Telling Medical Providers What to Do When You Can’t Tell Them What You Want Them to Do: Advance...

Te l l i n g M e d i c a l P r o v i d e r s W h a t t o D o W h e n Yo u C a n ’ t Te l l T h e m W h a t

Yo u W a n t T h e m t o D o : A d v a n c e D i r e c t i v e s & M e d i c a l O r d e r s F o r

S c o p e o f T r e a t m e n t ( M O S T )

G o o d t o G oO c t o b e r 2 0 , 2 0 1 5

revised 9/14/15

John A.K. Boyd, MDMRMC Ethics Committee Chair

Historical Perspective

• 1930 – my grandfather builds the first hospital in Wickenburg AZ (penicillin not discovered till 1928 and not available until 1941)

• 1960 – my father dies in the Phoenix VA hospital of an MI at the age of 43 (the first ICU was established in 1958)

• 1972 – I start medical school (high tech life support now available)

Dr. James Alfred Copeland (1871-1941), circa 1937

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Common Problem Case Scenarios

• Grandpa breaks his hip.– develops pneumonia and

ARDS– aunt Lucie from California

shows up at the 11th hour• Persistent Vegetative State

(PVS)

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Persistent Vegetative State(PVS)

• due to injury of the upper brain sparing the brain stem

• characterized by the return of sleep-wake cycles and of various reflex activities, but wakefulness is without awareness

• can “live” for years on tube feedings

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Informed Consent

• the basis for modern medical ethics

• historically a response to the Nuremburg trials

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Informed Consent

Prior to being treated:– the patient will receive a

description of the treatment to include its risks, benefits and alternatives, and

– the patient will agree to accept the treatment.

MRMC Policy

Definition of

Decisional Capacity

1) the ability to comprehend information relevant to the treatment being offered, and

2) the ability to deliberate in accordance with his/her own values and goals, and

3) the ability to communicate with care givers.

A patient has decisional capacity to consent to or to refuse treatment when the patient has:

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Advance DirectivesAvailable in Colorado

• Living Will• Medical Durable Power of

Attorney• CPR Directive

“Advance Directive” means an expression of treatment preferences, guidelines, or instructions regarding medical treatment made by an individual, or for an individual by that individual’s authorized agent, in advance of the need for such treatment.

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Living Will

• a written statement made when a patient (declarant) has decisional capacity which gives directions for withholding or withdrawing certain life- sustaining procedures when the patient:

1) has a terminal condition or PVS and2) has lost decisional capacity.

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“Terminal Condition”Colorado Law Definition

“Terminal Condition” means an incurable or irreversible condition for which the administration of life-sustaining procedures will serve only to prolong the dying process.”

Living Will

• must still have 2 witnesses• two physicians must certify terminal

condition or PVS• may include other instructions for care

following certification of terminal illness/PVS

• may include a list of persons to be notified of that certification, as well as a list of persons with whom healthcare providers may discuss the declarant’s condition and care

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Medical Durable Power of Attorney(MDPOA)

• a written statement made when a patient has decisional capacity which appoints specific surrogate decision-makers (agents)

• not limited to a terminal condition or PVS• takes effect at time of signature or when patient

loses decisionality• witness recommended but not required

When Can Your MDPOA Agent Begin Making Decisions?

Living Will vs MDPOA

Proxy Decision-Makers For Medical Treatment

CRS 15-18.5-103

• Used to establish a surrogate decision maker when there is no Medical Durable Power of Attorney or Guardian.

• Physician must declare that the patient has lost decisional capacity.

• Physician (or representative) contacts “interested persons.”

• “Interested persons” choose the proxy decision-maker.

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Colorado Designated Beneficiary Act (CRS 15-22-101-111)

• allows for two adult (over 18) persons to designate each other as beneficiaries of a number of items and instruments related to health care, medical emergencies, incapacity, death, and administration of estates

• the two adults cannot be married to each other or anyone else nor party to any other DB agreement

• a DB may assign the other DB the right to act as a Proxy Decision-Maker

CPR Directive• A written order signed by a patient with

decisional capacity and his/her physician instructing pre-hospital emergency personnel and other providers to withhold CPR (cardiopulmonary resuscitation).

• May be signified by wearing a necklace or bracelet.

CPR Directive Bracelet or Necklace

A unique and easily identifiable logo is engraved on the front side of the metal bracelets and necklaces. The name, birth date, sex, and race of the declarant are engraved on the back side along with the words "DO NOT RESUSCITATE." Wearing a bracelet or necklace is encouraged but not mandatory.

Ordering a No-CPRBracelet or Necklace

For more active folks with CPR directives, a special no-CPR bracelet or necklace can be obtained from: • Award and Sign Connection (http://

awardandsign.com/ or 303.799.8979) or • MedicAlert Foundation (

http://www.medicalert.org/ or 888.633.4298).

Out-of-Hospital CPR Outcomes

UpToDate 1/22/15• “resuscitation from out-of-

hospital Sudden Cardiac Arrest (SCA) is successful in only one-third of patients”

• “only about 10 percent of all patients are ultimately discharged from the hospital, many of whom are neurologically impaired”

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In-Hospital CPR Outcomes

UpToDate 1/22/15• “the outcome of patients who experience SCA

in the hospital is poor”• “49 percent of patients had return of

spontaneous circulation”• “15 percent overall survival to hospital

discharge”

Nursing Home CPR OutcomesPrehosp Emerg Care; Apr-Jun, 1997;

“Outcomes of cardiac arrest in the nursing home: destiny or futility?”

• 182 nursing home patients received CPR from July 1989-December 1993

• none survived

UpToDate Review 2/5/15• “Other studies have reported that only 1

percent of individuals who arrested in a SNF survived to be discharged from the acute hospital.”

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CPR Directive Legislative Changes 2010

• ANY form clearly stating refusal of CPR, signed by patient and patient’s physician is valid.

• Even if NOT signed by physician, any form signed by a patient should be honored.

• Copies, faxes, scans are just as valid as original.• Downloadable template on Colorado Advance

Directives Consortium and CDPHE Web sites.• Do Not Resuscitate ≠ Do Not Treat! Palliative care

should always be provided.

Medical Orders for Scope of Treatment (MOST)

• A document that consolidates and summarizes patient preferences for key life-sustaining treatments.

• Persons may refuse treatment, request full treatment, or specify limitations.

• It is primarily intended to be used by the chronically or seriously ill person in frequent contact with healthcare providers, or already residing in a nursing facility.

• Translates patient preferences into physician’s orders.• “Travels” with the patient and is honored in any setting:

hospital, clinic, day surgery, long-term care facility, rehab facility, hospice, or at home.

• Prompts patients and providers to regularly review, confirm, or update choices based on changing conditions.

MOST Orders

1. CPR: Yes or No2. Medical Intervention & Transfer: Full

Treatment, Selective Treatment or Comfort-Focused Treatment

3. Artificially Administered Nutrition & Hydration: Long Term, Short Term, or None

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Practical Suggestions• Consider Five Wishes – it incorporates

a Living Will and A Medical Durable Power of Attorney.

• Discuss your Advance Directives with close friends and family – especially with the agent(s) designated in your Medical Durable Power of Attorney.

• Talk to your physician if you are considering a CPR Directive.

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Colorado Advance DirectivesConsortium

• http://coloradoadvancedirectives.com/• website contains great sample forms and

educational materials