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When the Legal Aid Society of Palm Beach County, Fla., was contacted by a local hospital about a dispute involving a terminally ill patient with a living will, the legal aid group turned to Marnie Poncy for help. Poncy, an attorney who is also a registered nurse, has both the interest and expertise in such conflicts. The patient and her adult daughter didn’t want the hospital to take extraordinary measures to keep her alive, in keeping with the provisions of her living will. But the woman’s adult son threatened legal action if doctors at the hospital didn’t do all they could to prolong his mother’s life. On a pro bono basis, Poncy did a crisis intervention by getting Palm Beach State Attorney Barry Krischer on the phone to assure the nervous hospital medical staff that his office wouldn’t prosecute medical staff for abiding by the woman’s wishes, Legal Aid executive director Bob Bertisch says. Florida is one of only a handful of states whose laws are unequivocal in stating that a patient has the right of self-determination in whether or not to be treated for a medical condition. “It’s as far-reaching as any law I’m aware of,” Poncy says. Poncy launched a pilot bioethics project in Palm Beach County this week. The program will be administered by Legal Aid, which will provide office space for her and an administrative assistant. Poncy says the program will intervene in these types of end-of-life conflicts, as well as conduct educational programs for medical staff, lawyers and the general public about patients’ rights and Florida law governing this area. Bertisch says such end-of-life family dramas are surprisingly common. They may be particularly prevalent in South Florida. A recently study in the journal Health Affairs reported that Medicare spends more than twice as much per person per year in Miami as it does in Minneapolis — $7,847 versus $3,663. In their last six months of life, older Miamians had six times as many visits to medical specialists as those in Minneapolis. They also spent twice as much time in the hospital and were admitted to intensive care units more than twice as often. Yet, quality of care and life expectancy are no greater in Miami than in Minneapolis, the report said. “What increased spending buys you is generally unpleasant interventions like intensive care units and feeding tubes,” Dr. John Wennberg, a prominent Dartmouth University researcher who was one of the authors, told The New York Times this month. Too often, Poncy says, medicine “looks at death as a failure.” So doctors tend to keep dying people overtreated and confined to hospital rooms too long, she says. The end result, she adds, is that dying persons are not in charge of decisions about their own death. FROM NURSING TO LAW As an RN working for years with organizations such as the March of Dimes and the Red Cross, Poncy specialized in maternal and child health. After taking a three-week bioethics course at Georgetown University in the 1980s that dealt with conflicts in the legal and medical professions over end-of-life issues, Poncy decided to become a lawyer so she could try to bridge the gap between the two disciplines. Since graduating from Nova Southeastern University law school in 1988, she has practiced law in West Palm Beach, focusing on administrative law and medical issues. The West Palm Beach personal injury firm Searcy Denney Scarola Barnhart & Shipley uses her help on medical-related cases, including defective breast implants litigation a few years ago. She currently is co-counsel with partner Jack Scarola in a lawsuit alleging that a nursing home ignored an elderly patient’s living will and prolonged her life and suffering for a week. The woman’s granddaughter sued the nursing home for “wrongful prolongation of the dying process,” Scarola says. Poncy will continue work on that case in addition to her new duties. Poncy says she thinks hers is the only community-based bioethics program in South Florida. The pilot project was made possible through a $152,556 grant from the Palm Healthcare Foundation in West Palm Beach. “It’s the first grant of its kind that we know of,” Poncy says. She has recruited an advisory board comprised of Palm Beach County leaders in the legal, medical and hospice professions, including Krischer, Scarola, Dr. Jean Malecki, director of the Palm Beach County Health Department, Dr. Gail Cooney, medical director of Hospice of Palm Beach County and West Palm Beach solo attorney Stuart Klein, who represents some physicians’ groups. There’s a lot of research to support Poncy’s contention that health care providers overtreat dying patients and ignore their wishes, says Vicki Weisfeld, senior communications officer for the Robert Wood Johnson Foundation in Washington, D.C., a health care-related philanthropy. “The cure-oriented approach does make death seem like a failure,” she says. Scarola says it’s understandable that this occurs. After all, doctors’ training is aimed at saving lives. But economic motives sometimes prompt hospitals to prolong patients’ lives, he says. A dead patient is not a paying patient, he notes. Most hospitals have created ethics panels comprised of people from several professions to advise them on end-of-life issues. But, Poncy notes, those committees are accountable to the hospital, not to the patient and family. Her program, by contrast, will be completely independent, she says. Poncy says she won’t be surprised if some hospitals perceive what she is doing as duplicative of what their ethics boards do. “There are people who think they own issues or a process,” she says. “The ethics boards have similar responsibilities, but not the same responsibilities,” Scarola says. “The ethics boards protect the institutions for which they work. They are policy boards, as opposed to boards [created] to deal with exigent circumstances. [Poncy] will be a patient advocate.” Malecki doesn’t foresee problems with overlap or rivalries between hospital ethics boards and Poncy’s program. “I think it’s complementary,” she says. “I think ethics boards will welcome this.” NOT JUST FOR THE ELDERLY One common problem Poncy plans to address is convincing doctors to talk to Alzheimer’s patients earlier in their ailment about what level of medical care they want in their final days or weeks. “It’s harder to talk to a patient about losing his mind than dying,” she says. “So we don’t do it. But we should.” Poncy says she can’t predict exactly how the program will develop. “I’m going to be feeling my way a lot,” she concedes. She expects she’ll receive calls from family members, doctors and lawyers grappling with end-of-life questions. But she predicts that she won’t only be dealing with cases involving the elderly. Thorny bioethical issues also arise, for example, in the cases of young AIDS patients and severely impaired newborns. Indeed, Poncy already is planning to look into the case of a boy with Down syndrome who needs a heart transplant. She wants to know whether officials have bumped him lower on the waiting list for a new heart because of his disorder, and, if so, why. Poncy plans to speak to groups on bioethics at venues as varied as golf clubs and nursing homes. She’ll meet with doctors and lawyers. One of the things she’ll stress is that Florida law says that patients have a right to self-determination. “Just because you’re in a hospital, you don’t lose that right,” she says. It’s this education aspect of the pilot project that Malecki thinks is particularly important. She hopes that Poncy’s efforts will make physicians more aware of the need to discuss with patients the need to plan for what level of care they should receive if they have a fatal or debilitating illness. “If ever medicine needed to rely on law, it’s in this area,” Poncy says.

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