- Email: [email protected]
Medicaid managed care and emergency care
EDITORIALS
Self-Responsibility' on the other coast." It is time to rebalance individuals' health care rights with individual responsibility for healthy lifestyle choices and behavior change. SUMMARY Like all new health system reform proposals, the RC proposal is not perfect. It does, however, begin to raise many of the right questions. Asking the right questions is the first step in creating workable answers. Let us judge the RC approach, as John Kitzhaber, MD, suggests, when evaluating any new health plan by applying the following criterion: To what degree is it an improvement over the status quo?
&aries B Maclean, PhD Business Transition & Health Promotion Consultant Port~and, Oregon The author acknowledgesthe thoughtful conversationsand input by Elizabeth Skovron, MD, Hearth and Safety Director, West State, ]nc; LucyZ Martin, president, Lucy Martin & Associates Health Care Consultants; Kathleen Purdy, president, Business Strategies-EthicsConsultants; and Theresa Julnes, PhD, associate professor of public administration, Portland State University, all of Portland, Oregon.
Medicaid Managed Care and Emergency Care For several years, emergency medicine specialists have voiced concerns about the interaction of managed care plans and the delivery of services in emergency departments. It has been difficult to find an avenue on the national level to address these concerns because the regulation of insurance is a state government function. There is, however, one program under federal jurisdiction that now can be examined because of recent trends in the health care industry--Medicaid. There is a growing interest on both state and federal levels to broaden the use of managed care. States and the federal government seek to control and reduce costs and improve access to care in their Medicaid programs by requiring Medicaid recipients to use managed care plans for their health care. To date, 36 states are using managed care plans as part of their Medicaid programs, and it is estimated that all states will have at least one program by 1994.1 The number of patients currently enrolled ranges from less than 1% in 15 states to 100% in Utah and Arizona. 2 There are approximately 31 million Medicaid recipients in the United States, with 12% (3.6 million) of all Medicaid recipients enrolled in a managed care plan as of June 1992.1 In 1992 Senator Patrick Moynihan (D-NY) introduced a bill in the Senate to give states a broader ability to use managed care plans in their Medicaid programs and to encourage the development of primary care case management. Senator Moynihan, Chairman of the Senate Finance Committee, may push for this concept
116/1746
in future health care reform legislation. Interest in this concept also has been expressed in the House of Representatives. However, because of concerns raised by Representative Henry Waxman (D-CA), Chairman of the House Energy and Commerce Subcommittee on Health and the Environment, the bill was not introduced in the House. Representative Waxman was concerned that Senator Moynihan's proposal would give states too much flexibility to reduce benefits. It is clear that the Clinton administration will rely on managed care principles for health care reform. Arkansas is one of the states planning a managed care program for Medicaid recipients. 1 The experience that emergency physicians have with managed care should be instructive of problems that should be avoided in any reform plan. The Physician Payment Review Commission, in its 1992 Report to Congress, recommended that Congress encourage the use of managed care for Medicaid recipients. 3 The 1993 Report to Congress makes no mention of the problems patients requiring emergency care and emergency providers encounter when interacting with managed care plans. 4 In this document, the Physician Payment Review Commission recognized that Medicaid managed care plans do not always lower costs and noted that if enrollment is voluntarY, adverse selection will occur, with the healthiest Medicaid recipients enrolling in the managed care plan. There are some experts who support this view whereas others question this finding.3,5 In January 1993, the Government Accounting Office reviewed the growth in ED caseloads from 1985 through 1990 and noted that this growth was due to three major patient groups: Medicaid (34% increase), Medicare (29% increase), and the uninsured (15% increase). 6 They estimated that in 1990 about 43% of the patients seen in hospital EDs were nonurgent. Also, they identified the lack of a primary care provider, the inability to find a provider who accepted Medicaid, the lack of 24-hour access to a provider, transportation problems, and the lack of health insurance as significant barriers to alternative care for this group of ED patients.6, 7 They also noted that most patients received timely evaluation by an emergency physician regardless of the severity of illness or injury. This growth in ED use has developed over the same time flame as the growth in managed care plans for Medicaid recipients. The Inspector General of the Department of Health and Human Services recently recommended that states should develop initiatives to reduce nonemergency use of EDs by increased use of managed care. 8 However, the Government Accounting Office found that Medicaid managed care plans "have had mixed results in improving
ANNALS OF EMERGENCYMEDICINE 22:11 NOVEMBER1993
EDITORIALS
