Transcript advance directive - American Association for Thoracic Surgery

When Is Delegation Of DecisionMaking Appropriate?
Cardiothoracic Ethics Forum: Surgical Ethics Course
AATS 95th Annual Meeting
Seattle
April 25, 2015
Thomas A. D’Amico MD
Gary Hock Endowed Professor and Vice Chair of Surgery
Chief Thoracic Surgery
Chief Medical Officer, Duke Cancer Institute
Disclosure
Member, STS Standards and Ethics Committee
No conflicts related to this presentation
Case
• A 76-year old woman with bone-only metastatic
breast cancer developed shortness of breath
• CT: complex left pleural effusion, recurrent after
2 attempts of thoracentesis, cytology positive
• No documentation in EMR of relief of SOB
• Thoracic Surgery is consulted and she undergoes
left VATS drainage of effusion, decortication and
talc pleurodesis
Case
• No complications in the immediate post-op
period, although her CXR is not improved
• POD #3, she develops mental status changes
• The chart from the current hospitalization does
not document extent of disease or goals of care
• She does have an Advanced Directive on the
chart, but her status is not DNAR
• She has never had a Palliative Care Consult
Case
• No documentation that she has indicated which
of her 2 sons* has health care power of attorney
• POD 5: Progressive respiratory distress,
hemodynamic instability, and MS changes
• Family consultation with thoracic surgery care
team and medical oncologist (who refuses
Palliative Care consultation): continue aggressive
care, plan for Herceptin therapy. No DNAR
Case
• POD6: Respiratory arrest. Intubated and
resuscitated, requiring inotropic support
• POD 7-9: No improvement; unresponsive
• Palliative Care Consult
• POD 10: Conference with 1 son regarding the
specifics of the Advance Directive and what the
patient would have wanted in this condition
• POD 11: Meeting with both sons and pastor
Opportunities for Improvement
• The decision to operate was not based on
objective evidence (? Improve SOB)
• The care team was not aware of extent of disease
or goals of care
• The treating oncologist did not understand the
benefit of Palliative Care consultation
• The Palliative Care team was restricted by the
medical oncologist
Unpredictable Obstacles
• The family disregarded the Advance Directive
• It was difficult to have a conference that included
all of the surrogate decision-makers
• Delegation of decision-making was to the
oncologist and pastor
Common Delegation Of Decision-Making
1.
2.
3.
4.
Incompetent patients
Anesthetized patient in the OR
Unconscious patient in the ICU
Patients who request delegation
5. Children
Capacity for Medical Decision-Making
• Possession of values and goals
• Ability to communicate and understand
information
• The ability to reason and to deliberate about
one’s choices
President’s Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research (1982)
Incapacity
•
•
•
•
May be periodic
May be decision-specific
May be reversible
Not related to age, refusal of care, medical
diagnosis, social status
• ? Level of education
Surrogate Decision-Making
1.
2.
3.
4.
Directed Decision-Making (living will)
Delegated Decision-Making (power of attorney)
Devolved Decision-Making (default surrogate)
Displaced Decision-Making (court, guardian)
5. Deferred Decision-Making (physician)
Living Will
• Less than 1/4 of adult patients have completed a
living will
• Up to 1/2 of patients express strong desire to
share decision-making
• As many as 3/4 of adults admit that they would
prefer their health care providers to override their
stated preferences from living will in favor of
family’s directly opposing preferences
Surrogate Decision-Making
AMA Opinion 8.081
• Competent adults may formulate, in advance,
preferences regarding a course of treatment in the
event that injury or illness causes severe
impairment or loss of decision-making capacity
• These preferences generally should be honored
by the health care team out of respect for patient
autonomy
Surrogate Decision-Making
• Patients may establish an advance directive by
documenting their treatment preferences and
goals in a living will or by designating a health
care proxy (durable power of attorney for health
care) to make health care decisions on their
behalf
Surrogate Decision-Making
• When there is evidence of patient’s preferences
and values, decisions concerning the patient’s
care should be made by substituted judgment
• Consider the patient’s advance directive (if any),
the patient’s views about life and how it should
be lived, how the patient has constructed his or
her identity or life story, and the patient’s
attitudes towards sickness, suffering, and certain
medical procedures
Surrogate Decision-Making
• If there is no reasonable basis on which to
interpret how a patient would have decided, the
decision should be based on the best interests of
the patient…best promote the patient’s well-being
• Factors considered when weighing the harms and
benefits of various treatment options include the
pain and suffering associated with treatment, the
degree of and potential for benefit, and any
impairments that may result from treatment
