Medical platform/medical care decision-making for patients in permanent vegetative state ──A brief commentary on the Civil Judgment No. 2590 Tai Shang Zi No. 2590 of the Supreme Court

Author：Professor Hsiu-i Yang

Finally, the court must confront the most difficult end-of-life care decision-making problem—a permanent vegetative state.

A recent judgment by the Supreme Court triggered a comment from Professor Cong-Fu Chen, a giant in domestic medical law, that it was a “sad” judgment. The disputed facts of this judgment appear to be that the family members of terminally ill patients repented after signing the DNR, and exhausted all judicial channels after the death of their loved ones, and subjected all medical staff to a six-year judicial torture process. But when we walked into the world described in the verdict, we saw a car accident that brought a young man into the tragic state of “Permanent Vegetative Status” (PVS), and also put a whole family (Dad, Mother, sister) into the valley of hope-disappointment-despair; the medical system has spent a lot of resources, but it can only let this PVS patient live in a “non-life-saving” life-saving medical technology (respirator, nasogastric tube) non-dead state of being. It is estimated that there are 2,800 to 4,500 PVS patients in Taiwan. They have completely lost consciousness due to brain injury for more than 6 months and must rely on the life support system to survive in nursing institutions. Once the disease occurs, what is the most suitable for these PVS patients medical care? Who will make decisions for them? Under what circumstances might “death” be in the “best interests” of a patient in a permanent vegetative state? The real issue of the Supreme Court’s 110-year Taishang Zi No. 2590 civil judgment is about the medical care decision-making of permanent vegetative patients.

In this case, the young PVS patient was a resident of the respiratory care ward of a regional hospital. When the hospital found that the patient seemed to have gallstones that caused bile duct obstruction and jaundice, the hospital notified the family members who came to visit every day (the patient’s father and mother), He also asked whether he wanted to be transferred to another hospital for active treatment, but the patient’s father, the plaintiff of this case, never responded positively, while the patient’s mother clearly refused to be transferred. Therefore, this hospital treats symptoms according to its scale and equipment. In addition to giving antibiotics to treat jaundice by drip, antipyretics are given for fever, laxatives and suppositories for constipation, but the patient did not improve. When the heartbeat stopped at the end of the sepsis, the hospital did not give the patient CPR because the patient’s mother had signed a DNR.

Unexpectedly, after the patient passed away, the patient’s father argued that the hospital should actively transfer the patient for treatment, and that he was the legal guardian of the patient. The DNR signed by the patient’s mother was invalid, and a series of criminal and civil lawsuits started. For the criminal part, the sanction of non-prosecution was determined, and for the civil part, the Taipei District Court and the Taiwan High Court all believed that the care provided by the defendant hospital and medical colleagues to the patient was in line with medical practice. Although the patient’s father was ruled by the court as the patient’s guardian, But the mother is the first contact person recorded in the medical records. Therefore, the mother meets the relative status of the hospice and palliative care regulations, and the signed DNR is of course valid, so the doctor ruled in favor of the lawsuit. The patient’s father refused to accept it and appealed to the Supreme Court.

Obviously, the father and mother of the PVS patient in this case disagreed on the whole medical treatment. The mother knew that her son’s vegetative state was serious. He had been in a coma for three years and hadn’t even opened his eyes. If it was impossible for the PVS patient to wake up, why bother to transfer him to another hospital to actively treat his gallstones? If the local treatment in the institution is ineffective, the mother further believes that the CPR at the end of life is just a “delay” for her son, so the patient’s mother signed the DNR without hesitation.

The patient’s father didn’t seem to think so, but the patient’s father didn’t know how to make a decision. Although he was ruled by the civil court to be the patient’s guardian, he did not tell the hospital that his contact person on the medical record was only 3rd (patient sister 2nd), he probably doesn’t know what is in his son’s “best interest” ok, that makes him ignore the note his wife put on his door, he doesn’t answer the hospital Although he himself had previously signed the DNR, after the death of his son, he filed almost retaliatory medical malpractice lawsuits against the 12 doctors and nurses who had taken care of his son. The Supreme Court ignored how to examine whether the decision of the patient’s family is in line with the patient’s best under the ethical principles of “respect for autonomy”, “doing good”, “doing no harm”, and “justice” in making medical care decisions for PVS patients Instead, they followed a wrong line of legal reasoning: “Only terminally ill patients, family members can sign the DNR. Therefore, whether the patient in question is a terminally ill patient needs to be determined by two specialist doctors. It was identified as a terminally ill patient, so the facts were unclear, and it was sent back for retrial.”

This judgment of the Supreme Court is an obviously wrong judgment. First of all, not only terminally ill patients who meet the hospice and palliative care regulations, the family members can sign the DNR. In medical clinical practice, all kinds of patients may need CPR due to the progress of the disease course or unforeseen accidents entering a critical state. At this time, if the patient has an advance medical decision instruction in advance, the doctor can of course follow the instruction. Yes, but if not, the medical routine will ask the patient’s family members for opinions as a substitute decision to supplement the patient’s autonomy. Taking this case as an example, whether the patient is terminally ill is not the point. The point is that the PVS patient lacks the ability to consent to medical treatment. Therefore, when the patient has medical needs, the doctor of course seeks the consent of the family members. The real issue is whether physicians have a positive duty to protect against abuse of family agency if the family’s substitution decision is contrary to the patient’s “best interests”? The famous Baby Doe Act in the United States is to deal with the abuse of parental rights by parents, which affects the best interests of their severely disabled newborns, and the state should be able to intervene to protect the newborns.

Therefore, the real point of contention in this case should be to go back to an earlier point in time to judge: Is it not in the patient’s best interest for the patient’s mother to refuse to refer the patient to a large hospital for more aggressive gallstone treatment? If so, is the patient’s father, as a guardian, likely to prevent the abuse of his mother’s agency? Finally, I have to ask, if a PVS patient is in danger of being “abandoned” by his family, what positive obligation does the doctor have to protect the right to health and life of the PVS patient? These are questions the Supreme Court should take seriously, but in this case, they are fairly easy to answer. The patient’s parents are conscientious and caring parents. They visit the patient almost every day. The patient’s mother did not refuse medical treatment, but refused to refer him. The hospital has no reason to doubt the opinions of the family members. The patient’s father will be sad after losing his son. It is unacceptable to vent your grief and anger on the medical team, and a series of indiscriminate lawsuits.

The judgment of the Supreme Court is really “sad”. The car accident in 1999 claimed the deceased’s “biographical life”, and the “sepsis” in 105 years ended the deceased’s “biological life”. It has been going on, starting from 105 years, the father of the deceased filed a criminal complaint, and after being sanctioned without prosecution, he was dismissed by reconsideration; he turned to a civil lawsuit, and lost both the first and second trials. “Looks like a verdict in favor of the case. This case is still in the first trial. The defendants have 12 medical staff of natural persons and two hospital legal persons. Thinking about the physical and mental suffering of these medical staff during the 6 years of litigation, the Supreme Court hastily remanded for retrial and granted the deceased It is really sad that my father’s illusory hope of victory also makes all clinical medical colleagues at a loss.

Reprinted from UDN Yuanqi.com: Medical and Disease Platform/Medical Care Decision-Making for Patients in Permanent Vegetative State ──Supreme Court’s 110th Annual Taishang Zi No. 2590 Civil Judgment Brief Commentary｜Xinglin. Clinic｜Focus｜Venki.com (udn.com)