritual”
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Not about continuing physiological support
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Rituals within the “reasonably brief period”
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154
Custom & Practice
1254.4 on moral & cultural objections
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Look to NY custom since similar rule
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Bellevue Coney Island Elmhurst HarlemJacobi Kings County Lincoln Metropolitan North Central Bronx Queens Woodhull
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Mariah ScoonAdmit Feb. 19, 1996DDNC Feb 21, 1996Hospital gives 5 day (Wed - Mon)TRO to Feb. 28Hospital winsStay to Mar. 7Transferred on Mar. 1
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AlvaradoSept. 15, 1989 DDNCSept. 21 social workerSept. 22 parents fileOct 13 independent expertOct 18 orderAppeal dismissed (not dead)
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Transfers: McMath (CA) Hamilton (FL) Koochin (UT) Scoon (NY) Shively (KS)
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A Debate Over Life After DeathFebruary 10, 1997
10-year old girl
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164
Court rulings1254.4 on
moral objections
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Title VII, Civil Rights Act of 1964
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TRO
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Diagnosis confirmed by 3 CHO clinicians
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December 12
December 20
Accom
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December 20
December 24
Death confirmed
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Paul Fisher
Stanford Child Neurology
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December 24
January 5
Extension
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US ConstitutionFederal statutes
State constitution1254.4
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IssacLopez
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July 2
July 22
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Conclusion
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TYPE Ventilator only Permit rituals
LENGTH 24 hours Unless HTO
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Flexibility Sensitivity
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Thaddeus Mason Pope Director, Health Law InstituteHamline University School of Law1536 Hewitt Avenue Saint Paul, Minnesota 55104T 651-523-2519F 901-202-7549E [email protected] www.thaddeuspope.comB medicalfutility.blogspot.com
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References
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Medical Futility Blog Since July 2007, I have been blogging, almost daily, to medicalfutility.blogspot.com. This blog is focused on reporting and discussing legislative, judicial, regulatory, medical, and other developments concerning medical futility and end-of-life medical treatment conflict. The blog has received over 750,000 direct visits. Plus, it is distributed through RSS, email, Twitter, and re-publishers like Westlaw, Bioethics.net, Wellsphere, and Medpedia.
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Brain Death Rejected: Expanding Clinicians' Legal Duties to Accommodate Religious Objections and Continue Physiological Support, invited manuscript for 2015 Annual Conference Law, Religion, and American Healthcare, PETRIE-FLOM CENTER FOR HEALTH POLICY, BIOTECHNOLOGY, AND BIOETHICS, HARVARD LAW SCHOOL (May 2015).
Legal Aspects of Brain Death Determination, in 35 SEMINARS IN CLINICAL NEUROLOGY: THE CLINICAL PRACTICE OF BRAIN DEATH DETERMINATION (forthcoming 2015) (with Christopher Burkle).
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Review of Death before Dying: History, Medicine, and Brain Death (OUP 2014), 36 JOURNAL OF LEGAL MEDICINE (forthcoming 2015).
Legal Briefing: Brain Death and Total Brain Failure, 25(3) JOURNAL OF CLINICAL ETHICS 245-257 (2014).
Pregnant and Dead in Texas: A Bad Law, Badly Interpreted, LOS ANGELES TIMES (Jan. 16. 2014) (with Art Caplan).
Legal Briefing: Organ Donation, 21(3) JOURNAL OF CLINICAL ETHICS 243-263 (2010).