Latest news with #ArtCaplan
Medscape
5 days ago
- Health
- Medscape
Ethics of Artificial Hydration and Nutrition In Dementia
This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the NYU Grossman School of Medicine. I had a difficult case brought to me recently by someone who was trying to decide what to do with a patient with very bad dementia in terms of feeding. It's not the first time I've had this kind of case brought to me by physicians, and it probably won't be the last, but it remains a thorny, tough ethics quandary. I think everybody understands that there is a right — and we've had this affirmed since cases like Terri Schiavo or Nancy Cruzan — to not force artificial feeding (meaning by tube, in the nose, or in the stomach) or artificial hydration upon someone who doesn't want it. If you have the right to refuse treatment, it's been established — certainly in American law, and I would say by standards of care within the medical profession — that hydration and feeding, when they're done by mechanical means, tubes, or using artificial substances to supply nutrition, are medicine. As a medical intervention or a medical therapy, just like other interventions, such as dialysis or even refusing an amputation for a diabetic patient, the patient ultimately, if they're competent, has the right to refuse it. The challenge comes in the case that was presented to me. A woman, let's call her Mary Taylor, some years ago knew that she was at risk of getting Alzheimer's disease. She filled out her living will and discussed with her family that when she became demented, if she was unable to care for herself, if she couldn't recognize her family and friends, she did not want any medical interventions, including specifically hydration and nutrition. Sadly, she went through the course of declining and ended up at a nursing home. At the nursing home, the doctor who was treating her noticed that nurses were offering Mary food on a spoon and liquid on a spoon, that she was opening her mouth when the spoon was presented, and she was, if you will, eating and drinking. The physician, knowing that the family remembered this advance directive living will and knowing that they were the designated decision-makers, basically said stop the spoon-feeding. The nurses did not want to do it. They said it's ordinary care. It's not medical. It's just what you do as part of what one human being deserves from another human being — to offer them ordinary ways to drink water or to eat something. The case basically raises two tough ethics questions. Is feeding by spoon the same as medical intervention with artificial forms of hydration and nutrition? I believe it is. I believe that when you say 'no more food and nutrition,' it isn't just the equipment. I'll put it simply: It's who's on the end of the spoon. If nurses or doctors are feeding, it's medical. It's professional care, and you should be able to say no to that. Secondly, I do think if someone says 'I don't want to eat or drink anymore,' their intent and their values are clear. You could certainly rediscuss it with the family and say she seems to be accepting food and swallowing, and ask if that changes their mind or makes them think she might have decided differently. However, I think the wishes of the competent person, when they made the living will, are what should drive care if the person loses competency. They thought about it, they knew where they were headed, and I do think that's the value that ought to dominate thinking about whether we have to continue to try food and water for nutrition. Does that mean that you can't offer ice, lip balm, or other comfort means if someone is suffering because they're getting dehydrated and so on? Absolutely not. That isn't the same as feeding them. Here are some lessons to consider. It's important to pay attention when someone says they don't want food and water. Are nurses or anyone in a hospital or a nursing home trying to feed them anyway because they don't think of spoon-feeding as an artificial or medical intervention? I think they need education about that, and I think it's important to make sure that does not happen if that's what they said in their advance directives. I also believe advance directives and conversations with people, when they're competent or facing the potential loss of competency, should include discussions about whether they really mean everything, such as spoon-feeding or somebody offering you a glass of water. Is that included in what you are saying you do not want? We have to be thorough and comprehensive in making sure that we're clear so there really aren't disputes of what people did say no to and might say yes to if they no longer are able to tell us directly. I'm Art Caplan, at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thank you for watching.
