Ch. 46 Futility of Care Ch. 47 Advance Directives and End-of-Life Decisions

1. Ch. 46 Futility of CareCh. 47 Advance Directives and End-of-Life Decisions This is an interactive review of Ch. 46 & Ch. 47 material.

2. What law outlines a patient’s right to predetermine his or her own life-and-death decisions regarding medical care? • Informed consent • Advanced Directive • Patient Self-Determination Act of 1991 • American Medical Association’s Code of Ethics of 1997

3. The process by which a fully informed patient participates in choices about his or her health care. • Informed consent • Advanced Directive • Patient Self-Determination Act of 1991 • American Medical Association’s Code of Ethics of 1997

4. A Patient’s written instructions for life-sustaining care, to be used when the person is incapacitated. • Informed consent • Advanced Directive • Patient Self-Determination Act of 1991 • American Medical Association’s Code of Ethics of 1997

5. Treatment that does not return the patient to full function or meaningful “quality of life”? • Life-sustaining care • Palliative care • Futile Care • Restorative care

6. Another aspect of the term “futile” is that the treatment itself ordinarily would be effective, but the patient’s quality of life is not perceived to be: • what it used to be • long-lasting • Worth the expense • Worth prolonging

7. “Futile treatment” Defined • It fails to provide the patient with any therapeutic benefit • It has no physiologic effect on the body • It goes against the patient’s wishes • It merely prolongs the patient’s permanent unconscious state

8. “Futile treatment” should not be confused with: • Life-sustaining care • Palliative care • Ineffective treatment • All of these

9. Case of J.M. J.M. had a massive bilateral hemorrhagic CVA that rendered him “brain dead.” In the absence of an advanced directive, medical personnel sustained his life until relatives arrived. J.M. was on a ventilator and artificial hydration/nutrition to keep him alive.

10. Case of J.M. All tests revealed that J.M.’s condition was irreversible and that he would not regain consciousness or any level of meaningful functioning. The family was informed about his condition. In the absence of a written advance directive, J.M.’s family would need to act as his healthcare proxy, making his healthcare decisions.

11. Case of J.M. While this was a very difficult and heart- rending experience, the family discussed what J.M. would have wanted in this case. Thankfully all family members agreed that J.M. would not have wanted his life sustained under these circumstances.

12. Case of J.M. After saying their goodbyes to J.M., the family told the health care team to move forward with ending artificial life- sustaining measures. Pain management was continued. J.M. was taken off of the ventilator and he expired within an hour.

13. Determining the case: Would J.M.’s treatment have fallen under the “futile treatment” definition if he had continued to be treated? Would treatment have benefited J.M.? Would treatment have had a physiologic effect on J.M.’s body? Would treatment have been in keeping with the patient’s wishes? Would treatment prolonged J.M.’s permanent unconscious state?

14. Who decides these questions? First, Physician- Patient relationship: Physician’s professional judgment and pt’s informed consent as the boundary But, in the case of J.M, he could not give his informed consent because he was unconscious.

15. Who decides these questions? Second, the collective decisions of the pt, the physician, the family members, the agency, and judges. In the case of J.M., it was the collective decisions of the physician and the family members that worked together.

16. Who decides these questions? Third, if necessary the courts become involved in the process. In the majority of cases, courts hold that medical care should be continued, especially if the pt’s family wish the treatment to continue.

17. Patients have the right to refuse tx, but do they have a right to demand futile treatment? • State statutes addressing a patient’s right to refuse tx often include statements that these acts do not require physicians to give medically inappropriate (futile) care.

18. What are the three types of “advance directives”? • Living will • Durable power of attorney for health care • Advance directive for health care

19. In a Durable Power of Attorney for Health care, all are true statements except: • The adult appointing a surrogate decision- maker must be a competent adult • Competency = capacity to make decisions • The surrogate decision-maker begins making decisions at the time the document is signed. • Physician/court decides questions of pt. capacity / competence

20. In a Durable Power of Attorney for Health care, the surrogate decision-maker: • Should act to protect the pt’s wishes and /or in the pt’s best interests • Is a person chosen by the patient’s family • Is a person appointed by a court • Can spend the pt’s money as s/he sees necessary

21. An Advance Directive begins to be enforced when: • The competent adult signs the document • The court determines that the document is properly signed and witnessed • The individual becomes incapacitated as deemed by a physician or court • The pt’s family agrees to the timing

22. “Capacity” for decision making includes: • Ability to evaluate different options • Ability to communicate and understand information • Ability to reason and to deliberate about one’s choices • A, B, and C

23. Often a statement from one or two physicians indicating that the patient’s condition is not expected to improve is required prior to any action related to a Living Will. TRUE FALSE

24. Life support systems include artificial respiration, CPR, artificial hydration/nutrition, and pain management/control. TRUE FALSE. Pain control is considered separate from these other measures.

25. The authority of a Durable Power of Attorney for Health care is automatically revoked if/when the patient recovers “capacity.” TRUE FALSE

26. A patient’s written wishes referring specifically to his/her status becoming “terminal” or “permanently unconscious.” • Living Will • Durable Power of Attorney for Health Care/Health Care Proxy • Advance directive for health care • A or C

27. Based on your understanding of the readings so far, what is a “proxy”? • A document that authorizes a person to act on behalf of another. • An individual who has been granted authority to speak or act on behalf of another. • A law that determines the level of competence of an individual • None of these

28. Case law has indicated that people with a mental disability should not be allowed to execute advance directives. TRUE FALSE

29. Standards in practice and state laws presume CPR will be initiated unless a written order precludes it. TRUE FALSE

30. An automatic suspension of DNR orders in the perioperative setting would violate self-determination rights of the patient. TRUE FALSE

31. A patient makes changes to his advance directive and informs the nurse. She should: • Call the pt’s family to inform them of the changes • Communicate the changes to the pt’s primary physician • Deal with the issue later • Try to persuade the pt to reconsider making changes

32. A “persistent vegetative state” is a condition in which a patient exhibits reflexes but no significant cognitive function. TRUE FALSE

33. Termination of life support requires: • Following the pt’s written instructions • Following state statutes • Following relevant case law on determining the patient’s wishes • All of these

34. In Cruzan v. Director, Missouri Department of Health, multiple courts mandated the continued artificial nutrition/hydration of the patient because there was a lack of “clear and convincing evidence” regarding the pt’s wishes as to the withdrawal of treatment. TRUE FALSE

35. When a patient lacks “capacity” and s/he has not executed a DPOAHC or advance directive, the hospital’s ethics committee automatically begins to make decisions on behalf of the patient. TRUE FALSE. A surrogate—spouse, adult child, parent, etc. may begin to make decisions for the patient.

36. Not following a pt’s instructions in his/her advance directive will result in similar consequences as if a health care provider were to have: • Disregarded the pt’s refusal of tx • Committed abuse upon the pt • Violated HIPAA standards • Committed malpractice

37. Nurses and other health care personnel may sign as witnesses for their patients’ advance directives, so long as they can prove that they have not unduly influenced the patient. TRUE FALSE.