Atul Gawande - this Saturday at the New Yorker Festival

This Saturday at 10:00 a.m., Atul Gawande will be speaking at the New Yorker Festival on "How to Live when You Have to Die."  You can watch the event through FORA live and for 30 days afterward for $4.95.

Doctor Providing Futile Treatment Loses License

The UK General Medical Council struck off Robert Trossel.  The GMC found that he had provided treatments that were "unjustifiable on the basis of evidence, inappropriate, not in the best interests of patients and exploitative of vulnerable patients." (Daily Mail)

Black Patients Get More Unwanted Life-Prolonging Care at the End of Life

Jennifer Mack and colleagues just published a study in the Archives of Internal Medicine, showing that despite similar rates of end-of-life discussions (black vs white patients), more black patients than white patients received life-prolonging EOL care. Black patients with DNR orders were no less likely than black patients without DNR orders to receive life-prolonging EOL care.  The authors conclude:  "End-of-life discussions and communication goals seem to assist white patients in receiving less life-prolonging EOL care, but black patients do not experience the same benefits of EOL discussions.  Instead, black patients tend to receive life-prolonging measures at the EOL even when they have DNR orders or state a preference for symptom-directed care."

Betancourt Is Published in A.3d

The New Jersey Appellate Division's opinion in Betancourt v. Trinitas Hospital was published in West's Atlantic Reporter:  1 A.3d 823, 415 N.J.Super. 301.

Disregarding the Family and Deciding to Pull the Tube

In the latest issue of the Journal of the American Board of Family Medicine, Dr. Jennifer Frank has a moving first-person story of how she decided to disregard a family's request and pull the feeding tube that "was likely to only prolong the poor quality of life" of her profoundly demented patient.  While she was initially prepared to accede with the rest of the treatment team, she found that she could not do it after the patient said "Please, no. No."  Interestingly, her attending concurred with her decision:  "I disregard the family's requests if they go against what the patient would want or if I think it is futile care."  The first reason, when there is evidence for it, is usually better grounded than the second.  I explore this in "Surrogate Selection: An Increasingly Viable, But Limited, Solution to Intractable Futility Disputes," for which I just got the revised and edited draft.

The Standard of Care Retards Improvement

This article by Daniel Merenstein in the January 2004 JAMA nicely illustrates the limits to most statutory safe harbors to refuse inappropriate end-of-life medicine.  The safe harbors are linked to and contingent upon standard of care.  But the standard of care is often to provide aggressive end-of-life treatment.  The legal definition of standard of care protects the continued use of outdated protocols.  As Merenstein writes:  "In our legal system, the physicians who are slow to change are the winners."

A Summit on Medical Futility: Medicine, Ethics, & Law

This conference (called a "summit") at Connecticut's Hartford Hospital, next month, looks superbly constructed to move beyond mere education and onto transformative change.  It looks like a great model for other states to follow.  Indeed, several other states are already planning such workshops.  The conference is focused on "solutions" and on "the future."

• Solutions: Physicians from Yale University Medical Center, Bridgeport Hospital, as well as an attorney from the Harvard Division of Medical Ethics will present their solutions to balancing and respecting the medical judgments of physicians and the preferences of patients and/or their decision makers when life support interventions are the focus.


• The Future: Lawyers and an government representative will discuss possible approaches to reconciling physicians’ obligations to maintain their professional integrity while taking into account CT law.

The conference description states:  "Physicians are not morally obligated to provide medical interventions, e.g., life support systems like CPR or artificial ventilation, that they do not think are medically indicated, will offer no benefit, or may cause harm – BUT are they legally obligated to provide them? Who decides based on what criteria?  The purpose of this Summit is to gather persons from the disciplines of medicine, law, and ethics from around the state of Connecticut to begin the discussion needed to reconcile the problem of hospital-based medical futility and to shape a program of action."  Here is the schedule:

• 7:30 - 8:00 am Registration (no fee) &; Breakfast


• 8:00 – 8:10 am Statement of the Issue - Dr. Harold Schwartz


• 8:10 – 8:30 am Paradigm/Exemplar Case - Medical Futility Defined; AMA Recommendations - Dr. Barbara Bennett Jacobs


