Calif. Supreme Court raises standard for withdrawing life support

Physicians should go to extra lengths to make sure a patient has left "clear and convincing" evidence of end-of-life wishes.

By Tanya Albert, AMNews staff. Sept. 3, 2001.

A California Supreme Court decision last month underscored how important it is for physicians to take an extra few minutes to talk to patients about advance care directives.

The court ruled that if a patient is conscious but not terminally ill, comatose or in a persistent vegetative state, a patient's conservator may not withhold artificial nutrition and hydration without "clear and convincing" evidence that it is what the patient would want or that it is in the patient's best interest.

California joins only a handful of states to set the burden of proof so high in cases where a person hasn't named a health care proxy or hasn't left an advance directive that outlines his or her wishes. Most states require "reasonable" evidence.

Some physicians say the decision is a good one that ensures patients' wishes will be followed. Others argue the decision sets such a high standard that it essentially establishes a blanket policy that takes away an individual's right to have a conservator make a decision.

"What the court has done is cause people to be vulnerable to the worst form of suffering," said internist and medical ethicist Lawrence J. Schneiderman, MD, a professor at University of California, San Diego. "Only 10% to 20% of people have gone to the trouble of taking the formal steps to appoint a surrogate decision-maker. That means the vast majority will be kept alive."

Oakland, Calif., geriatrician James Mittelberger, MD, said patients need protections at the end of life, but that a blanket policy is not the answer. [...]