Transcript Ethics in Long Term Care

End of Life:
Planning and Care
Terence Grewe, D.O.
Corporate Medical Director
Trinity Hospice, LLC
Ethics in Long Term Care
 Ethical Principles
 Advanced Planning
 Withholding/ Withdrawing Therapy
 Medical Futility
 Physician Assisted Suicide
 Hospice and Palliative Medicine
Ethical Principals
 Beneficence: physicians are obligated act
always in the patient’s best interest
 Nonmaleficence: physicians are obligated
to do no harm
 Autonomy: patients have a right to make
their own decisions
 Justice: physicians should treat patients
with similar conditions equally
Decision-Making Capacity
 Patient’s ability to understand
information
 To make decisions based on the
information
 To communicate a choice
Decision-Making Capacity
 May be temporarily compromised by:
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Drugs
Psychological disturbances
Medical conditions
Advancing disease
 Is not always the same as competence
Determining Decision-Making
Capacity
 Frequent observations by physicians,
family, surrogates, and other health care
professionals
 Asking the patient to paraphrase topics
under discussion
 Psychiatric consultations
 Mental status tests (MMSE, etc.)
Decision Making Capacity
 Patients should be considered to have
decision-making capacity when in doubt
 When a patient lacks capacity, previously
expressed wishes should be honored
Decision Making Capacity
 Surrogate decision makers should attempt
to make decisions based on what the
patient would want as well as their best
interest
Advanced Planning
 Advanced Care Planning
 Advanced Directives
 Power of Attorney for Health Care
 Surrogates
What is advance care planning?
...
 Process of planning for future medical
care
 Values and goals are explored,
documented
 Determine proxy decision maker
 Professional, legal responsibility
. . . What is advance care
planning?
 Trust building
 Uncertainty reduced
 Helps to avoid confusion and conflict
 Permits peace of mind
5 steps for successful advance
care planning
1. Introduce the topic
2. Engage in structured discussions
3. Document patient preferences
4. Review, update
5. Apply directives when need arises
Step 1: Introduce
the topic
 Be straightforward and routine
 Determine patient familiarity
 Explain the process
 Determine comfort level
 Determine proxy
Step 2: Engage is structured
discussions
 Proxy decision maker(s) present
 Describe scenarios, options for care
 Elicit patient’s values, goals
 Use a worksheet
 Check for inconsistencies
Role of the proxy
 Entrusted to speak for the patient
 Involved in the discussions
 Must be willing, able to take the proxy role
Patient and proxy education
 Define key medical terms
 Explain benefits, burdens of treatments
 Life support may only be short-term
 Any intervention can be refused
 Recovery cannot always be predicted
Elicit the patient’s values and
goals
 Ask about past experiences
 Describe possible situations
 Write a letter
Use a validated advisory
document
 A number are available
 Easy to use
 Reduces chance for omissions
 Patients, proxy, family can take home
Step 3: Document patient
preferences
 Review advance directive
 Sign the documentation
 Enter into the medical record
 Recommend statutory documents
 Ensure portability
Step 4: Review, update
 Follow up periodically
 Note major life events
 Discuss, document changes
Step 5: Apply directives
 Determine applicability
 Read and interpret the advance directive
 Consult with the proxy
 Ethics committee for disagreements
 Carry out the treatment plan
Common pitfalls
 Failure to plan
 Proxy absent for discussions
 Unclear patient preferences
 Focus too narrow
 Communicative patients are ignored
 Making assumptions
Preparation for the
last hours of life . . .
 Advance planning
 personal choices
 caregivers
 setting
 Loss, grief, coping strategies
. . . Preparation for last hours of
life
 Educating / training patients, families and
caregivers
 communication
 tasks of caring
 what to expect
 physiologic changes, events
 symptom management
Advance practical planning . . .
 Financial, legal affairs
 Final gifts
 bequests
 organ donation
 Autopsy
. . . Advance practical planning
 Burial / cremation
 Funeral / memorial services
 Guardianship
Choice of caregivers
 Be family first, caregivers only if
comfortable
 everyone comfortable in the role
 seek permission
 change roles if stressed
Choice of setting . . .