• 8:30 – 8:50 am Legislative Background to Removal of Life Support Systems - Chapter 368w Sec. 19a-570 through 19a-580g - The Honorable Robert Killian; Hartford Probate Court


• 8:50 -9:00 am Discussion with Panelists &; Participants


• 9:00 – 9:15 Short Break Panel Set-up/ Networking


• 9:15 – 10:15 am Panel: Solutions – Panel Moderator: Dr. Barbara Jacobs Dr. Mark D. Siegel - Yale New Haven Hospital - Dr. Harris Jacobs – Bridgeport Hospital - Attorney Carol Powers – Harvard Medical School Division of Medical - Ethics Community Ethics Committee


• 10:15-10:45 Discussion with Participants


• 10:45 – 11:45 Panel: The Future – Panel Moderator: Dr. Hank Schwartz - Attorney Zita Lazzarini (UConn Health Center) - Attorney Joan Feldman (Shipman & Goodwin) - Jonathan Harris (5th District Senator; Co-Chair Public Health Committee)


• 11:45 – 12:15 pm Discussion with Panelists &; Participants


• 12:15– 12:45 pm Summit Summary - Dr. Michael Drescher

New Case - Wheelock v. Doers (Tenn. App. 2010)

This week, the Tennessee Court of Appeals issued its opinion in Wheelock v. Doers.  Basically, providers allegedly both wrote a DNR order and then later refused to perform CPR even at the specific and vocal instruction of the family and appointed agent.  It is a factually complicated case, with questions of causation and advance directive authority.  But at the trial level, the judge was squarely looking at the medical futility questions.

• We have had a great deal of discussion here about medical services and the request of medical care providers as to whether there can be a cause of action for not providing medical services that a health care provider finds are not within those services required to be given under the standard of care, but at this point I don't believe the law of this state allows a patient or others to bring an action against a health care provider for not providing services that, within the standard of care, would not have been provided.


• And the classic, the easiest example I can think of it, we talked about something specific in this case, but I think we're going to get away from it, so the issue is clearly identified. A patient walks in and says I want a full-body MRI to find out if I have got cancer anywhere. And a health care provider, it could be one of several different types, under the standard of care is not required and will not order that service because that's not required of the standard of care.


• Can that health care provider then be sued for not providing the service requested of them that is available and can be given, but is not necessary under the standard of care? I think the answer at this point is no. And there is a lot of reasons-you can say no and yes in regard to that question, but I think at present there has been no indication that there is a cause of action for that in Tennessee.


• Just because a patient says I want it, does that mean you have to give it and continue giving it to when? But those are the reasons why it is left to the standard of care in the health-care industry, be it the nurses' standard of care or the doctors,' the reason why that's left to that decision.

NJ Appellate Law Blog on Betancourt v. Trinitas Hospital

A New Jersey appellate law blog does a nice job summarizing the Appellate Division's decision in Betancourt v. Trinitas Hospital.  "The trial judge concluded that the hospital should not make the medical decisions for Betancourt but rather they should be made by a surrogate who could take his personal views and values into account in deciding what treatment was appropriate. Therefore, the judge granted the plaintiff’s application and ordered the defendant to not withhold treatment. . . .  The Appellate Division granted the [plaintiff's] motion and dismissed the defendant’s appeal."

Washington State - A Fairer Due Process Approach to Futility Disputes

The Washington State Medical Association annual meeting is next week.  The Executive Committee of the WMSA has recommended that the House of Delegates adopt AMA opinion 2.037 -- with minor amendments.  The WMSA Committee found that the AMA policy "overlooks certain essential elements of due process which should be added to achieve the stated goal of due process."  The WMSA proposed language is certainly an improvement.  But it still does not go far enough to constitute what the Committee calls a "true due process policy."  The nature of the institutional review is still wholly undefined.  Who is on this committee?

Symbolic Resuscitation, Medical Futility, and Parental Rights

On Monday, PEDIATRICS posted a to-be-published debate article between Joel Frader, Eric Kodish, and John Lantos. The debate is whether a DNR order is appropriate for a 2-year-old girl with septo-optic dysplasia, microcephaly, seizure disorder, and other issues.  The parents are developmentally delayed and do not have custody.  Both the grandmother, who has custody, and the state child protection agency agree with the DNR order, if the hospital ethics committee approves it.  A second point of debate is over whether to do a ("symbolic") show code instead of a (more honest) no code for the sake of the parents.

