Class Session 19End of Life Decisions

Mrs. Samia Almusalhi

• Competent individuals can make their wishes known via an advance directive.

• Three legal instruments currently meet the act's definition of advance directive are:

1. Living will:

2. Durable power of attorney healthcare proxy (DPOAHC):

3. Advance directive for health care:

1. Living will:

• A competent adult may prepare a document providing direction as to life-sustaining medical care in the event this individual may become terminal or permanently unconscious. It is in following two situation:

a. Terminal: Incurable or irreversible medical condition that without administration of life support will result in death in a relatively short period of time.

b. Permanent unconsciousness: Permanent coma or persistent vegetative state that is irreversible, patient is not aware of self or environment and shows no response to environment

2. Durable power of attorney healthcare proxy (DPOAHC): A durable power of attorney healthcare proxy enables a competent individual to name someone (usually a spouse, parent, adult child, or other adult) to exercise decision-making authority, under specific circumstances, on the individual's behalf.

• 3. Advance directive for health care: an individual will provide accurate instructions for the type of care he or she does or does not desire in a number of scenarios.

• The individual may also appoint a proxy decision maker to help interpret the application of the specific instructions.

Patient Self-Determination Act (rule),

• upon admission, All patients or family members must be advised of their right to make decisions about their health care, including the right to establish written advance directives.

• The Joint Commission is in line with federal regulations that patients be informed about their right to advance directives and the extend the hospital is able to go to honor the directive.

What is coming under a written living will?

• life-support systems, including artificial respiration, cardiopulmonary resuscitation, and artificial means of nutrition and hydration may be provided, withheld, or removed but does not mean that the patient will not be provided measures of pain control or comfort.

What is Living will?

Ex.

What is Living will?

Forms vary state to state and include state definitions (such as "terminally ill" and "life sustaining treatment") Usually applies when patient is terminally ill; not all states include persistent vegetative state (vegetative state means kept alive by medical intervention) No designation of agent or surrogate decision maker Living will must select or exclude certain provisions of care based on the illness/injury Physicians make decisions based on interpretation of the living will

What are the three basic elements for the capacity for decision making?

1. Ability to evaluate different options

2. The ability to communicate and understand information

3. The ability to reason and to discuss about one's choices

Durable Power Of Attorney (counselor) for Health Care

• In the durable power of attorney for healthcare document, a competent adult appoints a proxy decision maker.

• Determination of capacity for decision making is done by a primary physician or judicial hearing in the court.

• Ideally, the patient chooses a surrogate with whom a trusted relationship has been established, often a family member or close friend who knows the patient well enough to have had discussions pertaining to end-of-life decisions and treatment choices.

• The agent's intent should be to protect the patient's wishes or to act in a manner that fosters the best interests of the patient if the patient's wishes are not known.

• If the surrogate is not acting in a manner consistent with this or is making what appear to be inappropriate decisions, the nurse needs to protect the patient from the harm. Then, reporting to the patient's physician, the nursing supervisor, and the ethics committee.

Durable power of attorney/healthcare proxy (DPOAHC):

• a. Authority is effective upon determination that the patient lacks capacity

• b. Ceases effectiveness (revoked) upon recovered capacity of the patient

• c. Capacity determination is made by primary physician or judicial process

• d. Decisions are made in accord with patient instruction; absent instruction, decisions are made to the best interest and personal values of the patient

• e. Usually must be in writing with witness (unless state statute specifies otherwise)

• f. Some states may recognize oral advance directive under certain conditions, such as statement to healthcare provider or to specified surrogate (such as spouse or adult child)

Advance Directives for Health Care

• Do Not Resuscitate Orders:

• Implementation of CPR does not require an order, yet withholding CPR does.

• under various institutions' policies on CPR, other measures, such as intubation, may be included and need to be expressly excluded if the patient only desires CPR without intubation.

• States that do have statutes regarding DNR orders presume the patient's consent to CPR unless there is a written order by a physician responsible for the patient's care and may require it be witnessed.

• For surrogate decision making to become effective when the patient lacks capacity, the primary physician and a concurring physician will need to document the existence of a terminal condition and that resuscitation is useless.

• An automatic suspension of DNR orders in the perioperative setting would violate self determination, but rather DNR orders should be reviewed with the patient and family prior to the surgical procedure.

What is Nurse's Role in advance directives?

• Nurses' responsibility in advance directives is to educate, document, and communicate.

• The nurse should document if the patient has signed advance directives or not (and place a copy in the medical record.

• The nurse should also communicate the existence of advance directives, including any changes by the patient, to the primary physician.

• Not communicating the fact that a written living will exists or that the patient made statements regarding end-of-life decisions acts to deny the patient's rights of autonomy and self-determination and sets the stage for a legal cause of action against providers.

• the ANA suggests that nurses question patients upon admission as to the existence of any advance directives. If none are in place, they should ask if the patient desires to create such a directive.

• Educating the patient about the advance directive:

• If so, the nurse has the responsibility to see that the patient has the information needed to make an informed decision about treatment and options.

• The nurse should encourage the patient to ask questions about medical issues.

• The nurse also should encourage the patient to be as clear as possible about the choices.

• If the statements by the patient are of a general nature, such as "no machines to keep me alive," it is the nurse's responsibility to educate the patient.

• Termination of Life Support

• Terminating life support requires following the patient's written instructions, state statutes (rules) on determining the patient's wishes.

• Standards:

• The Joint Commission addresses compliance with a patient's wishes regarding end of-life decisions (2008, Standard RI 2.80). The patient receives information on the right to accept or refuse treatment, including resuscitation.

Surrogates

• surrogate may make a decision to withdraw "or withhold life sustaining treatment when the patient lacks capacity.

• Surrogate decisions effective when a patient has not executed advance directives or appointed an agent by DPOAHC or the agent appointed is not reasonably available. The physician responsible for care determines if the patient is terminal or permanently unconscious (defined by state statutes).

The surrogate is responsible to communicate to others that the surrogate has assumed authority. The statute will list the

classes in order of priority but in general the order is as follows:

• 1. Spouse, which may include an adult who shares emotional, physical, and financial relationship of a spouse; revoke if legally separated

• 2. Adult children• 3. Parent• 4. Adult siblings• S. Adult grandchildren• 6. Adult nieces, nephews, uncles, aunts• 7. Adult relative who is familiar with the patient• 8. If no members previously listed are available, then an

adult who has exhibited concern of the patient and shares values with the patient

What would happen in case of Conflicts?

• When there are numerous members of a class, the majority decision is respected.

• If the class is split, the providers may refer the case to the ethics committee or other third-party mediator or to a court.

• If it cannot be resolved, the class may be disqualified and the next priority class consulted.

Liability

• If medical providers do not follow the instructions of an advance directive, they subject themselves to the same inquiry and consequences that would occur if they ignored a refusal to treatment.

• Some statutes state that healthcare providers must comply with the instructions in a living will. However, in some cases a physician who cannot do so for reasons of conscience can choose to not follow through with the directive.

• However, there may be a statutory duty to advise the patient and the patient's family of this policy at the time of admission to the facility so that they may be given the option of transferring the patient to a provider who will honor the directive.

• Finally, nurses or other medical personnel should not sign as witnesses for any advance directive. The nurse works too closely with the patient, and in certain circumstances, the claims of excessive influence could surface.

• In most states, the law prevents nurses or other healthcare providers from acting as surrogates for health care for patients. In most states, the advance directive statutes prevent nurses or other health care providers from being named as their patients' healthcare agent unless there is a blood relationship.

Thank You