Medscape
30-07-2025
- Health
- Medscape
Terri Schiavo's Legacy: When to Ethically Stop Life Support
This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at NYU Grossman School of Medicine in New York City. Twenty years ago this month, from the time I'm talking with you, in March 2005, a young woman named Terri Schiavo was allowed to die. It was one of the most controversial, and probably the most important, end-of-life-care cases ever to unfold in the United States. Terri was left permanently unconscious after a heart attack. Her husband [Michael Schiavo], after efforts were made to see if they could revive her and after efforts were made to see if she really was permanently unconscious, basically said she would not want to be in this state. She was kept alive by artificial nutrition, artificial fluids, and he said she just wouldn't want to be hereunable to think, sense, or feel, implying, "I know her, I have decision-making authority, and I want her feeding tubes and her artificial fluids disconnected. I want her to be allowed to die. That's what she would want." He wasn't saying that's what he would want. He said that's what she would want, acting as her, if you will, guardian or person making a substituted judgment. Terri's parents and her brother did not agree. They felt that Terri might recover. They also argued that they weren't totally convinced she was completely unable to communicate, think, feel, or hear. They made tapes when they went to visit her that suggested that she wasn't totally unconscious and was somewhat responsive. They went to court in the state of Florida where Terri was after her heart attack in a long-term care facility and engaged in a legal battle with Michael, the husband, to keep her alive. That fight took over 8 years, I think. It went up and down the Florida court system as to who could make the decision on whether artificial nutrition and fluids could be stopped. The fight reached 14 Florida courts, up and down their appellate system, then five federal courts, then intervention from the US Congress on the side, I should add, of Terri's parents and siblings. There were people arguing from the floor of Congress, including Congressman David Weldon and Senator Bill Frist [both of whom are physicians], that they didn't think she was in a permanent vegetative was very controversial because they made that diagnosis based on videos, without seeing her. Ultimately, the Supreme Court was approached. They said they were not going to hear the case, but the last court decision gave authority to the husband. On March 31, 2005, Terri's artificial life support was discontinued and she died. That case has reverberated throughout American healthcare ever since. It's not just a story of how we got to where we are in terms of having the right to stop care that a person doesn't want. This set the stage for stopping care that some people think is not medical care — food and water — but others argue quite vociferously that it's technology coming through a tube made out of special solutions,not eating pudding off a spoon. One issue that seems to have been resolved by the Schiavo case is that artificial feeding, artificial life support, and artificial fluids are medical technologies and can be stopped. At the same time, we have had many arguments since about how you adequately diagnose permanent vegetative state. Some scientists today are arguing that even with what we think is permanent vegetative state, there still may be some consciousness there. I don't believe that was true at all for Terri because on autopsy, her brain had shrunk to the size of a walnut. Her optic nerves had disconnected from her brain. She would not have been able to sense, feel, observe, or respond to any stimuli. Do we have to make a more precise diagnosis of permanent vegetative state before we get into arguments about what to do next? I do believe also that it's important, if you are dealing with someone who's terminally ill or has a serious illness, to get the discussion going early about who's in charge. We still have fights between husbands, families, sisters, and cousins coming in about who has veto power or decision-making power. The earlier we can establish who it is that the patient wants to speak for them if they can't, the better. Reenacting that war that we saw in the courts and Congress over Terriis a lesson that early communication, although it's hard to do, can really save terrible and disturbing emotional battles — not only for the family, but also for the nurses, doctors, and everybody who's involved in treating someone when one of these fights breaks out about stopping food and water, shutting off the ventilator, or stopping dialysis or antibiotics. Terri has quite a legacy. She left us with the understanding that it is possible legally and ethically to end life support, that someone else can make that decision, and that a [spouse] has more standing than the rest of the family. Given all that, it's still important to engage in early, explicit discussion about who ought to be in charge if the patient can't be. I'm Art Caplan, at the Division of Medical Ethics at NYU Grossman School of Medicine. Thanks for watching.