Case Consultation Training (NJ)

The Tri-County Regional Ethics Committee, serving Burlington, Gloucester, and Camden counties in New Jersey, will be offering a case consultation training on September 24th.  More information here.  





TREC is also offering an all-day conference, "Professional Viewpoint in End-of-Life Ethical Dilemmas,"  on Wednesday, November 17th in Runnemede, NJ.  Attorney Jeroold Rothkoff will discuss "Legal documents needed to avoid a crisis."  Social worker Marcie Cooper will "Controversies in health care ethics."  And physician Stephen Goldfine (also CMO at Samaritan Hospice and NJ HPO Hospice Physician of the Year) will discuss "Aspects of communication in quality end-of-life care: difficult conversations."

Bill Gates on Limiting End-of-Life Treatment to Save Public Education

In July, Bill Gates spoke at the Aspen Ideas Festival.  The full video is here.  The excerpt below is a clip where Gates says that we must examine the tradeoffs that we are already now making between end-of-life care (billed to Medicaid and Medicare) and other public goods like primary and university education.  We are spending increasingly more on the former, says Gates, at the expense of the latter.

“The access that used to be available for the middle class is just rapidly going away,” Gates said. “That's a trade-off that society is making because of very, very high medical costs.”  The country has demonstrated an unwillingness to question if “spending $1 million on the last three months” of a person's life is a cost-effective direction, especially considering the same amount of money can keep 10 teachers employed. Gates called for the nation to do a better job of examining the benefits of costly end-of-life medical care.  “That's called the death panel and you're not supposed to have that discussion.”

Berwick: "I Plan No Rationing"

Dr. Donald Berwick, the new CMS head, told health insurance executives in Washington yesterday that he does not advocate rationing or major "top down'' government solutions to transform the health care system.  In his first major speech since President Obama named Berwick with a recess appointment in July, Berwick said he does not support withholding care from Americans as means of controlling costs.  "I want lower costs without harming a hair on any patient's head," Berwick added. (Wall Street Journal)

Palliative Care Grand Rounds (Sept. 2010)

This month's Palliative Care Grand Rounds (a collection of some of the best recent relevant blog posts) was posted here last week.  

Wawrzyniak v. Livingstone & Sunnybrook Health

I posted a copy of the Complaint (aka Statement of Claim) in Wawrzyniak v. Livingstone & Sunnybrook Health here.  While the Toronto Star made the medical staff's conduct here seem rather culpable, the allegations in the Complaint go even further.  Yesterday, the Toronto Star printed a number of predictably angry letters.  A few excerpts:

• "My visits to several hospitals in Toronto have taught me that if you are frail and elderly in a hospital, the care will be good, but don’t expect heroics to keep you alive."


• "I remember the American scare tactics about “death committees” ingovernment-funded health care and how amazed I was to hear something so ridiculous. Well now, we don’t even have committees."

Futility and Nurses' Moral Distress

In the latest Dimensions of Critical Care Nursing, Ruthie Robinson reviews studies that show medical futility is the leading cause of moral distress among nurses.  Nurses suffer moral distress because they "know the right thing to do" but institutional constraints make it nearly impossible to pursue that right course of action.  Quotes from the studies include:  "I often equate my job with keeping dead people alive." and "[I]t was like ventilating a corpse."  





Robinson also reviews several models for addressing inappropriate treatment at the end of life.  While obviously concerned to avoid and address distress, Robinson is most concerned with the loss of experienced nursing staff.  I might observe, here, that a non-insignificant fraction of students in my health law classes each year are critical care nurses seeking to move to compliance or legal work.

