End-of-Life Decisions and Doctor’s Dilemma

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End-of-Life Decisions and Doctor’s Dilemma

What would doctors respond when a patient’s Living Will go against relatives’ wishes?

Legally, this is not a tough question.  A Living Will is a document written by a person when still legally fit to do so requesting to refuse medical treatment. A Living Will is supported by Section 12 of the National Health Act, B.E. 2550 (A.D. 2007), which states that “A person shall have the right to make a Living Will in writing to refuse the public health service which is provided merely to prolong his/her terminal stage of life or to make a Living Will to refuse the service as to cease the severe suffering from illness.”

In practice, however, many problems arise once there are conflicts between the patient’s will and relative’s expectation to prolong the patient’s life.  While doctors would like to act according to the patient’s wish, it is likely that they face the risk of being sued by patient’s relatives. This has resulted in doctor’s dilemma and hence the demands on having clear guidelines so that they can act appropriately.

A Living Will is a constitutional right of a patient to die at the end stage of life as he or she wishes, says Surasit Sangviroatjanapat, chief judge of the Office of the President of the Supreme Court.  But when doctors withdraw life support, do doctors face any legal offense? This question, in Surasit’s opinion, needs to be pondered deeply among people in our society, taking into consideration different experiences in other countries.   He cites a case in Germany last year, when relatives of a patient sued a team of doctors who removed feeding tube from a patient in coma.  The court decided that doctors are not guilty.

Meanwhile Public Prosecutor Dr. Uthai Athivej of the Office of the Attorney General, views that although Section 12 of the National Health Act protects medical professionals, practical processes must be in compliance with regulations and methods specified in the Ministerial Regulations, which doctors need to understand profoundly and clearly.

The Section 12 of the National Health Act is designed with respect on dignity of all terminally ill patients to have the right to end their lives without unnecessary physical and mental suffering.  It allows palliative care for improved wellbeing at end stage of life.  However, despite being enforced for more than a decade, in practice most of terminally ill patients in Thailand are either ignorant to or have no access to other options like palliative care.   A study from Thai Palliative Care Association finds that 18% of hospital patients are terminally ill patients, only 17% of which is under palliative care.

“A survey in ICU rooms found that half of ICU patients and 20% of patients in hospital wards do not receive palliative care. They are unconscious and waiting end of life with life support devices. This, in fact, causes unnecessary sufferings to both patients and relatives, as well as the healthcare fund system.  I believe good management of palliative care can bring about good family relationship and then laws are no longer necessary because we have no intention to end patients’ lives. We only wish to lessen their suffering and let them die naturally,” says Assoc. Prof. Dr. Srivieng Pairojkul, president of Thai Palliative Care Association.

All involved parties should join forces in making doctors’ guidelines in compliance with the Section 12, Assoc. Prof. Dr. Srivieng wishes.  “At present, we do not have any guideline. And it is necessary for hospitals to appoint ethics committees in cases where doctors cannot make decisions or where conflicts arise among patient’s relatives.  If relatives’ wishes go against the patients’ will, it is the ethics committee, and not doctors, who needs to talk to and consult with patient’s relatives.”

By HRDO Team