Instructions on Current Life- Sustaining Treatment Options Form: Objectives and Use Jack Schwartz Attorney Generals Office April 2008

2 Whats the Key Issue? > 30,000 hospital and nursing home deaths annually in Maryland Most after a chronic illness Most after a decision about medical interventions Is there a good answer to the Why question? Why are we pursuing this pathway, instead of another?

3 Good Answers to the Why? Question Because the patient chose this pathway Told us so after informed consent discussion Pointed the way in an advance directive Because this pathway fits the patients values and beliefs Because this pathway provides the best care, given the patients condition

4 Bad Answers to the Why? Question Because Doctor X always does it this way Because its too soon after surgery for the patient to die Because Relative Y said shed sue us if we didn't We just went ahead, we dont really know why

5 Care Planning and Delivery Steps Identifying issues for which decision needed now Discussing goals/options with the right decision maker Documenting decisions Writing physician orders All of these should be done, form or no form LST Options form meant to improve existing process

6 Legal Framework Has Not Changed Types of advance directives Proxy standards What would patient want, if known? Living will or similar advance directive is direct evidence What is in patients best interest? Surrogate authority Patient in terminal or end-stage condition, PVS Physician authority Medically ineffective treatment

7 Terminal Condition Incurable No recovery even with life-sustaining treatment Death imminent No definition of imminent Medicare hospice criterion sometimes used

8 End-Stage Condition Progressive Irreversible No effective treatment for underlying condition Advanced to the point of complete physical dependency Death not necessarily imminent Primarily advanced dementia, maybe other diseases

9 Persistent Vegetative State No evidence of awareness Only reflex activity, conditioned response Wait medically appropriate period of time for diagnosis One of two physicians who certify PVS must be neurologist, neurosurgeon, or other expert re cognitive functioning

10 What Is the LST Options Form? Standardized format re patient/proxy preferences about current issues What decisions ought to be made now? Not another advance directive Nursing homes must offer Other facilities may use Physician to sign But, not a physicians order; not an EMS/DNR Order

11 Why the Form? Better planning when no advance directive Better application of advance directive to clinical situation More awareness of main goal of care Better communication if patient transfers

12 LST Options Form and Advance Directives ADLST Options Capacity required?YesNo Locked into place after incapacity? YesNo Hypothetical, future issues? YesNo

13 Part A: Main Goal of Care Premise: specific treatment preferences serve a goal, not ends in themselves What do you hope to achieve?

14 Part B: Advance Directive and Contact Information Attach prior or newly created advance directives Provide contact information for proxy Health care agent, if any Top-priority surrogates

15 Part C: DNR Status Yes, attempt CPR No, allow natural death No answer is not a DNR order, even after physician signs Should be implemented with facility- specific or EMS/DNR Order

16 Part D: Ventilator Yes, even indefinitely Yes, for a therapeutic trial Time limit may be specified No

17 Part E: Hospital Transfer Yes, for any indicated condition Yes, for acute injury only No

18 Part F: Medical Workup Yes, all indicated tests Treatment planned after diagnosis Limited tests only Noninvasive, low risk No

19 Part G: Antibiotics Yes Yes, but not by IV No, except if needed for comfort

20 Part H: Artificially Administered Fluids/Nutrition Yes, even indefinitely Yes, for a therapeutic trial Time limit may be specified Yes for IV fluids; no for nutrition No

21 Part I: Other Treatment Issues as Specified Yes, even indefinitely or repeatedly Yes, for an acute episode only No

22 If LST Options Form Is Filled Out: Must travel with patient New attendings must consider Starting point for discussion Can be basis for physicians orders Must be reviewed if material change in patients condition Clinical judgment about what = material change But: loss of capacity = material change

23 Related and Noteworthy: Ethical Framework Endorsed by State Advisory Council on Quality Care at the End of Life, Attorney Generals Office Intended to: Make explicit the process for quality care delivery Can be adapted in facility policies Identifies key steps and rationale for each Click on Health Policy Click on Ethical Framework

24 Additional Resources Click on Health Policy Text of Health Care Decisions Act Summary, slide shows, algorithm LST Options form Explanatory Guides Advance directive materials Legal opinions and advice letters I am now thoroughly confused but better informed. Martin Dawes, BMJ 331 (2005): 362