access to care, assuring the quality of care and saving money." 1 In 1990 the Health Care Financing Administration (HCFA) began the Quality Assurance Reform Initiative to improve quality assurance processes and develop standards for managed care plans with Medicaid risk contracts. W h e n finalized, the document will serve only as guidance for states' quality assurance programs because HCFA is reluctant to mandate new Medicaid requirements. Thus, states can adopt the standards in full, in part, or not at all. It would require Congressional action to standardize Medicaid quality assurance policy across all states. Under HCFNs plan, there are two components. The first is external oversight where HCFA has the responsibility to specify standards, define acceptable state monitoring, and oversee state monitoring of organizations with risk contracts. The main role of state Medicaid programs is to monitor directly the quality assurance programs of risk-based organizations. Managed care organizations with Medicaid risk contracts are directly responsible for monitoring and improving the quality of care. There are also external quality review organizations, independent organizations that conduct annual quality-of-care reviews of risk-based organizations for the state Medicaid programs. The second component is the internal quality assurance programs. Although there currently are no federal standards for quality assurance programs, the HCFA proposal does define standards for internal quality assurance programs. These standards include a statement that quality assurance programs should have a process for quality assessment and a remedial process to address problems for all types of services provided to all enrollees in all settings. It is important that quality assurance efforts at all levels specifically address issues of access to emergency care to ensure that patients are not put at risk and to identify problems with managed care service delivery. All patients should have a primary care provider to provide continuity of care and ensure needed preventive care. It is up to members of the health care community to seek ways to reduce and control the costs of health care. Using managed care plans for Medicaid recipients is one attempt to achieve these goals, but experience has demonstrated several serious problems. The American College of Emergency Physicians Subcommittee on Managed Care has identified several of these issues related to managed care, which also are applicable to Medicaid managed care plans. These include • Difficulty in patients' obtaining timely authorization from their "gatekeeper" • Some plans instructing patients to call the primary care physician in lieu of accessing the emergency medical
NOVEMBER1993
22:11
ANNALS OF EMERGENCY MEDICINE
system by dialing 911 for clearly emergency conditions, resulting in a delay in receiving needed emergency care • Delays in obtaining timely and appropriate consults from other specialists within the patient's health plan, thereby delaying needed follow-up or specialty care • Demands to transfer unstable patients to participating facilities in violation of federal antidumping laws • Determining that the service provided was not medically necessary because the case was determined retrospectively not to have been a bona fide emergency. This issue has financial repercussions for both patients and providers. Recently, the ACEP National Health Policy Subcommittee identified additional problems with Medicaid managed care plans that need further quantification. These include • The fact that many public health facilities that provide most medical services for Medicaid patients are not structured to compete with the private sector and may be affected disproportionately by Medicaidmanaged care plans • Inadequate benefit packages, particularly for psychiatric care and specialized care required by those with disabilities • Inadequate patient education, resulting in patients who have never seen their primary care physician to whom they were assigned, are unaware who their primary care physician is, are unaware they are in a managed care plan, or do not know what managed care is • Assignment of patients to a physician who is geographically difficult for them to see • Patients living in metropolitan areas, which may encompass more that one state, may try to receive care in a state other than the state in which they reside. This may occur because of convenience, previous relationship with a provider, or lack of understanding by the patient. Therefore, the patient may come to the ED seeking services such as rewriting prescriptions or referral to another provider in the state • Patients whose assigned primary care physician is no longer part of the Medicaid program and who have never been reassigned • There is little incentive for Medicaid patients to use managed care • Long waits for appointments because of insufficient numbers of providers and excessive numbers of patients assigned to a single practitioner • Language barriers that make it more difficult for the patient to access the managed care plan or achieve follow-up • Providers who are not available beyond ~'normal" business hours and patients who are unaware of how to obtain care after hours
1747/1
17
EDITORIALS
• Difficulty in ensuring that the patient will receive needed follow-up care because of inability to contact the assigned provider or long waits for appointments These are patient care issues that profoundly affect the quality of emergency care and are of concern to emergency physicians. They reinforce the fact that access to care is not ensured by only handing out an insurance card. Emergency physicians can serve a constructive role in identifying both patient care issues and administrative problems and then use those experiences to aid state and federal officials during the planning and implementation of new managed care programs. This is an important issue for emergency medicine. The health of 31 million Americans depends on it.