Medscape
30-06-2025
- Health
- Medscape
Death Clock App Not Ready for Prime Time, Says Ethicist
This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at NYU's Division of Medical Ethics at our medical school. I came across a really interesting app called the Death Clock. It is exactly what it sounds like. It basically is an app where you feed in all your health information, personal information, social information — any fact about you — and it promises to tell you your death basically is a forecaster of when you're going to die. You might say, some people might have an interest in that. What's the issue? Well, I think there are many issues. Should a patient come and ask you about this, I think you'd be wise to be ready to answer in case this app or others like it that are coming take first problem is, can we accurately predict your death date, even given a whole array of personal information? I still don't think so. Having worked now for a while on geroscience, meaning what factors cause senescence — not diseases in old age, like Alzheimer's disease or Lewy body dementia, but just aging — we don't really understand why some people age at different rates. There's a disease called progeria where a 10-year-old can go through aging and end up looking like a 90-year-old at the age of 11. Then, there are clearly differences in the rates at which people age from midlife to old age. We don't understand them well, but we're learning. I think an app that says it can tell you your death date is not accurate. Some people aren't going to want to know their death date without getting counseling. If someone asks if they should buy the app, I think either that company or you, as the doctor, had better be prepared to counsel them about what it would mean if it predicted an early death or a death that's coming soon. Aside from fear and worry, what plans should they make?Should they fill out advanced directives? Should they not retire to Arizona sooner? They're going to want information and counseling, and somebody has to provide it to them, and I don't see this company doing that yet. People need to at least try to cope with bad news. Another reason the company says the app is interesting is it'll push you to make lifestyle changes that will extend your death they offer — I think it was for $50 a year, if I remember right — a program to counsel you, claiming to be targeted to your particular situation, so that you can live longer. I doubt that is necessary either. We all know how to counsel patients in terms of wanting to live simple steps. I don't mean simple to do, but I mean five or six rules that hold up: lose weight, more exercise, moderate drinking, wear your seatbelt, don't use recreational drugs in excess. We know what the tricks are if you want to add lifespan. I don't think you need to sign up for anybody's program yet. Probably the biggest worry I have is, who's going to get all this information? I don't trust this company not to resell. I don't trust this company to protect individual identity. Even if they tried, with hackers and accidents, having this private company control identifiable information — boy, I think that's a much bigger risk than any benefit you might get from having the death clock. Overall, I'm still not ready. I did take a peek at my own prediction. I've got some time left, which is good to know, but that was just curiosity so that I could talk to you about it. In general, I don't think this is ready for prime time. I do think the downsides still outweigh the benefits, so I would be pretty cautious before I set the death clock with a patient. I'm Art Caplan, at the Division of Medical Ethics at NYU Langone. Thanks for watching.
Medscape
24-06-2025
- Health
- Medscape
Hologram Doctor: Not Who I'd Like to Visit, Says Ethicist
This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at the Division of Medical Ethics, at NYU Langone Health System in New York City. I am not a hologram. What am I talking about? Well, a new cancer clinic in Tennessee is starting to offer to its patients a hologram doctor. Some of you will know what this is like. It's been used now in shows and performances, like at Sphere in Las Vegas. All of a sudden, you're able to go to a show by Michael Jackson, who is long since dead, but they can project him onto the stage. This is also true for other singers, performers, or even figures from the past. They're very realistic looking, and you feel like you're in the presence of maybe someone who's still alive. That technology is being touted as a way to improve care for people in rural areas. Many of those folks have to travel very far to get regular exams and surveillance from a doctor or a nurse. Some of them require a 3- or 4-hour drive. It's a real burden. It's hard for many of these people, some of whom are frail, older, or sick from the treatments themselves. It's hard for them to get there. The clinic has come up with this idea to make a hologram of a generic doctor, put that doctor in a studio with good lighting and good technology, and beam it out to the homes of these patients — or let them travel somewhere where the setup is a little more friendly that is maybe not 3 hours away. Maybe they could have studios that, for many people, are only an hour away. I see some benefit. I think doing video conferencing and that style of thing often is a little cold and distant. The lighting isn't good, and the sound may be bad. It's not a professional production, and it may not give you the nuance and the detail that you want to see if you're trying to do an exam. It's better, if you will, to have the higher-level tech. There are issues. One, in rural areas, we don't really have great Wi-Fi service. The rates of carrying detailed signals aren't that good. I'm not sure much of this is going to make it into a rural person's home. I still see travel required, which cuts back in some ways on the attractiveness. It may be better to send the actual doctor to four or five clinics once in a while than to try and rely on the hologram doctor going out to the rural patients at locations where the signal still is not going to be that great. I also worry that for much of this work, while you can see some things, you can't see other things. Yes, you can detect a rash, and sure, you could see certain things about certain skin cancers, but are we really ready to say that we can conduct an exam remotely on a cancer patient with complicated disease? I'm not sure. Again, I'm no oncologist, but it makes me nervous that a thorough exam would be something you could do. In a weird way, this might work better for dermatology. It might work better for certain kinds of family medicine practice, where someone's nervous about a rash, headache, or some symptoms that you could handle remotely. This patient group strikes me as maybe more complicated. The other problem is the legal situation is unclear. What would it mean to make an error? What would it mean to actually give bad advice or misdiagnose? Who's responsible? Who's going to be able to hold someone accountable? What if the patient really isn't comfortable and doesn't give you all the information that they might if it was face-to-face? In person, that whole area looks murky, unresolved, and even dangerous to practice in until the rules are laid out clearly about who's responsible for what and what the standard of care is for using this kind of technology. Are we going to see more of it in the future? I think so. Is it ready for prime time now to an underserved rural population? I'm not sure it's here yet. We'll have to keep an eye on it. Maybe improvements will come. Maybe our infrastructure for handling Wi-Fi and this kind of thing will improve, but for now, I'm not sure that the hologram doctor is the doctor that I'd want to visit. I'm Art Caplan, at the Division of Medical Ethics at NYU Langone Health Systems. Thanks for watching.