Surrogate Decision-Making
• Any quality of life considerations should be
measured as the worth to the individual whose
course of treatment is in question, and not as a
measure of social worth
• One way to ensure that a decision using the best
interest standard is not inappropriately influenced
by the surrogate’s own values is to determine the
course of treatment that most reasonable persons
would choose in similar circumstances
Surrogate Decision-Making
• Physicians should recognize the proxy or
surrogate as an extension of the patient, entitled
to the same respect as the competent patient
• Physicians should provide advice, guidance, and
support; explain that decisions should be based
on substituted judgment when possible and
otherwise on the best interest principle; and offer
relevant medical information and opinions
Surrogate Decision-Making
• In general, physicians should respect decisions
that are made by the appropriately designated
surrogate and based on the standard of
substituted judgment or best interest
• In cases where there is a dispute among family
members, physicians should work to resolve the
conflict through mediation
Surrogate Decision-Making
• Physicians/ethics committee should uncover the
reasons that underlie disagreement and present
information that will facilitate decision-making
• When a physician believes that a decision is
clearly not what the patient would have decided,
not be reasonably judged to be in the patient’s
best interests, or primarily serves the interest of a
surrogate/third party, an ethics committee should
be consulted before requesting court intervention
Surrogate Decision-Making
• Physicians should encourage patients to
document treatment preferences or to appoint a
health care proxy and discuss their values
regarding health care and treatment in advance
• Because documented advance directives are often
not available in emergency situations, physicians
should emphasize to patients the importance of
discussing treatment preferences with individuals
who are likely to act as their surrogates
Power of Attorney
Advantages
1. Promotes Autonomy
2. Avoids guardianship
3. Cost reduction
4. Takes pressure off
family members
Disadvantages
1. Lack of monitoring
2. No standard of conduct
for agent (substituted
judgment, best interest)
3. Broad authority
4. ? Risks (Brooke Astor
Case)
Advance Directives
1.
2.
3.
4.
Most people do not have one
Forms may be difficult to understand
May change their mind
Health care providers may not be aware of
existence or location
5. Incorporation in EMR?
Advance Directives: Advantages
1. Starts communication regarding goals of care
2. Existence alone may cause care-givers to stop
and think before decision-making
3. Empowers the patient
4. Existence of a current Advance Directive is more
likely to lead to updated Directives, with age, comorbidities, change in family structure
Physician Orders for Life Saving (POLST)
• Standardizing physician EOL orders to
implement patients’ goals of care
• Requires exploring care goals: abx, CPR,
intubation, comfort
• MD orders in bright pink
28
29
POLST Distribution in US
Default Surrogates (Family)
•
•
•
•
Priority of surrogates
Scope of decision-making authority
How are disagreements handled?
Close friend vs family
Deferring to the Physician
1. Spectrum of patient trust, from skepticism to
trust to dependence
2. For surgery, varying degree in the use if
decision-making aids
3. What are the barriers to communication?
Barriers to effective EOL conversations
• 1040/1234 potential subjects (84.3%) participated
• 29 participants : development cohort
• Codes validated by analyses of responses from 50
randomly drawn subjects from the validation
cohort (n= 996 doctors)
• 99.99% reported barriers to conduct EOL
conversations, with 85.7% admitting it is very
challenging, especially to pts of different ethnicity
Barriers to effective EOL conversations
1.
2.
3.
4.
Language and medical interpretation issues
Religio-spiritual beliefs about death and dying
Doctors’ ignorance of pt cultural beliefs, values
Patient/family's cultural differences in truth
handling and decision making
5. Patients’ limited health literacy
6. Patients’ mistrust of doctors and the health care
system
Doctors rate the relative importance of the 6 primary barriers to effective EOL conversations
Role Reversal in the Conversation on Dying
https://www.youtube.com/watch?v=vApg3qAn55s&feature=youtu.be
Summary
• The need for surrogate-decision making,
especially at end-of-life, often complicates
patient care
• Living Wills, Advance Directives, Health Care
Powers Of Attorney, POLST all contribute to
improving the decision-making process
• All are underused for a variety of reasons
• Talk to patients before operating on them
Surrogate Decision-Making: Issues
1. Patient Capacity
2. Health Care Power of Attorney
3. Advance Directive
4. Guardianship
Capacity
Must be judged according to a standard set by that
person’s own habitual or considered standards of
behavior and values, rather than by conventional
standards held by others
Silberfield and Fish, When the Mind Fails (1994)