Compassionate Care or Death Panel: The Dilemma of Futile Treatment in the ED

At the American College of Emergency Physicians conference later this month in Las Vegas:

Compassionate Care or Death Panel: The Dilemma of Futile Treatment in the ED (James D. Mills, Jr. Memorial Lecture) (WE-121)

Wednesday, September 29 ,  12:30 PM - 2:20 PM

We have all read the articles about “Death Panels.” The dilemma of futility in emergency treatment contributes to emergency providers’ emotional stress, primarily when people have unrealistic expectations. Do we have a moral and ethical obligation in regards to futile care? There needs to be fundamental change in how we practice, but how do we get there? During this course, the moderator will present cases to illustrate the dilemma of futility. The panelists will role-play, demonstrating the professional challenges arising from requests for futile treatment. They will illustrate techniques to define and communicate appropriate expectations in patient care to family and other professionals. Suggested strategies for implementation into your ED and community will be summarized in order to assist you in changing local medical and community standards.

Objectives:

• Debate when treatment in the emergency department is futile.


• Assess your professional role in determining futility.


• Demonstrate communication of appropriate expectations to families and other health care providers.


• Suggest strategies when confronting futility in everyday practice that can be implemented to change your local medical and community standards.

Faculty:

Arthur R. Derse, MD, JD, FACEP

Gregory L. Henry, MD, FACEP

Jerome R. Hoffman, MA, MD, FACEP

Gregory Luke Larkin, MD MPH FACEP

Daniel J. Sullivan, MD, JD, FACEP

West Virginia Leads the Nation in Advance Care Planning

While LaCrosse, Wisconsin has extraordinarily high ACP rates, those do not obtain state-wide.  In contrast, about 49 percent of West Virginians have completed an advance directive that outlines the level of care and type of treatment they wish to receive as they near the end of life.  "In West Virginia, we're leading the country in teaching doctors and nurses about how to talk to patients and families about their [options]," said Dr. Alvin Moss, director of the state's Center for End-of-Life Care and a professor of medicine at West Virginia University.   (Charleston Gazette)  So, what exactly does West Virginia do?

• Distributed 250,000 POST forms


• Statewide palliative care network , placing consultation teams in hospitals, nursing homes and hospice centers to provide information, help patients identify the appropriate person to appoint as their medical power of attorney, lead discussions on how much suffering a patient is willing to bear

Physicians' Fears of Malpractice Lawsuits Are Not Assuaged by Tort Reforms

The September 2010 issue of HEALTH AFFAIRS is devoted to medical malpractice.  One article seems particularly appropriate to medical futility disputes.  Emily Carrier and colleagues found that "Physicians' Fears of Malpractice Lawsuits Are Not Assuaged by Tort Reforms."

“The consequences of being sued are perceived as potentially disastrous to one’s medical reputation, psychological well-being, and financial stability. Finally, physicians tend to view lawsuits as random events, unpredictable and uncontrollable, because they are not viewed as related to the quality of care provided. These factors may lead to a fear of suits that seems out of proportion to the actual risk of being sued.”

“Although many medical professional organizations continue to press for liability-limiting tort reforms, we found that many such reforms were not associated with a significant difference in physicians’ malpractice concerns.”

When is Enough Simply Enough? Shining Light on Medical Futility Through Bernstein v. Superior Court

Phillip L. Kim published a new note in the SMU Science and Technology Law Review (Volume 13, Number 2, Spring 2010: 231):  “When is Enough Simply Enough? Shining Light on Medical Futility Through Bernstein v. Superior Court.”  The Bernstein case is worth reading (I blogged about it here in Feb. 2009).  Kim reviews the case and provides a little critical commentary, but does not add much that is not already in the court's opinion itself.

Wawrzyniak v. Sunnybrook Health - More About Communication than Standard of Care

In a recent review of end-of-life conflicts, John Luce notes that healthcare providers are overwhelmingly successful when sued for unilaterally refusing life support.  Similarly, Barry Swadron, the Toronto lawyer representing Wawrzyniak in her lawsuit against Sunnybrook Health, says her suit "could be the thin edge of the wedge in terms of doctors deciding who’s going to live and who’s going to die.”  But, by focusing on the standard of care issue, both Luce and Swadron may be missing what is most salient about this case. 

In his article, Luce focuses only on actions for medical malpractice.  But that is not the only legal theory under which families might proceed.  As I have argued here and here, the theory under which families are most often successful, in lawsuits for unilateral refusal of life support, is intentional infliction of emotional distress (aka outrage).  