Medscape
06-06-2025
- Health
- Medscape
Restricting Kids' Cell Phone Use at School: Ethicist
This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at the NYU Grossman School of Medicine, where I'm the head of the Division of Medical Ethics. The state that I live in, Connecticut, has seen some very interesting legislative proposals recently around cell phone use. Many other states — New York, New Jersey, and many others — are having similar Connecticut one, I think, is the furthest along of them all. It becomes important because I think parents ask questions about cell phone use for their kids. What should I be thinking? Should I restrict it? Is it dangerous? What should I do? The state of Connecticut wants to help. First, they've proposed legislation to pull cell phones out of schools — at least kindergarten up through high school — to get the cell phones taken away from the kids so that they're not distracted and that they're paying attention to the teacher and also engaged in social interaction. Even more radically, there's a proposal in Connecticut, a bill that would ban in young children from being able to access social media platforms, iPads, cell phones, or whatever between midnight and 6:00 AM. Is this a good idea? A colleague of mine at NYU, Jonathan Haidt, wrote a book called The Anxious Generation . He believes that the rates we see of teenagers who are now experiencing anxiety, which has increased from 2010 to today from 1 in 10 to 1 in 4; the number of teenagers experiencing depression, which has gone up from 1 in 10 to 1 in 5; and even death by suicide, one of the leading causes of deathfor kids aged 15-24, have to do with social media. Harassment, peer pressure, and getting stalked and bombarded with messages that attack self-esteem, target young people, and make them feel bad about their bodies can absolutely create mental health disorders. Is there sufficient evidence in his book?Do we have sufficient evidence from other studies to say for sure it's the cell phone or the iPad that somebody's looking at late at night? I'm going to concede that we don't. There's suggestive evidence, but not really many gold-standard studies that say, yes, it's the cell phone, iPad, or computerand where they are on social media. On the other hand, I support these legislative efforts, like Connecticut's, to get the cell phones out of school, to get kids talking to one another, to get them paying attention more, and to do what we can to get them off [of their devices] in the middle of the night. I would look at it this way.[Cell phones] may be causing problems by giving access to disturbing social media outlets. Let's face it, social media is a cesspool at this point, a sewer all over the place, and the companies that run it are doing nothing to self-regulate it. If we're wrong, the worst that happened is [kids] are not online for certain parts of the day. I know parents sometimes say, well, what about if there's a shooting or an emergency at school? I think we can manage that. You can absolutely have teachers with cell phones. The staff can have cell phones. It's not that there wouldn't be any ability to alert the police or to allow some communication as necessary with the kids.I don't think the rarity of a school shooting, as much as we worry about it, is enough to say, yes, let's let the kids just get lost all day long at school in their cell phones. I also understand why people are asking how this is going to really be enforced. Maybe it will be possible at school when you ask the kids to turn the cell phones in and lock them up or put them in a pouch where the teacher has the code or is that enforceable at home at night? One of the things missing, I think, from these efforts in Connecticut and elsewhere to decrease access by young kids to social media is the use of parental controls. I think some social platforms do a pretty good job saying before you give that cell phone to your kid or let them have their own computer, you're going to be able to program it with social parental discretion controls. Other platforms don't seem to care. Let's set some standards and expectations about what parents could do and would be able to do to restrict access at different times. It's going to take an across-the-board effort from parents, government requirements, and a willingness of people who control social mediato try to make sure that kids aren't getting in trouble, but we have to really start to take steps. We've got a problem in just saying there's nothing we could do about it, like the horse is out of the barn. That's not a response. I support the Connecticut effort. We'll see. I don't think federal government's going to be moving in this area anytime seem oriented toward deregulation. I think many states may, and I think that's something that, as physicians, we should try to support. Less access to social media at certain times of the day and night is not a bad thing for kids. I'm Art Caplan. I'm at the Division of Medical Ethics at NYU Grossman School of for watching.
