Opinion ID: 2262015
Heading Depth: 1
Heading Rank: 8

Heading: court intervention in the decision to terminate life support

Text: This is a guardianship case. Pursuant to Maryland Code (1974, 1991 Repl.Vol.), Estates and Trusts Art., ง 13-708(c), where there is a guardianship the court must authorize withdrawing medical procedures which would involve a substantial risk to the life of the disabled person. The majority appropriately points out: We emphasize that this case does not deal with a terminally ill patient[ [2] ] who has neither a living will nor a durable power of attorney, who has no guardian, and whose family and health care providers are in agreement about the use or discontinuance of life-sustaining measures. (Footnote added). 329 Md. at 204 n. 4, 618 A.2d at 752 n. 4. Where an incompetent patient is in a persistent vegetative state or is terminally ill and there is no designated guardian, then those closest to the patient, if unanimous, should be able to make the decision to terminate life support without judicial intervention. The courts are less suited than the patient's loved ones, acting with concurrence of the patient's physicians, to make these decisions. Most authorities agree that there is no need for judicial approval if there is a unanimous decision by those closest to the patient and the patient's health care providers that life support should be terminated. See, e.g., State Justice Institute, Guidelines for State Court Decision Making in Life-Sustaining Medical Treatment Cases Guideline 3, at 36-37 (2d ed. 1992) (trial court should decline jurisdiction unless it finds parties are not in agreement as to patient's actual or probable wishes); American Bar Association, Standards Relating To Trial Courts ง 2.73.5, at 122-23 (1992) (Disputes regarding a decision to forgo, continue, or withdraw life-sustaining medical treatment (LSMT) preferably should be resolved without court involvement, and the commentary to that standard indicates [m]ost LSMT decisions are made by the patient or the patient's family and the health care provider without recourse to the courts.); M. Yuen, Comment, Letting Daddy Die: Adopting New Standards for Surrogate Decisionmaking, 39 UCLA L.Rev. 581, 600 (1992) (Although several courts initially suggested that the judicial system was the appropriate forum to decide whether life-sustaining treatment could be withdrawn from an incompetent patient, courts have more recently declined to require judicial intervention as a prerequisite to [the family and attending physicians] making such decisions. (Footnote omitted)); K. Opperman, Note, Termination of Life-Sustaining Treatment: Who and How to Decide?, 33 N.Y.L.Sch.L.Rev. 469, 479 (1988) (Most treatment decisions for the incompetent patient are highly private decisions made by family and physicians who follow the termination of life-sustaining treatment guidelines of the institution where they practice. Logically, if all parties are acting in good faith, this is where treatment decisions should remain. (Footnotes omitted.)); see also Conservatorship of Morrison, 206 Cal. App.3d 304, 312, 523 Cal. Rptr. 530, 535 (1988) (Judicial intervention in `right-to-die' cases should be minimal.... [C]ourts should intervene only if there is disagreement among the conservator and other interested parties and they have exhausted all nonjudicial efforts to resolve the dispute. (Emphasis in original)); Conservatorship of Drabick, 200 Cal. App.3d 185, 198, 245 Cal. Rptr. 840, 847 (Patients make their own treatment decisions with the advice of their physicians. Family members, and sometimes other persons, participate when the patients cannot. Courts, on the other hand, become involved only when ... there are disagreements.), cert. denied, 488 U.S. 958, 109 S.Ct. 399, 102 L.Ed.2d 387 (1988); In re L.H.R., 253 Ga. 439, 321 S.E.2d 716, 722-23 (1984) (hospital was required to remove life supports from infant in vegetative state per wishes of parent and guardian ad litem ); Matter of Lawrance, 579 N.E.2d 32, 41-43 (Ind. 1991) (Parents were permitted, without court approval, to withdraw nutrition and hydration from a never-competent patient in a persistent vegetative state. The court stressed that judicial intervention is not appropriate when physicians and family members are in agreement, and noted that medical ethics and professional regulations provide safeguards against any abuse.); Matter of Jobes, 108 N.J. 394, 529 A.2d 434, 451 (If a disagreement arises among the patient, family, guardian, or doctors, or if there is evidence of improper motives or malpractice, judicial intervention will be required. We expect, however, that disagreements will be rare and that intervention seldom will be necessary.), stay denied, 483 U.S. 1036, 108 S.Ct. 6, 97 L.Ed.2d 796 (1987). Jobes cites surveys that strongly support the desirability of family members making medical decisions for incompetent persons. It concludes that [e]very recent survey that we have found indicates that society believes that a patient's family members should function as his or her surrogate decisionmakers. Jobes, 529 A.2d at 446 n. 11. There is, of course, the danger that uncaring selfish family members will be motivated by a desire to get rid of incompetent relatives who are unwanted and burdensome. The safeguard in this situation will be that health care providers probably will not concur and should require court approval if they believe the family is not really acting in good faith and in accord with the patient's probable views. In addition, Maryland statutes require all hospitals to have Patient Care Advisory Committees, sometimes called Ethics Committees. Md.Code (1982, 1990 Repl.Vol., 1992 Cum.Supp.), Health-General Art., งง 19-370 to 19-374. The committees have, at a minimum, one physician and one nurse, neither of whom is directly involved with the patient's care, as well as one administrator and one social worker. These committees could review a family's request to withdraw life-sustaining medical treatments for a patient if there is any question about whether the request is appropriate or made in bad faith. As long as there is no guardian appointed, the great weight of authority holds that there is no need for judicial approval for decisions to terminate life support of an incompetent patient who is terminally ill or in a persistent vegetative state when the family and the health care providers are in agreement on the decision. The obvious reason for permitting those closest to the patient to make this decision is that they are in the best position to determine what the patient would have chosen if the patient were able to make the choice. Since the unanimous opinion of those closest to the patient is almost universally accepted as the basis for a decision to terminate an incompetent patient's treatment when there is no guardian, the same criteria should be used by the court as a basis for a decision to terminate an incompetent patient's treatment where there is a guardian.