While unilateral refusal itself has never been held per se outrageous, this case has elements of wrongfulness above and beyond unilateral refusal. Specifically, based on press coverage of the lawsuit, provider conduct here appears to have been both insensitive and secretive: 

• The daughter was not just overruled but was overruled "without consultation"  [This is not allowed in Texas, Virginia, California, or any other U.S. state permitting unilateral refusal.]


• A hospital representative admitted that the end-of-life policy does not allow doctors to make unilateral decisions "without communicating with the family"


• The daughter attempted to bag her father herself, while a doctor said "nobody will come"


• The patient's chart was changed from full code to DNR without consent or even explanation.  When confronted, a doctor said "This is for his own good."

New Case: Wawrzyniak v. Sunnybrook Health Sciences

Many recent medical futility dispute cases both in the United States and Canada have been ex ante cases.  In these cases the patient is still alive and one side or the other goes to court.  Sometimes, the patient's family is seeking an injunction ordering healthcare providers to continue life-sustaining treatment.  Other times, it is the provider who goes to court to seek a declaratory judgment or to replace the decision maker (e.g. through the CCB) who will not consent to the less aggressive treatment providers think appropriate.  

On the other hand, in ex post cases, the family sues for damages after providers have already proceeded to withdraw life support without the family consent.  Wawrzyniak v. Sunnybrook Health Sciences is this type of case. Joy Wawrzyniak has filed a $1 million lawsuit against Sunnybrook and two of its physicians.  The lawsuit claims that while Wawrzyniak and her father had repeatedly requested that he receive lifesaving treatment in case of a medical emergency, doctors unilaterally overruled those wishes without consent or consultation.  (Toronto Star)  

Barry Swadron, the Toronto lawyer representing Wawrzyniak, said her suit could set legal precedent in Canada.  “This could be the thin edge of the wedge in terms of doctors deciding who’s going to live and who’s going to die.”  Maybe.  But it is worth noting that providers have won almost all the ex post futility cases that have gone to court.

Privacy Quizzes

Assign 1 point for each NO answer.
_T__ It conducts a criminal or civil background check before hiring employees who will have access to personal identifying information and screens cleaning services, temp services, and contractors.
_T__ It provides cross-cut paper shredders at each workstation or cash register area for the disposal of credit card slips, sensitive data or prescription forms.
_T__ It "wipes" electronic files, destroys computer diskettes and CD-ROMs, and properly removes any data from computers before disposal.
_T__ It uses an alternate number instead of a Social Security numbers (SSNs) for employee, client and customer ID numbers.
_T__ It requires its health insurance providers to use an alternate number rather than the SSN for employee ID numbers on health insurance cards.
_T__ It has trained designated staff about security procedures in sending sensitive personal data by fax, email or telephone.
_T__ It places photos on employee business cards for better identification and security.
_T__ It keeps all personal data about employees and customers in locked cabinets.
_T__ It stores sensitive personal data in secure computer systems with access restricted only to qualified persons with a legitimate.
_?__ It has implemented electronic audit trail procedures to monitor who is accessing what and enforces strict penalties for illegitimate browsing and access.
_T__ It has installed encryption and other data safeguards for workplace mobile computers, such as laptops and PDAs, that contain files with sensitive personal data.
__T_ It has trained employees in how to receive personal identifying information from customers and clients without jeopardizing their security. For example, pharmacists who do not ask you to repeat your SSN aloud in a busy store.
_T__ It has a policy of never selling or sharing data about employees or customers.
_T__ It never asks for more data than absolutely necessary. For example, a health club does not need a SSN nor does a vet really need your driver's license number.
_T_ It does not print full SSNs on paychecks, parking permits, staff badges, time sheets, training program rosters, lists of who got promoted, on monthly account statements, on customer reports, you name it.
_T__ It notifies customers and/or employees of computer security breaches involving sensitive personal information.
_T__ It has developed a crisis management plan that includes instructions to prevent identity theft if SSNs and/or financial account numbers are obtained illegitimately or in case sensitive employee or customer data is lost, stolen, or acquired electronically.
_T__ It has adopted a comprehensive privacy policy that includes responsible information-handling practices and has appointed an individual and/or department responsible for the privacy policy, one who can be contacted by employees and customers with questions and complaints.

