Presentation on theme: "Advance Directives (mostly)"— Presentation transcript:
1 Advance Directives (mostly) Christopher Kearney MDDirector of Palliative MedicineMedStar Union Memorial HospitalFebruary 2, 2013
2 “How gravely ill becomes dying” (why it will always be difficult) “The widespread and deeply held desire not to be dead”Medicine’s inability to precisely foretell the future“If death is the only choice, many patients who have only a small amount of hope will pay a high price to continue the struggle”Finucane T. JAMA.1999;282.22
3 History Informed Decision-Making Hippocratic oath makes no mention of obligation to converse with patients. ( Physician duty to follow regiment that will benefit patient; … led to trust, obedience, and then cure)Prohibition against touching without permission originated from ancient Germanic tradition forbidding torture of free men.Plato in Laws describes winning the patient’s confidence before prescribing therapy
4 Informed Consent/Informed Refusal In the 19th century, Thomas Percival’s Medical Ethics did not mention right to choice, but tells us when patient refuses, one should not force treatment, as it would likely complicate treatment.AMA’s first Code of Ethics 1847: “patients obedience should be prompt and implicit”
5 History of IC/IRIn 1914 Justice Benjamin Cardozo wrote “Every human being of adult years and sound mind has a right to determine what shall be done with his own body”In 1957, Salgo v Stanford: the term informed consent first used and uniformed consent not considered valid consent in case of physician withholding facts necessary for intelligent decision making.
6 Competent patientAMA Principles 1957 “A surgeon is obligated to disclose all facts relevant to the need and performance of the operation”Uniform recognition by American courts that competent patient has informed right to refuse treatment, even if it is life-sustaining.
7 Incompetent patientQuinlan v Supreme Court NJ – Pt had right to refuse ventilator support, and her parents could act as her “surrogates” making “substituted judgment”Barber v Superior Court - “ordinary” vs “extraordinary” language dropped in favor or “benefit and burden” (if burden outweighs benefit, treatment can be forgone)
8 Cruzan caseRight to refuseAdvance directive / Surrogates
9 Maryland Health Care Decisions Act 1993 Recognized status of Advance DirectiveAppoint Health Care Agent (previously Power of Attorney for Health Care)Create Health Care Instructions (previously Living Will)Futile Care “MD’s not required to provide treatment which is medically ineffective”
10 Md HCDA 1993Defined hierarchy of surrogate decision-making and linked to MD certification that patient is:1) Terminal2) Persistent vegetative state3) End stage condition
11 Hierarchy for Decision-Making GuardianHealth Care AgentSpouseAdult childrenSiblingsOther relatives“Friends”
12 Terminal Condition Incurable, progressive disease No expectation of recovery even with life-sustaining treatmentDeath “imminent”
13 Vegetative State Awake with no evidence of awareness Brainstem function preservedPersistent for 30 days
14 End-Stage Condition Progressive Irreversible No effective treatment for underlying conditionAdvanced to the point of complete physical dependencyDeath not necessarily “imminent”Ie. advanced dementia
15 Medical Ineffective Treatment A physician need not provide treatment that is believed to be medically ineffective or ethically inappropriate. Medically ineffective treatment is defined as treatment that, as certified by the attending and a consulting physician, to a reasonable degree of medical certainty, will neither prevent or reduce the deterioration of the health of an individual nor prevent the impending death of an individual.
