Public Health Law Map - Beta 5 - Medical and Public Health Law Site

Physicians made money by billing for patient visits and for doing procedures on
patients in the hospital. Although physicians have financial interests in life- support
decisions, their interests are not as great as those of hospitals. The physicians’
stakes are as much emotional as financial. Physicians are torn between the urge to
help specific identified patients avoid unnecessary suffering and a traditional
reluctance to talk to patients about death and dying. Until diagnosis-related groups
(DRGs) were introduced in the 1980s, physicians were rewarded by hospitals for
keeping patients on life support as long as possible because the hospitals were paid
based on the number of days the patient was hospitalized. Now irrespective of their
personal feelings, physicians are under pressure from hospitals, managed care
providers, and the federal government to save money by denying and terminating
life support. This pressure is directed at all patients, not just those who are clearly
terminally ill.
c) Hospitals
The growth of intensive care medicine has paralleled the growth of hospitals as
businesses. Hospitals have evolved from “physicians’ workshops” to independent
agents in medical care delivery. It is hospitals, rather than physicians, that bear the
financial impact of termination of life-support decisions. Most legal challenges to
termination of life-support decisions have been brought by hospitals rather than
physicians.
The most controversial issue in critical care medicine is the extent to which
financial concerns have driven hospital attitudes on termination of life-support
decisions. Until the prospective payment system was put in place, termination of
life support also meant the termination of a substantial income stream from the
patient’s insurer. Although it would be unfair to see reimbursement considerations
as controlling, it is clear that they have had an impact on ethical decision making. It
is likely that the technological imperative was greatly strengthened by its
profitability. [Powerly KE, Smith E. The impact of DRGs on medical care workers
and their clients. Hastings Cent Rep. 1989;19:16.] The troubling question now is
the extent to which prospective payment systems lead to the denial of necessary
medical care. [Dougherty CJ. Ethical perspectives on cost containment. Hastings
Cent Rep. 1989;19:5.]
d) Families
Families often have deeply ambiguous feelings about termination of life support. In
general, families want their loved ones given all the benefits of medical technology,
including advanced life support. The family’s interests become compelling when a
patient with dependent children refuses life-saving treatment. At the same time,
families are the main witnesses to the suffering and degradation that accompany
the long-term life support of an incompetent patient. This creates a humanitarian
urge to terminate life support, which is often complicated by unresolved feelings of
guilt over family issues unrelated to life support. For example, a family may want to
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