Can doctors be compelled to provide futile care?

A New Jersey appeals court heard arguments in April on a case that is expected to clarify physicians' part in determining treatment in medically futile cases.

Judges will decide whether family members could compel Trinitas Regional Medical Center to continue life-sustaining care for their comatose father when hospital doctors believed further treatment was medically inappropriate. Legal experts said the case has the potential to set a precedent in New Jersey and beyond for decisions on end-of-life care.

A trial judge in March 2009 blocked Trinitas from discontinuing life support for 73-year-old Ruben Betancourt, who lapsed into unconsciousness after complications from cancer surgery. After the family sought treatment at other facilities, Betancourt was readmitted to Trinitas for renal failure and started on dialysis, ventilator support and tube feeding, according to court records.

Hospital doctors advised the family that he was in a persistent vegetative state and that ongoing treatment would be futile and inhumane. Betancourt's family members disagreed with the assessment and, believing their father was still responsive, sought and won a court order prohibiting Trinitas from withdrawing support without their consent.

Trinitas appealed, and a decision in Betancourt v. Trinitas is pending in the New Jersey Appellate Division. Betancourt died in May 2009.

Physicians agree that patients and their proxies should have a say in such end-of-life decisions, said Lawrence Downs, general counsel and director of public health at the Medical Society of New Jersey. But so should the doctors who are providing the care, he added. MSNJ, joined by other state health care organizations, filed a friend-of-the-court brief in the case.

End-of-life care decisions should be a collaborative process, Downs said. "But where the care demanded by the family is futile from a medical perspective, there needs to be a better way to resolve the question than going to court to order doctors to provide care they are uncomfortable providing. ... The doctor is the medical expert and should have a place at the table to give guidance."

Trinitas said it consulted with Betancourt's family and made efforts to transfer him elsewhere but could not find another facility willing to continue caring for him.

"Patients do have a right to choose among available and appropriate treatment, but not to decide what's medically appropriate," and in this case, doctors had done all they could do, said Trinitas' vice president and general counsel Sam Germana.

But Betancourt's attorney, Todd Drayton, said the hospital decided on its own to discontinue support.

"We're not saying patients have the right to demand extraordinary or experimental treatment a hospital feels is inappropriate. That's not the issue," he said. "The facts of our case are whether or not a hospital can unilaterally terminate life-sustaining support over the objections of the family."

The answer is no, Drayton said. He pointed to state Supreme Court precedents upholding patients' rights to determine their care or have someone act on their behalf, particularly in end-of-life circumstances.

Downs said New Jersey case law primarily has addressed patients' rights to refuse or withdraw medical treatment.

The Betancourt case, however, opens the door for the courts to address for the first time whether doctors must continue providing care they consider medically unwarranted and even unethical, he added.