 Burdens, benefits weighed
 Permit family presence
 privacy
 intimacy
. . .Choice of setting
 Minimize family burden
 risk to career, personal economics, health
 ghosts
 Alternate setting as backup
Advanced Directives
 Allow patients to make decisions on health
care issues while the still have capacity
 Become effective when the patient loses
decision making capacity
 Living will: documents that state the
patients desires
Durable Power of Attorney for
Health Care
 Designates a person to act as an agent or
proxy to make decisions on behalf of the
patient
 In absence usually spouse, then adult
children, parents, and siblings
Withholding or Withdrawing
Therapy
 Principles for withholding or withdrawing
therapy
 Withholding or withdrawal of
 artificial feeding, hydration
 ventilation
 cardiopulmonary resuscitation
Role of the physician . . .
 The physician helps the patient and
family
 elucidate their own values
 decide about life-sustaining treatments
 dispel misconceptions
 Understand goals of care
 Facilitate decisions, reassess regularly
. . . Role of the physician
 Discuss alternatives
 including palliative and hospice care
 Document preferences, medical orders
 Involve, inform other team members
 Assure comfort, nonabandonment
Common concerns . . .
 Legally required to “do everything?”
 Is withdrawal, withholding euthanasia?
 Are you killing the patient when you
remove a ventilator or treat pain?
. . . Common concerns
 Can the treatment of symptoms constitute
euthanasia?
 Is the use of substantial doses of opioids
euthanasia?
Life-sustaining treatments
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Resuscitation
Elective intubation
Surgery
Dialysis
Blood transfusions,
blood products
 Diagnostic tests
 Artificial nutrition,
hydration
 Antibiotics
 Other treatments
 Future hospital, ICU
admissions
8-step protocol to discuss
treatment preferences . . .
1. Be familiar with policies, statutes
2. Appropriate setting for the discussion
3. Ask the patient, family what they
understand
4. Discuss general goals of care
. . . 8-step protocol to discuss
treatment preferences
5. Establish context for the discussion
6. Discuss specific treatment preferences
7. Respond to emotions
8. Establish and implement the plan
Aspects of informed consent
 Problem treatment would address
 What is involved in the treatment /
procedure
 What is likely to happen if the patient
decides not to have the treatment
 Treatment benefits
 Treatment burdens
Example 1: Artifical feeding,
hydration
 Difficult to discuss
 Food, water are symbols of caring
 PEG tubes and artificial hydration may
actually induce suffering
Review goals of care
 Establish overall goals of care
 Will artificial feeding, hydration help
achieve these goals?
Address misperceptions
 Cause of poor appetite, fatigue
 Relief of dry mouth
 Delirium
 Urine output
Help family with need to give
care
 Identify feelings, emotional needs
 Identify other ways to demonstrate caring
 teach the skills they need
Normal dying
 Loss of appetite
 Decreased oral fluid intake
 Artificial food / fluids may make situation
worse
 breathlessness
 edema
 ascites
 nausea / vomiting
Example 2: Ventilator
withdrawal
 Rare, challenging
 Ask for assistance
 Assess appropriateness of request
 Role in achieving overall goals of care
Immediate extubation
 Remove the endotracheal tube after
appropriate suctioning
 Give humidified air or oxygen to prevent
the airway from drying
 Ethically sound practice
Terminal weaning
 Rate, PEEP, oxygen levels are decreased
first
 Over 30–60 minutes or longer
 A Briggs T piece may be used in place of
the ventilator
 Patients may then be extubated
Ensure patient comfort
 Anticipate and prevent discomfort
 Have anxiolytics, opioids immediately
available
 Titrate rapidly to comfort
 Be present to assess, reevaluate
Prevent symptoms
 Breathlessness
 opioids
 Anxiety
 benzodiazepines
Prepare the family . . .