GeorgesC Benjamin, MD, FACEP Gaithersburg, Maryland Ellen H Taliaferro,MD, FACEP EmergencyService San FranciscoGeneralHospital San Francisco, California LarryBedard, MD, FACEP EmergencyServices Marin GeneralHospital Greenbrae, California StephanieA Kennan American Collegeof EmergencyPhysicians Washington,DC 1. Medicaid: States Turn to Managed Care to Improve Access and Control Costs. Washington, OC, US Government Accounting Office, GAO/HRD-93-46, March 17, 1993. 2. American MedicalAssociation News, Managed Care for Medicaid, February 8, 1993. 3. Physician Payment Review Commission: Annual Report to Congress, 1992. 4. Physician Payment Review Commission: Annual Report to Congress, 1993. 5. Bucha nan J, Leibowitz A, Keesey J, et al: Cost and Use of Capitated Medical Services: Evaluation of the Program for Prepaid Managed Care, Santa Monica, California, Rand Corp, 1992. 6. Emergency Departments: UnevenlyAffected by Growth and Changein Patient Use. Washington, DC, US Government Accounting Office, GAO/HRO-93-4,January 4, 1993. 7. Use of Emergency Rooms by Medicaid Recipients. Washington, OC, US Department ' of Health and Human Services, Office of the Inspector General, OEI 96-99-99189, March 1992. 8. Controlling Emergency Room Use.Washington, DC, US Department of Health and Human Services, Office of the Inspector General, 0El 96-99-00181, October 1991.
To Live and Die in Arizona See related article, p 1703.
Armed with good intentions and declaring that laws relating to prehospital resuscitation "need not be complex, either in their language or in their implementation" and should be "simply and easily understood" and that concerned parties "must not seek a perfect statute," the state of Arizona, applauded by Dr Iserson in his article in this issue of Annals, "A Simplified Prehospital Advanced Directive Law: Arizona's Experience," unwittingly may have pronounced a premature epitaph for many unsuspecting and
118/ 1748
otherwise salvageable patients. In the process, Arizona has created a medical and legal nightmare for itself. The Arizona statutory experiment with "prehospital directives" is highly unusual in several respects. Not the least of these is that the statute authorizes any person to execute what is referred to as a "prehospital advanced directive" (PHAD) to refuse CPR or certain methods of advanced life support. 1 There is no requirement that the patient be terminally ill or indeed that the patient have any existing illness whatsoever. According to Dr Iserson (who participated in the legislative deliberations that preceded the statute), the statute's failure to define "terminal illness" or to restrict the use of such prehospital directives to patients who are actually terminally ill was intentional. This is curious because Dr Iserson's claims of support for the statute are founded entirely on the rights of the terminally ill to refuse unneeded and unwanted prehospital interventions. None of the authors or studies he cited even remotely support either his premise or a conclusion that advance directives should be applied in a prehospital setting to nonterminally ill patients. The Arizona statute also allows a potential patient to carry a full- or reduced-size document that may be "checked" to indicate that the patient refuses any of the following methods of treatment: chest compressions, defibrillation, assisted ventilation, intubation, or advanced life support medications. Such general, arbitrary limitations on resuscitation have been rejected by the Hastings Center 2 and by the American Heart Association3,4 on a variety of both ethical and medical grounds even when they are proposed for application only in cases of terminal illness. Arizona not only codifies this error for prehospital application but compounds it by allowing even normal and healthy patients to determine, in advance, what methods of resuscitation they will refuse. It is not difficult to imagine that many healthy young adults without proper legal or medical advice easily could sign such a directive, believing it would prevent them from being maintained "by machines" or in a persistent vegetative state. Instead, such a directive may have the practical effect of rendering emergency medical services (EMS) providers or emergency physicians virtually powerless to provide even the most basic life support to resuscitate an otherwise valuable and salvageable human life. Faced with such a directive, a health care provider could not safely perform routine CPR on or artificially ventilate a drowning or heart attack patient; intubate the trachea to remove an obstruction to the airway; or even give simple IV fluids. Whatever justification there may be for withholding such modalities of therapy from a terminally ill patient who has with real informed consent refused them, there
ANNALS OF EMERGENCY MEDICINE
22:11
NOVEMBER 1993
Self-Responsibility' on the other coast." It is time to rebalance individuals' health care rights with individual responsibility for healthy lifestyle choices and behavior change. SUMMARY Like all new health system reform proposals, the RC proposal is not perfect. It does, however, begin to raise many of the right questions. Asking the right questions is the first step in creating workable answers. Let us judge the RC approach, as John Kitzhaber, MD, suggests, when evaluating any new health plan by applying the following criterion: To what degree is it an improvement over the status quo?
