In response to: Withdrawal of life-sustaining treatment in the first year of life

Abstract

In describing their experiences that deal with medically inappropriate interventions since the enactment of the Texas Advance Directives Act, Eason et al. (September 2008 issue) 1 describe six patients who underwent withdrawal of care as outlined by the Texas Advance Directives Act. This article provides a good overview of the Texas Advance Directives Act in practice, the rarity with which it is invoked, and the outcomes of representative cases. The authors conclude, in part, that 'a major part of the solution to these conflicts lies in improved communication. 1 ' This conclusion suggests that communication gaps or breakdowns played at least some role in these extraordinary cases, though the authors do not explore in detail the nature of these presumed communication gaps. The authors go on to state that 'There was no evidence that other considerations such as insurance status, socioeconomic status, race, or gender played any role in bringing the cases to the MARC, or in the resulting decision of the MARC. 1 ' However, it is striking that all six patients reviewed in this report were minorities; one infant was Hispanic and the other five were African American. The authors appear to omit from their conclusion the possibility that racial and ethnic differences may be a barrier to effective communication between clinicians and patients/families. Such potential communication gaps and challenges have been earlier explored and documented in the literature. In a paper specifically describing the implementation of the Texas Advance Directives Act, Truog emphasized that, 'Many of these cases are the product of a severe breakdown of trust in the relationship between the clinicians and the patient's family. Even in the best circumstances, physicians often communicate poorly, and this deficiency is exacerbated when the communication must occur across the gaps created by language, class, and culture.' 2 Studies have shown that physician communication in the intensive care unit is often ineffective, with up to half of patients' families showing a poor comprehension of the intensive care unit diagnoses and treatments. 3 The lack of effective communication at the end of life may be amplified when differences exist in the cultural or ethnic backgrounds of physicians and their patients or families. It has been shown that racial and ethnic disparities between physicians and patients can be barriers to effective communication. 4,5 In addition, there are significant differences in end-of-life preferences among different ethnic groups. Multiple

Is There Ever a Role for the Unilateral Do Not Attempt Resuscitation Order in Pediatric Care?

“…17–19 Others have called the statute biased and unfair, as committees reviewing the cases sided with the clinicians in >90% of cases, 20,21 and in the only published report of pediatric patients for whom the law was applied, all patients were either Hispanic or African-American. 22,23 Such findings raise significant concerns about justice and equity, two considerations of great importance in modern medical care.…”

“…A recent policy statement put forth by the Society of Critical Care Medicine minimizes the significance of these differential beliefs, 2 and experience with the Texas Advance Directives Act has done little to assuage these concerns. 23,46…”