Are You at Risk for Identity Theft? Test Your "Identity Quotient"_F__ I receive several offers of pre-approved credit every week. (5 points)
_T__ I do not shred the pre-approved credit offers I receive (cross-cut shredder preferred) before putting them in the trash. (5 points)
_F__ I carry my Social Security card in my wallet. (10 points)
_T__ I use a computer and do not have up-to-date anti-virus, anti-spyware, and firewall protection. (10 points)
_T_ I do not believe someone would break into my house to steal my personal information. (10 points)
_F__ I have not ordered a copy of my credit reports for at least 2 years. (20 points)
_F__ I use an unlocked, open box at work or at my home to drop off my outgoing mail. (10 points)
_T__ I do not have a P.O. Box or a locked, secured mailbox. (5 points)
_F__ I carry my military ID in my wallet at all times. (It may display my SSN.) (10 points)
_T__ I do not shred my banking and credit information, using a cross-cut “confetti” shredder, when I throw it in the trash. (10 points)
_F__ I throw away old credit and debit cards without shredding or cutting them up. (5 points)
_T__ I use an ATM machine and do not examine it for signs of tampering. (5 points)
_F__ I provide my Social Security number (SSN) whenever asked, without asking why it is needed and how it will be safeguarded. (10 points)
_F__ Add 5 points if you provide it orally without checking to see who might be listening nearby.
F___ I respond to unsolicited email messages that appear to be from my bank or credit card company. (10 points)
_T__ I leave my purse or wallet in my car. (10 points)
F___ I have my driver's license number and/or SSN printed on my personal checks. (10 points)
T___ I carry my Medicare card in my wallet at all times. (It displays my SSN.) (10 points)
F___ I do not believe that people would root around in my trash looking for credit or financial information or for documents containing my SSN. (10 points)
__F_ I do not verify that all financial (credit card, debit card, checking) statements are accurate monthly. (10 points)



Thank You for taking the SonicWALL Phishing IQ Test
# Subject Your Answer Correct Answer Test Result Explain Answer
1. Paypal Legitimate Phishing
2. Wells Fargo Legitimate Legitimate
3. IRS Phishing Phishing
4. Discover Card Legitimate Phishing
5. Bank of Choice Phishing Legitimate
6. Downey Savings Phishing Phishing
7. Yahoo Phishing Phishing
8. UPS Legitimate Legitimate
9. Paypal Phishing Phishing
10. IRS Phishing Phishing
You got 7 out of 10 correct.
70%

Ilovemyninja

Tell Me the Truth: Conversations with my Patients about Life and Death

In a book published earlier this month by Penguin titled, Tell Me the Truth: Conversations with my Patients about Life and Death, Australian oncologist Ranjana Srivastava discusses end-of-life communication.  





In a recent interview in the Sidney Morning Herald, Srivastava explains: "we do not talk to our patients as fully as we ought or when we fail to address their concerns that we know lurk beneath the surface - sometimes because we lack the time, but often because we are unsure how to do so.''  She continues:  ''We spend a lot of money on futile medicine and intensive care at the end of life and if we have limited resources like every nation does, we need to be thinking about how those resources are best allocated. I think investing in palliative care and boosting support services for sick people is very important. Those things should not be an adjunct."  

Cancer patients put up with the most and complain the least, endowed with an uncommon wisdom that is a privilege to observe. It is not simply that they see the big picture; if you spend long enough with them, they help you see it too.'

What really happens when someone hears the words, 'You have cancer?'  What has preceded it and what comes after? Written with great compassion and honesty, this is a rare view from the other side of the desk. Oncologist Ranjana Srivastava reflects on the very human side of the medical profession – the moral dilemmas, the anxieties, the empathy  – and shows us that the best doctors are the ones who keep learning by listening to their patients.

This book is much more than an oncologist's diary; it is an acknowledgement of the incredible courage of ordinary people as they confront the big issues of life and death.

Regulating Physician Behavior: Taking Doctors’ 'Bad Law' Claims Seriously

Sandra Johnson's superb article, "Regulating Physician Behavior: Taking Doctors’ 'Bad Law' Claims Seriously," was just posted to SSRN, making it more readily accessible to non-lawyers.  This article is a masterful review and elucidation of deep legal problems underlying medical futility disputes.  Here is the abstract.  