16 Imminent death Today? Tomorrow? Next week? Next month? Not define by legislatureHospice criteria
17 Who needs it? The “Surprise Question” Would you be surprised if your patient died in the next six months?Joann Lynn
18 Approaches to Decision-Making Silence + assumptionsTalk but no documentsTalk + advance directives
19 “ Leave it to my Family to Decide” Default surrogates have limited power for decision-makingPermitted to withhold life-sustaining treatment only in the three conditions as certified by MDRisk of disagreement (equal surrogates), burden, legacy of bitterness
20 Talk…no document Differing memories Family may not be thinking as one “Gift” to leave clear direction, sparing loved ones difficult decisions in stressful times
21 Health Care Agents Selection, scope of authority up to individual Agent to decide based on“Wishes of the patient,” unless “unknown or unclear”Then, “patient’s best interest”
22 Health Care Instructions Follows “If … then …” model“If I lose capacity and I’m in [specified conditions],Then no CPR, ventilator, feeding tube, etc.”Or: aggressive interventions requestedHealth Care Instructions triggered when two physicians certify:Terminal conditionEnd-stage conditionPersistent vegetative state
23 Decision- making capacity Understanding informationReflection with personal valuesMake decisionCommunicate choice
24 Determining CapacityGenerally, capacity addressed with those closest to the pt, resorting to court neither necessary nor desirable.Judicial involvement only in absence of acceptable surrogate, disagreement among surrogates, complex capacity issues
25 Mr. Green 82 year-old widower, 3 children Former smoker, had end-stage lung diseaseprogressive Alzheimer’s DementiaNursing home residentThird admission with respiratory failureNo Advance Directive
26 Mr. Green Bipap for three days, not eating Daughter and son local, son distantNo decisions re: ICU transfer, “code status”, intubation
27 Family DisagreementElder daughter: “Dad was a fighter, do everything to keep him alive.”Son and younger daughter: “Dad wouldn’t have wanted this, and he’s suffering. It’s time to stop.”What do we do?Who decides?
28 Hospital settingQuestion of appropriate aggressiveness of care (We can do it , but should we?)Consent is assumed, diagnostic testing and therapy easily available, so often applied first, evaluated later.Patient at great disadvantage and beneficence predominates over autonomy
29 DOES THE PATIENT HAVE DECISION MAKING CAPACITY? Comfort Care DialogueIn light of the patient’s status, prognosis, and available treatment options, the goals of care need to be evaluated.DOES THE PATIENT HAVE DECISION MAKING CAPACITY?Patient DOES have decision making capacityPatient does NOT have decision making capacity and is not expected to regain it. Clinical assessment of incapacity by 2 physicians must be documented in progress notes.Advise the patient of the consequences, risks, benefits and alternatives. Details MUST be documented in progress note section of chart
30 Comfort Care DialoguePatient does NOT have decision making capacity and is not expected to regain it. Clinical assessment of 2 physicians must be documented in progress notes.Patient has appointed a Healthcare AgentPatient has NOT appointed a Healthcare AgentAdvise the agent of the consequences, risks, benefits and alternatives. MUST be documented in progress note section of chart2 Physicians MUST document in chart: end-stage condition, terminal condition and/or persistent vegetative state to utilize the following options.
31 Comfort Care Dialogue Yes No Yes No 2 Physicians MUST document in chart: end-stage condition, terminal condition and/or persistent vegetative state to utilize the following options.Family and Physicians obligated to follow instructions.Patient has a living will or health care instructions.YesNoA surrogate is available to make decisionsYesSurrogates guided by patient’s best interest.NoNo known surrogate or same level surrogates disagreeEthics consultation required. 2 MD’s certify that LST is medically ineffective
32 Health Care Agent and Health Care Instructions HCA and Physicians obligated to follow patient’s known wishesBest to appoint agent and make certain wishes known
33 Maryland Formalities Two witnesses Statutory form optional -- Over 18 years of age, not the chosen agentNotary no requiredStatutory form optional --Oral AD can be documented in patient recordAdvance Directives generally honor all states
34 Changing or Revoking an Advance Directive Presumed valid, no expirationOnly patient may change/revokeReviewAgents still available?Contact information current?Care preferences the same?
35 Pitfalls Advance directive done but limited discussion I know that’s what it says, but she didn’t understand.”Using ambiguous language“No heroic measures.”Treatment decisions may change over timeMexican proverb: “The appearance of the bull changes, once you enter the ring.”
36 Making It Work in the Real World Copies to HCA,family/friends, doctor and hospitalMOLST
37 Maryland MOLST Medical orders for life sustaining treatment Valid everywhere in the state.Are not AD’s and Do not replace AD’sEnduring, portable NP or Physician Orders
38 More Information: Attorney General’s Office Forms: callForms and other information via the Internet:Then click on “Advance Directives/Living Wills”Much other material on Maryland law and policyThen click on “Health PolicyGoogle MOLST
39 The Troubled Dream of Life Daniel Callahan “A medicine that embodies an acceptance of death would represent a great change in the common conception, and might set the stage for viewing the care of dying people not as an afterthought when all else has failed, but as one of the ends of medicine. The goal of a peaceful death should be as much a part of the purpose of medicine as the promotion of good health. That means medicine must abandon the modern cultic myth that in the cure of disease lies the cure of death.“
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