&aries B Maclean, PhD Business Transition & Health Promotion Consultant Port~and, Oregon The author acknowledgesthe thoughtful conversationsand input by Elizabeth Skovron, MD, Hearth and Safety Director, West State, ]nc; LucyZ Martin, president, Lucy Martin & Associates Health Care Consultants; Kathleen Purdy, president, Business Strategies-EthicsConsultants; and Theresa Julnes, PhD, associate professor of public administration, Portland State University, all of Portland, Oregon.
Medicaid Managed Care and Emergency Care For several years, emergency medicine specialists have voiced concerns about the interaction of managed care plans and the delivery of services in emergency departments. It has been difficult to find an avenue on the national level to address these concerns because the regulation of insurance is a state government function. There is, however, one program under federal jurisdiction that now can be examined because of recent trends in the health care industry--Medicaid. There is a growing interest on both state and federal levels to broaden the use of managed care. States and the federal government seek to control and reduce costs and improve access to care in their Medicaid programs by requiring Medicaid recipients to use managed care plans for their health care. To date, 36 states are using managed care plans as part of their Medicaid programs, and it is estimated that all states will have at least one program by 1994.1 The number of patients currently enrolled ranges from less than 1% in 15 states to 100% in Utah and Arizona. 2 There are approximately 31 million Medicaid recipients in the United States, with 12% (3.6 million) of all Medicaid recipients enrolled in a managed care plan as of June 1992.1 In 1992 Senator Patrick Moynihan (D-NY) introduced a bill in the Senate to give states a broader ability to use managed care plans in their Medicaid programs and to encourage the development of primary care case management. Senator Moynihan, Chairman of the Senate Finance Committee, may push for this concept
116/1746
in future health care reform legislation. Interest in this concept also has been expressed in the House of Representatives. However, because of concerns raised by Representative Henry Waxman (D-CA), Chairman of the House Energy and Commerce Subcommittee on Health and the Environment, the bill was not introduced in the House. Representative Waxman was concerned that Senator Moynihan's proposal would give states too much flexibility to reduce benefits. It is clear that the Clinton administration will rely on managed care principles for health care reform. Arkansas is one of the states planning a managed care program for Medicaid recipients. 1 The experience that emergency physicians have with managed care should be instructive of problems that should be avoided in any reform plan. The Physician Payment Review Commission, in its 1992 Report to Congress, recommended that Congress encourage the use of managed care for Medicaid recipients. 3 The 1993 Report to Congress makes no mention of the problems patients requiring emergency care and emergency providers encounter when interacting with managed care plans. 4 In this document, the Physician Payment Review Commission recognized that Medicaid managed care plans do not always lower costs and noted that if enrollment is voluntarY, adverse selection will occur, with the healthiest Medicaid recipients enrolling in the managed care plan. There are some experts who support this view whereas others question this finding.3,5 In January 1993, the Government Accounting Office reviewed the growth in ED caseloads from 1985 through 1990 and noted that this growth was due to three major patient groups: Medicaid (34% increase), Medicare (29% increase), and the uninsured (15% increase). 6 They estimated that in 1990 about 43% of the patients seen in hospital EDs were nonurgent. Also, they identified the lack of a primary care provider, the inability to find a provider who accepted Medicaid, the lack of 24-hour access to a provider, transportation problems, and the lack of health insurance as significant barriers to alternative care for this group of ED patients.6, 7 They also noted that most patients received timely evaluation by an emergency physician regardless of the severity of illness or injury. This growth in ED use has developed over the same time flame as the growth in managed care plans for Medicaid recipients. The Inspector General of the Department of Health and Human Services recently recommended that states should develop initiatives to reduce nonemergency use of EDs by increased use of managed care. 8 However, the Government Accounting Office found that Medicaid managed care plans "have had mixed results in improving
ANNALS OF EMERGENCYMEDICINE 22:11 NOVEMBER1993
EDITORIALS