Physician behavior is a key target of government regulation intended to improve the efficiency, quality, and accessibility of health care. Yet according to physicians’ “bad law” claims, the legal effort to promote patient health and well-being has actually caused significant harm. These “bad law” claims - that malpractice litigation prompts defensive medicine, that patients’ rights policies prompt doctors to provide futile care, that controlled substance laws cause physicians to undertreat patients in pain - have diminished in significance due to the deconstruction of professionalism. Claims are often discarded as the cries of “bad apple” doctors or in the interest of creating a more egalitarian or consumer-oriented model of medicine.

This article argues that physicians’ “bad law” claims should be taken seriously. The way physicians react to legal requirements can negatively impact the effectiveness of the law and the quality of patient care. Thus physician behavior must be included as an important factor in the effort to evaluate and improve the performance of the law. Taking seriously physicians’ “bad law” claims is a first step to understanding how physicians react to legal risks and consequently, how well laws perform.

This article begins by addressing the dynamic relationship between the health law reform agenda and the medical profession.  Part II considers categories of physicians’ “bad law” claims, recognizing that some may be dishonest or misinformed but arguing that many claims have credence as legitimate responses to extralegal shadow systems or truly harmful legal standards.

Part III assesses common responses to physicians’ “bad law” claims. Providing specific examples, the article argues that current responses - e.g. educating doctors on the law; immunity statutes; safe harbor provisions - are inadequate because they fail to account for the realities of the medical professional or the nature of the law.

Finally, Part IV makes two recommendations for taking physicians “bad law” claims seriously and thereby effectively evaluating and improving the reform effort. First, it advocates evaluating the law through its population-based effects on physician behavior. Second, it recommends tailored monitoring and investigative processes that allow formal legal standards rather than policy decisions to govern the regulatory process.

Right to Know (aka R2K) Laws

Dominic Wilson at Oxford chastises the United States for enacting laws that "should not be."  He finds it "astounding that a state" -- he focuses on New York -- "feels that it is necessary to legislate to make doctors do what they should be doing anyway."  After all, Wilkinson notes, "the United States has enshrined autonomy as the keystone of medical ethics." 

Alas, common law duties of informed consent have not proven sufficient to induce physicians to discuss end-of-life options with patients.  Sure, New York's new "right to know" or R2K law is awkward (and perhaps offensive to healthcare providers) in that it legislates the content of the physician-patient relationship.  But the failure to empower patients about these very important decisions is so widespread that legislation has become necessary.  

New York joins California and Vermont, which also have R2K laws:

• N.Y. A.B. 7617 (2009) (Gottfried), enacted as Ch. 331, codified at N.Y. Pub. Health Law 2997-C.


• Cal. A.B. 2747 (2009) (Berg), codified at Cal. Health & Safety Code § 442.5.


• Vt. H.B. 435 (2009) (Patient Bill of Rights for Palliative Care and Pain Management), enacted as Vt. Laws No. 25, codified at Vt. Stat. tit. 18 § 1871

Bills have been introduced in other states, Including Arizona and Maryland:

• Ariz. S.B. 1311, 49^th Leg. (2009).


• Md. H.B. 30 (2009) (Bobo & Manno)

IQ tests

1. Microsoft Email Link
Legitimate ... CORRECT

2. PayPal Email Link
Fraud ... CORRECT

3. eBay Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

4. US Bank Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

5. PayPal Email Link
Fraud ... INCORRECT
(The correct answer was Legitimate)

6. Earthlink Email Link
Legitimate ... INCORRECT
(The correct answer was Fraud)

7. Citibank Email Link
Fraud ... CORRECT

8. eBay Email Link
Fraud ... CORRECT

9. Paypal Email Link
Legitimate ... CORRECT

10. Visa Email Link
Fraud ... CORRECT
You got 6 out of 10 correct, or 60 %



These were my scores for my mailfrontier test.
On the identity theft IQ test I scored 55 and 50-99 is considered average
On the workplace identity theft IQ test I had 1 “NO” answer

