“Instructions on Current Life-Sustaining Treatment Options” Form: Objectives and Use

1. “Instructions on Current Life-Sustaining Treatment Options” Form: Objectives and Use Jack Schwartz Attorney General’s Office April 2008

2. What’s 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 patient’s values and beliefs • Because this pathway provides the best care, given the patient’s condition

4. Bad Answers to the “Why?” Question • Because Doctor X always does it this way • Because it’s too soon after surgery for the patient to die • Because Relative Y said she’d sue us if we didn't • We just went ahead, we don’t 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 patient’s 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 physician’s 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

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 physician’s orders • Must be reviewed if material change in patient’s 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 General’s Office • Intended to: • Make explicit the process for quality care delivery • Can be adapted in facility policies • Identifies key steps and rationale for each • http://www.oag.state.md.us • Click on “Health Policy” • Click on “Ethical Framework”

24. Additional Resources • www.oag.state.md.us • 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