 Describe the procedure
 Reassure that comfort is a primary
concern
 Medication is available
 Patient may need to sleep to be
comfortable
Example 3: Cardiopulmonary
resuscitation
 Establish general goals of care
 Use understandable language
 Avoid implying the impossible
 Ask about other life-prolonging therapies
 Affirm what you will be doing
Write appropriate medical
orders
 DNR
 DNI
 Do not transfer
 Others
Medical Futility
 Patients / families may be invested in
interventions
 Physicians / other professionals may be
invested in interventions
 Any party may perceive futility
Definitions of
medical futility
 Won’t achieve the patient’s goal
 Serves no legitimate goal of medical
practice
 Ineffective more than 99% of the time
 Does not conform to accepted community
standards
Is this really a futility case?
 Unequivocal cases of medical futility are
rare
 Miscommunication, value differences are
more common
 Case resolution more important than
definitions
Conflict over treatment
 Unresolved conflicts lead to misery
 most can be resolved
 Try to resolve differences
 Support the patient / family
 Base decisions on
 informed consent, advance care planning,
goals of care
Differential diagnosis of futility
situations
 Inappropriate surrogate
 Misunderstanding
 Personal factors
 Values conflict
Surrogate selection
 Patient’s stated preference
 Legislated hierarchy
 Who is most likely to know what the patient
would have wanted?
 Who is able to reflect the patient’s best
interest?
 Does the surrogate have the cognitive ability
to make decisions?
Misunderstanding of diagnosis /
prognosis
 Underlying causes
 How to assess
 How to respond
Misunderstanding: underlying
causes . . .
 Doesn’t know the diagnosis
 Too much jargon
 Different or conflicting information
 Previous overoptimistic prognosis
 Stressful environment
. . . Misunderstanding:
underlying causes
 Sleep deprivation
 Emotional distress
 Psychologically unprepared
 Inadequate cognitive ability
Misunderstanding:
how to respond . . .
 Choose a primary communicator
 Give information in
 small pieces
 multiple formats
 Use understandable language
 Frequent repetition may be required
. . . Misunderstanding: how to
respond
 Assess understanding frequently
 Do not hedge to “provide hope”
 Encourage writing down questions
 Provide support
 Involve other health care professionals
Personal factors
 Distrust
 Guilt
 Grief
 Intrafamily issues
 Secondary gain
 Physician / nurse
Types of futility conflicts
 Disagreement over
 goals
 benefit
Difference in values
 Religious
 Miracles
 Value of life
A due process
approach to futility . . .
 Earnest attempts in advance
 Joint decision making
 Negotiation of disagreements
 Involvement of an institutional committee
. . . A due process approach to
futility
 Transfer of care to another physician
 Transfer to another institution
Euthanasia and PhysicianAssisted Suicide
 Proponents stress patient autonomy and
mercy
 Opponents claim harm to patients
 Patient’s request for PAS should signal a
problem with the patient’s care
 Expert palliative care can eliminate the
desire for PAS
The legal and
ethical debate . . .
 Principles
 obligation to relieve pain and suffering
 respect decisions to forgo life-sustaining
treatment
 The ethical debate is ancient
 US Supreme Court recognized
 NO right to PAS
. . . The legal and
ethical debate
 The legal status of PAS can differ from
state to state
 Oregon is the only state where PAS is
legal (as of 1999)
 Supreme Court Justices supported
 right to palliative care
6-step protocol to respond to
requests . . .
1. Clarify the request
2. Assess the underlying causes of the
request
3. Affirm your commitment to care for the
patient
. . . 6-step protocol to respond
to requests
4. Address the root causes of the request
5. Educate the patient and discuss legal
alternatives
6. Consult with colleagues
Hospice and Palliative Medicine
 When cure is not possible, treatment goals
change
 From prolonging life to controlling
symptoms
 Emphasis on advanced planning and
ongoing care rather than crisis intervention
Palliative Treatments
 Enhance comfort
 Improve quality of life
 Relieve symptoms and suffering
 Includes medicines, therapies and
sometimes radiation, surgery, etc. To
improve quality of life
End of Life Issues
 Recognize life-ending disease processes
and address them with patients and
families
 Help patients make end-of-life decisions
such as living wills, power of attorney and
DNR
 Consider Hospice and Palliative care
when cure is not an option
End of Life
Physicians can help patients and
their families face the end-of -life,
make reasonable end-of -life
decisions and eliminate suffering
to allow the patient to live their last
days to the fullest