TWEEDLEDEE

Online Therapy

Serenity Online Therapy

Serenity Online is for counseling and is a professional secure website. Carl Benedict in the state of Maryland is a (LCPC) which stands for Licensed Clinical Professional Counselor and is a therapist in clinic for mental health for 12 years. With Serenity Online, Carl offers e-mail and chat therapy. Carl is counseling philosophy believes in wisdom for everyone and helps discover wisdom in individuals. Carl facilitates process through active listening as he strives to understand his or her life from the inside out and helps to develop emotional intelligence, the ability to skillfully utilize feelings to create a more fulfilling life (Benedict, 2010). To begin counseling through Serenity Online the individual must be 18, must not be suicidal to others, and must read the services available to him or her. An individual wanting chat therapy must complete a background questionnaire and pay for the first session fees and after 48 hours of fee paid Carl will e-mail to set up first appointment for chat therapy. An individual wanting e-mail counseling it is the same steps as chat therapy, but a step that has to be done is the submission form and Carl will send after payment a one to three page counseling professional paperwork. As of right now Carl is only accepting chat therapy.

Twinkie

The Growth of the "Bad" Patients

In her new book, The Empowered Patient, Elizabeth Cohen encourages people to "be the bad patient," one who pipes up and questions the physician.  This morning's USA Today, reports that more empowered patients question their doctor's orders.  The article focuses on diagnostic testing, but this greater involvement surely applies more broadly, including to end-of-life care.

Philip Nitschke: Upcoming North American Public Meetings

The Peaceful Pill Handbook Newsletter

New Digital Edition You can order the eHandbook from our website: Print Edition The book can be ordered from these vendors: Exit Safe Suicide Meetings & Workshops Nth America Tour 2010 Meetings & Workshops with Dr Philip Nitschke MD PhD Public Meetings provide an outline of the legislative history & current political status of Safe/ Assisted Suicide. These meetings are free & open events (11am - 12 noon). Safe Suicide Workshops follow immediately from Public Meetings & provide the latest end of life information for Seniors, the Seriously Ill & their Families based on the Peaceful Pill eHandbook updates on practical end of life issues (1 - 4pm). Topics Covered Includes the latest research on: •  The Barbiturates: Sources, Storage, Testing & the Ohio Single Drug Protocol •  Gases: Helium, Nitrogen, Argon - the physiology of hypoxia, flow rates & detection, the role of carbon dioxide •  Peaceful Poisons: Carbon Monoxide, Cyanide - Production, Risks, Safety Procedures •  Other Options - Prescription and Non-Prescription Substances - Combinations, Substitutes, Warnings Meeting Dates & Venues Vancouver - Canada Thursday 7  October, 11am - 4pm (Public Mtg 11am - 12 noon; Workshop 1 - 4pm) Unitarian Church of Vancouver 949 49 Ave West, Vancouver, BC, V5Z 2T1. Toronto - Canada Wednesday 13  October, 11am - 4pm  (Public Mtg 11am - 12 noon; Workshop 1 - 4pm) Workman Hall, 1st Unitarian Congregation of Toronto 175 Claire Ave St West, Toronto, ON, M4V 1P7. New York, NY Wednesday 20  October, 11am - 4pm (Public Mtg 11am - 12 noon; Workshop 1 - 4pm) Community Church of New York 40 East 35th St, New York, New York 10016. Orlando, FL Saturday  23  October, 11am - 4pm (Public Mtg 11am - 12 noon; Workshop 1 - 4pm) A Gathering Place, 1st Unitarian Church of Orlando 1901 Robinson St East, Orlando, Florida 32803. San Francisco, CA Friday 5  November, 11am - 4pm  (Public Mtg 11am - 12 noon; Workshop 1 - 4pm) Audre Lorde Room, Women's Building 3543 18th Street #8, San Francisco  CA  94110. Attendance Exit Members  - Free Exit Membership - $100 (per annum, includes workshop) (US$/ Ca$) Subscribers to Peaceful Pill eHandbook - $40 (US$/ Ca$) Non Members - $60 (US$/ Ca$) Bookings eMAIL:      contact@exitinternational.net OR CALL:        1-248-809-4435 OR FAX:          1-360-844-1501 OR MAIL: Download form (Canada & US)  - click HERE and Mail to:       Exit International US               PO Box 4250                  Bellingham WA 98227               Web: www.exitinternational.net          &      www.peacefulpill.com Note: Exit reserves the right to refuse entry to any person for any reason. Photo ID may be requested on the day.