Women’s birth plans and do-not-resuscitate orders are disregarded in half of US states if they fall unconscious or can’t communicate in labor, a new study reveals.
Childbirth is a dangerous process – especially in the US, where maternal mortality rates are high – and the process can change courses dramatically at any moment.
These chances are precisely why most women work with their doctors or doulas to design a birth plan describing how they want their delivery to go, what measures they’re not comfortable with and who should make decisions if they cannot.
But those patient wishes go out the window in many states and, in 12, a woman can be kept alive by any means necessary until her baby can be delivered safely, whereas anyone else’s ‘do not resuscitate’ wishes would be respected, Mayo Clinic research found.
In 25 US states, women’s end-of-life wishes are considered invalid if she is pregnant (two darkest blues), and in 12 states, women can be kept alive as long as necessary until their fetus can be delivered safely (darkest blue)
Since 2006, the proportion of women that experience serious or life-threatening complications while they are pregnant or giving birth has shot up by 45 percent.
These complications may come as a result of surgical deliveries via C-section, or may make C-sections and hysterectomies necessary.
In most instances, an advanced directive – or living will – gives a patient a voice even when they fall unconscious while under a doctor’s care, or are otherwise unable to understand and evaluate medical information and make and communicate decisions.
These documents may instruct doctors what to do if various medical situations arise, when to stop trying to resuscitate the patient, when to take the patient off life support and to whom to give decision-making power.
In 25 states, these legal documents are automatically invalidated if a woman is pregnant.
Pregnancy itself is considered a condition that renders women incapable of making decisions for themselves.
And in 19 states, the surrogate a woman designated to make decisions in her stead has only limited authority, according to the the new study.
Disturbingly, in Alabama, Idaho, Indiana, Kansas, Michigan, Missouri, Oklahoma, South Carolina, Texas, Utah, Washington and Wisconsin, a brain dead pregnant woman’s vital organs can be kept alive as long as necessary to incubate a fetus until it’s developed enough for delivery – even if that’s not what she or her family wanted.
These policies and laws (they are not written into every state’s statute) have put families through considerable pain and resulted in controversy and lawsuits over the years.
For example, in 2014, Marlise Muñoz was just 14 weeks pregnant when she suddenly collapsed at home.
When she arrived at a Texas hospital, doctors discovered she’d suffered a massive pulmonary embolism. It was clear she was brain dead and would never regain consciousness.
Muñoz’s husband and family were certain she wouldn’t have wanted to be kept a living vegetable, and it was far too soon to deliver the fetus she’d be carrying.
But, in Texas, neither Muñoz’s wishes nor her family’s mattered. It was illegal there to take a pregnant person carrying a living fetus off life support.
Her husband filed a lawsuit and eventually won. But it took two months before they were finally able to take Muñoz off the ventilator and say goodbye to her and the fetus she carried.
At least, in Texas, the official documents for advanced directives explain that pregnancy triggers an exemption.
In 19 states, these documents make no mention of pregnancy restrictions, so women and their families have no idea that none of their best-laid plans will matter if the worst happens.
So far, a few court cases, like Muñoz’s, have taken up this issue, but resolved it on technicalities. There don’t appear to have been any ethical or constitutional challenges to pregnancy restrictions.
‘Honoring a person’s wishes at the end of life is widely recognized as profoundly important to humane, ethical care,’ wrote Dr Anne Drapkin Lyerly in a commentary accompanying the JAMA article.
‘To that end, efforts to help individuals make their preferences about end-of-life care known have involved advance care planning, including the completion of advance directives and identification of a surrogate decisionmaker.’
But in the US, simply being pregnant demotes a woman’s status in the eyes of state laws and policies.
‘[R]estricting advance directives in pregnancy can only be accomplished by viewing women as less than persons, potentially reducing them to “fetal containers,”‘ Dr Drapkin Lyerly wrote.
‘[This] pit[s] the interests of the woman against those of the fetus rather than considering them as an integrated unit that includes a person whose rights to bodily integrity are inviolable.’