4. Catechism on Life

1. PATIENTS cannot oblige health-care providers to offer treatment  “contrary to generally accepted health care standards”.

4654.  This division does not authorize or require a health care provider or health care institution to provide health care contrary to generally accepted health care standards applicable to the health care provider or health care institution.

2. A HEALTH care provider may decline to comply with an individual health care instruction or health care decision for reasons of conscience or because the instructions are contrary to the policy of the institution.

4734. (a) A health care provider may decline to comply with an individual health care instruction or health care decision for reasons of conscience.

         (b) A health care institution may decline to comply with an individual health care instruction or health care decision if the instruction or decision is contrary to a policy of the institution that is expressly based on reasons of conscience and if the policy was timely communicated to the patient or to a person then authorized to make health care decisions for the patient.

4735.  A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution.

3. PHYSICIANS or institutions that decline to comply with advance directives must inform patients or surrogates and make efforts to transfer care to another provider

4736.  A health care provider or health care institution that declines to comply with an individual health care instruction or health care decision shall do all of the following:

    (a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient.

    (b) Unless the patient or person then authorized to make health care decisions for the patient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient to another health care provider or institution that is willing to comply with the instruction or decision.

    (c) Provide continuing care to the patient until a transfer can be accomplished or until it appears that a transfer cannot be accomplished.  In all cases, appropriate pain relief and other palliative care shall be continued.

2. Pope John Paul II

a. California law requires health care providers to comply with individual health care instructions and health care decisions of patients or, when appropriate, their surrogate decision-makers except:

 (1) When the decision of a patient or surrogate decision-maker would require medically ineffective health care; or

 (2) When the decision of a patient or surrogate decision-maker would require health care contrary to generally accepted health care standards; or

 (3) For reasons of conscience.

 b. Section D.1., below, describes the procedure that should be followed when a physician and a patient or a surrogate decision-maker disagree about the appropriateness of life-sustaining treatment for the patient.

a. Before a physician decides not to comply with an individual health care instruction or health care decision, the physician should make serious efforts to reconcile his/her views with those of the patient or the surrogate decision-maker.

b. If these efforts fail, the physician should convene members of the health care team, including consultants, nurses, social workers, clergy and others involved in the patient’s physical and spiritual care to meet with the patient/surrogate decision-maker and whomever the patient/surrogate invites in an effort to reach agreement. The facility’s bioethics committee or a similar body can be helpful in such situations by facilitating discussion and clarifying the issues.

c. If these efforts fail, the physician must:

(1) promptly inform the patient and/or the surrogate decision-maker;

(2) make all reasonable efforts to assist in transferring the patient to another physician who is willing to comply or to another facility; and

(3) provide continuing care until transfer can be arranged or until it appears that a transfer cannot be accomplished.

d. There is much disagreement among physicians and other health care professionals, lawyers and ethicists about the circumstances in which it is justifiable to forgo or continue life-sustaining treatment over the objections of a patient or surrogate decision-maker. The law does not define “medically ineffective health care” or “care contrary to generally accepted health care standards” nor does it clearly specify a course of action when the efforts to transfer the patient have failed. Therefore, facility policies and procedures, approved by both the hospital and the medical staff, should require all of the following elements:

 (1) that where the physician is unwilling to follow the patient’s or surrogate decision-maker’s wishes for reasons of conscience, it is the physician’s duty to transfer the patient to another physician who is willing to follow the patient’s or surrogate decision-maker’s wishes.

 (2) that when the physician’s decision not to comply with a patient’s or surrogate decision-maker’s decision concerning life-sustaining treatment is based on either “medically ineffective health care” or “care contrary to generally accepted health care standards,” the case is reviewed to ensure that the proposed actions are within the range of medically and ethically appropriate alternatives.

 (3) that the procedure by which the decision is implemented is clearly defined.

 (4) that legal advice is sought as appropriate.

e. In all cases, physicians must continue to order comfort measures, including pain relief and other palliative care.

f. If the matter remains unresolved, the physician should consult legal counsel.

1. In cases in which life-sustaining treatment is forgone, the medical record should include:

a. A clear statement in the physician’s progress notes of all relevant information concerning the treatment decision, including the treatment plan, the diagnosis and prognosis, and how they have been established, along with documentation of any consulting opinions that have been obtained;

b. A statement in the physician’s progress notes that documents discussions with a patient with decision-making capacity or with an appropriate surrogate decision-maker or a valid advance directive. In the case of a patient without capacity and without a surrogate decision-maker and who has not left instructions, the review described in Section D.2 above is documented.

c. A written order, if an order is required to effectuate the decision.

2. Decisions to forgo life-sustaining treatment should be made in accordance with any applicable facility policies and procedures.

1. Most cases involving the forgoing of life-sustaining treatment can be, should be, and are, resolved without the involvement of the courts.

2. However, when necessary, the courts may be approached to resolve legal disputes, such as when a physician believes that the surrogate decision-maker is not acting in the patient’s best interests or if the physician cannot choose among available surrogate decision-makers with similarly close relationships to the patient.

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