access to care, assuring the quality of care and saving money." 1 In 1990 the Health Care Financing Administration (HCFA) began the Quality Assurance Reform Initiative to improve quality assurance processes and develop standards for managed care plans with Medicaid risk contracts. W h e n finalized, the document will serve only as guidance for states' quality assurance programs because HCFA is reluctant to mandate new Medicaid requirements. Thus, states can adopt the standards in full, in part, or not at all. It would require Congressional action to standardize Medicaid quality assurance policy across all states. Under HCFNs plan, there are two components. The first is external oversight where HCFA has the responsibility to specify standards, define acceptable state monitoring, and oversee state monitoring of organizations with risk contracts. The main role of state Medicaid programs is to monitor directly the quality assurance programs of risk-based organizations. Managed care organizations with Medicaid risk contracts are directly responsible for monitoring and improving the quality of care. There are also external quality review organizations, independent organizations that conduct annual quality-of-care reviews of risk-based organizations for the state Medicaid programs. The second component is the internal quality assurance programs. Although there currently are no federal standards for quality assurance programs, the HCFA proposal does define standards for internal quality assurance programs. These standards include a statement that quality assurance programs should have a process for quality assessment and a remedial process to address problems for all types of services provided to all enrollees in all settings. It is important that quality assurance efforts at all levels specifically address issues of access to emergency care to ensure that patients are not put at risk and to identify problems with managed care service delivery. All patients should have a primary care provider to provide continuity of care and ensure needed preventive care. It is up to members of the health care community to seek ways to reduce and control the costs of health care. Using managed care plans for Medicaid recipients is one attempt to achieve these goals, but experience has demonstrated several serious problems. The American College of Emergency Physicians Subcommittee on Managed Care has identified several of these issues related to managed care, which also are applicable to Medicaid managed care plans. These include • Difficulty in patients' obtaining timely authorization from their "gatekeeper" • Some plans instructing patients to call the primary care physician in lieu of accessing the emergency medical
NOVEMBER1993
22:11
ANNALS OF EMERGENCY MEDICINE
system by dialing 911 for clearly emergency conditions, resulting in a delay in receiving needed emergency care • Delays in obtaining timely and appropriate consults from other specialists within the patient's health plan, thereby delaying needed follow-up or specialty care • Demands to transfer unstable patients to participating facilities in violation of federal antidumping laws • Determining that the service provided was not medically necessary because the case was determined retrospectively not to have been a bona fide emergency. This issue has financial repercussions for both patients and providers. Recently, the ACEP National Health Policy Subcommittee identified additional problems with Medicaid managed care plans that need further quantification. These include • The fact that many public health facilities that provide most medical services for Medicaid patients are not structured to compete with the private sector and may be affected disproportionately by Medicaidmanaged care plans • Inadequate benefit packages, particularly for psychiatric care and specialized care required by those with disabilities • Inadequate patient education, resulting in patients who have never seen their primary care physician to whom they were assigned, are unaware who their primary care physician is, are unaware they are in a managed care plan, or do not know what managed care is • Assignment of patients to a physician who is geographically difficult for them to see • Patients living in metropolitan areas, which may encompass more that one state, may try to receive care in a state other than the state in which they reside. This may occur because of convenience, previous relationship with a provider, or lack of understanding by the patient. Therefore, the patient may come to the ED seeking services such as rewriting prescriptions or referral to another provider in the state • Patients whose assigned primary care physician is no longer part of the Medicaid program and who have never been reassigned • There is little incentive for Medicaid patients to use managed care • Long waits for appointments because of insufficient numbers of providers and excessive numbers of patients assigned to a single practitioner • Language barriers that make it more difficult for the patient to access the managed care plan or achieve follow-up • Providers who are not available beyond ~'normal" business hours and patients who are unaware of how to obtain care after hours
1747/1
17
EDITORIALS
• Difficulty in ensuring that the patient will receive needed follow-up care because of inability to contact the assigned provider or long waits for appointments These are patient care issues that profoundly affect the quality of emergency care and are of concern to emergency physicians. They reinforce the fact that access to care is not ensured by only handing out an insurance card. Emergency physicians can serve a constructive role in identifying both patient care issues and administrative problems and then use those experiences to aid state and federal officials during the planning and implementation of new managed care programs. This is an important issue for emergency medicine. The health of 31 million Americans depends on it.
