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Alternative Treatments

Alternative or complementary medicine is a common term for health practices which are generally not available from modern physicians and hospitals. The physician should not abandon the patient who elects to try an alternative treatment. Requests by patients for alternative treatment require balancing the medical standard of care with a patient’s right to choose care on the basis of his or her values and preferences.

Such a request warrants careful attention from the physician. Before advising a patient, the physician should ascertain the reason for the request, for example, whether it stems from dissatisfaction with current care. The physician should be sure that the patient understands his or her condition, standard medical treatment options and expected outcomes.

The physician should encourage the patient requesting alternative treatment to seek literature and information from reliable sources. The patient should be clearly informed if the option under consideration is likely to delay access to effective treatment or is known to be harmful. The physician need not participate in the monitoring or delivery of alternative care to the patient. However, physicians should recognize that some patients may select alternative forms of treatment. This decision alone should not be cause to sever the patient–physician relationship.

Disability Certification

Some patients have chronic, overwhelming or catastrophic illnesses. In these cases, society permits physicians to justify exemption from work and to legitimize other forms of financial support.

In keeping with the role of patient advocate, a physician should assist a patient who is medically disabled in obtaining the appropriate disability status. Disability evaluation forms should be completed factually, honestly and promptly.

Physicians will often find themselves confronted with a patient whose problems may not fit standard definitions of disability but who nevertheless seems deserving of assistance (for example, the patient may have very limited resources or poor housing). Physicians should not distort medical information or misrepresent the patient’s functional status in a misguided attempt to help these patients. The trustworthiness of the physician is jeopardized, as is his or her ability to advocate for patients who truly meet disability or exemption criteria.

Care of the Physician’s Family, Friends and Employees

Physicians should avoid treating themselves, close friends or members of their own families. Physicians should also be very cautious about assuming the care of closely associated employees. Problems may include inadequate history taking or physical examination as a result of role–related discomfort on the part of patient or physician. The physician’s emotional proximity can result in a loss of objectivity. If a physician does treat a close friend, family member or employee out of necessity, the patient should be transferred to another physician as soon as it is practical. Otherwise, requests for care on the part of employees, family members or friends should be resolved by assisting them in obtaining appropriate care. Fulfilling the role of informed and loving adviser, however, is not precluded.

Determination of Death

The irreversible cessation of all functions of the entire brain is an accepted legal standard for determining death when the use of life support precludes the use of traditional cardiopulmonary criteria. After a patient has been declared dead by brain-death criteria, medical support should ordinarily be discontinued. In some circumstances, such as the need to preserve organs for transplantation, to counsel or accommodate family preferences or to sustain a viable fetus, physicians may temporarily support bodily functions after death has been determined.

Organ Donation

There is an increasingly demanding need for organs and tissues. Physicians should be involved in community efforts to make potential donors aware of their option to make a gift that would enhance life, health or sight by organ or tissue donation. Physicians should obtain consent from the patient for the disposal and use of tissue, organs or other body parts removed during diagnostic or operative procedures. All potential donors should communicate their preference to their families and have it listed on such documents as driver’s licenses or organ donor cards.

Physicians caring for dying or brain–dead patients who are potential donors should inquire about whether the patient had expressed preferences about donation. Federal and state law and health care accreditation bodies require that hospitals have procedures to ensure that families of hospitalized potential donors are made aware of the option to consent to organ donation. The issue of organ donation often arises in very difficult circumstances and may carry significant symbolic import for the family. Physicians should approach families with sensitivity and compassion.

Furthermore, organ procurement raises ethical concerns about the determination of death that have been partly addressed by legislation that defines brain death. It can also create conflict or the appearance of conflict between the care of a potential donor and the needs of a potential recipient. The care of the potential donor must be kept separate from the care of a recipient. The potential donor’s physician should not be responsible for the care of the recipient nor be involved in retrieving the organs or tissue. However, the potential donor’s physician may alert an organ–tissue procurement team of the existence of a potential donor. Once brain death has occurred and organ donation is authorized, the donor’s physician should know how to maintain the viability of organs and tissues in coordination with the procurement team. Before declaration of brain death, treatments proposed to maintain the function of transplantable organs may be used only if they are not expected to harm the potential donor, whether by causing symptoms or by compromising the chance of survival.

Irreversible Loss of Consciousness

Persons who are in a persistent vegetative state are unconscious but not brain dead. Since their condition is not progressive, patients in a persistent vegetative state are not terminally ill. They lack awareness of their surroundings and the ability to respond purposefully to them. The prognosis for these patients varies with cause. Some physicians and medical societies believe that there are no medical indications for life–prolonging treatment or access to intensive care or respirators when patients are confirmed to be in a persistent vegetative state.

They conclude that these patients cannot experience any benefits or suffer any discomfort and that all interventions should therefore be withdrawn. However, many patients or families value life in and of itself regardless of the neurologic state. For these reasons, goals of care should guide decisions about life–prolonging treatment for patients in a persistent vegetative state in the same manner as for other patients without decision–making capacity.

Intravenous Fluids and Artificial Feedings

Artificial administration of nutrition and fluids is a life–prolonging treatment. As such, it is subject to the same principles for decisions as other treatments. Some stages of illness/diseases require high levels of proof before previous statements or advance directives can be accepted as firm evidence that a patient would not want these treatments in the setting of terminal illness, permanent unconsciousness, or advanced dementia. For this reason, physicians should counsel patients to establish advance care directives and complete these carefully. Clinically, there is unfounded concern that discontinuing the use of feeding tubes will cause suffering from hunger or thirst despite research findings to the contrary. Physicians should carefully address this issue with family and caregivers.