GeorgesC Benjamin, MD, FACEP Gaithersburg, Maryland Ellen H Taliaferro,MD, FACEP EmergencyService San FranciscoGeneralHospital San Francisco, California LarryBedard, MD, FACEP EmergencyServices Marin GeneralHospital Greenbrae, California StephanieA Kennan American Collegeof EmergencyPhysicians Washington,DC 1. Medicaid: States Turn to Managed Care to Improve Access and Control Costs. Washington, OC, US Government Accounting Office, GAO/HRD-93-46, March 17, 1993. 2. American MedicalAssociation News, Managed Care for Medicaid, February 8, 1993. 3. Physician Payment Review Commission: Annual Report to Congress, 1992. 4. Physician Payment Review Commission: Annual Report to Congress, 1993. 5. Bucha nan J, Leibowitz A, Keesey J, et al: Cost and Use of Capitated Medical Services: Evaluation of the Program for Prepaid Managed Care, Santa Monica, California, Rand Corp, 1992. 6. Emergency Departments: UnevenlyAffected by Growth and Changein Patient Use. Washington, DC, US Government Accounting Office, GAO/HRO-93-4,January 4, 1993. 7. Use of Emergency Rooms by Medicaid Recipients. Washington, OC, US Department ' of Health and Human Services, Office of the Inspector General, OEI 96-99-99189, March 1992. 8. Controlling Emergency Room Use.Washington, DC, US Department of Health and Human Services, Office of the Inspector General, 0El 96-99-00181, October 1991.
To Live and Die in Arizona See related article, p 1703.
Armed with good intentions and declaring that laws relating to prehospital resuscitation "need not be complex, either in their language or in their implementation" and should be "simply and easily understood" and that concerned parties "must not seek a perfect statute," the state of Arizona, applauded by Dr Iserson in his article in this issue of Annals, "A Simplified Prehospital Advanced Directive Law: Arizona's Experience," unwittingly may have pronounced a premature epitaph for many unsuspecting and
118/ 1748
otherwise salvageable patients. In the process, Arizona has created a medical and legal nightmare for itself. The Arizona statutory experiment with "prehospital directives" is highly unusual in several respects. Not the least of these is that the statute authorizes any person to execute what is referred to as a "prehospital advanced directive" (PHAD) to refuse CPR or certain methods of advanced life support. 1 There is no requirement that the patient be terminally ill or indeed that the patient have any existing illness whatsoever. According to Dr Iserson (who participated in the legislative deliberations that preceded the statute), the statute's failure to define "terminal illness" or to restrict the use of such prehospital directives to patients who are actually terminally ill was intentional. This is curious because Dr Iserson's claims of support for the statute are founded entirely on the rights of the terminally ill to refuse unneeded and unwanted prehospital interventions. None of the authors or studies he cited even remotely support either his premise or a conclusion that advance directives should be applied in a prehospital setting to nonterminally ill patients. The Arizona statute also allows a potential patient to carry a full- or reduced-size document that may be "checked" to indicate that the patient refuses any of the following methods of treatment: chest compressions, defibrillation, assisted ventilation, intubation, or advanced life support medications. Such general, arbitrary limitations on resuscitation have been rejected by the Hastings Center 2 and by the American Heart Association3,4 on a variety of both ethical and medical grounds even when they are proposed for application only in cases of terminal illness. Arizona not only codifies this error for prehospital application but compounds it by allowing even normal and healthy patients to determine, in advance, what methods of resuscitation they will refuse. It is not difficult to imagine that many healthy young adults without proper legal or medical advice easily could sign such a directive, believing it would prevent them from being maintained "by machines" or in a persistent vegetative state. Instead, such a directive may have the practical effect of rendering emergency medical services (EMS) providers or emergency physicians virtually powerless to provide even the most basic life support to resuscitate an otherwise valuable and salvageable human life. Faced with such a directive, a health care provider could not safely perform routine CPR on or artificially ventilate a drowning or heart attack patient; intubate the trachea to remove an obstruction to the airway; or even give simple IV fluids. Whatever justification there may be for withholding such modalities of therapy from a terminally ill patient who has with real informed consent refused them, there
ANNALS OF EMERGENCY MEDICINE
22:11
NOVEMBER 1993