Talking to Your Patients Talking to Your Patients about Advance Directivesabout Advance Directives

Stephanie Reynolds, ACHPNStephanie Reynolds, ACHPNDawn Kilkenny, LCSWDawn Kilkenny, LCSWPalliative Care DepartmentPalliative Care Department917-219-4652 (Pager)917-219-4652 (Pager)

When?When?

On the first clinic visit, and anytime after On the first clinic visit, and anytime after that if there is a change in status.that if there is a change in status.

Every time they are admitted to the Every time they are admitted to the hospital.hospital.

Why?Why?

Patient autonomy: all patients Patient autonomy: all patients with decision-making capacity are with decision-making capacity are entitled to make their own entitled to make their own decisionsdecisions

Why? cont’dWhy? cont’d

If healthcare professionals do not initiate If healthcare professionals do not initiate discussions regarding advance directives, this discussions regarding advance directives, this can result in:can result in: Delays in treatment, while the families are struggling Delays in treatment, while the families are struggling

to determine what the patient’s wishes would be in to determine what the patient’s wishes would be in certain situationscertain situations

Conflicts between medical staff and families Conflicts between medical staff and families regarding goals of careregarding goals of care

Patient and family distress, and dissatisfaction with Patient and family distress, and dissatisfaction with carecare

Health Care ProxyHealth Care Proxy

Allows a patient Allows a patient with decisional capacitywith decisional capacity to designate someone they know and to designate someone they know and trust to make medical decisions for them trust to make medical decisions for them if they are not able to do so themselvesif they are not able to do so themselves

Legal document, witnessed by two Legal document, witnessed by two peoplepeople Witnesses Witnesses cannotcannot be proxy or alternate be proxy or alternate No need for lawyer or notaryNo need for lawyer or notary

Health Care Proxy, cont’dHealth Care Proxy, cont’d

With a HCP, the designated proxy is With a HCP, the designated proxy is legally able to make medical decisions on legally able to make medical decisions on behalf of the patient.behalf of the patient.

Without a HCP, the surrogate can only Without a HCP, the surrogate can only make a decision about DNR. If they feel make a decision about DNR. If they feel that pt would have wanted withdrawal of that pt would have wanted withdrawal of treatments or are in conflict with the treatments or are in conflict with the treatment team, notify Palliative Care, treatment team, notify Palliative Care, Risk Management, or Patient Relations.Risk Management, or Patient Relations.

What decisions can the What decisions can the HCP make?HCP make?

In a patient In a patient documenteddocumented not to have decisional not to have decisional capacity, the HCP can be engaged to capacity, the HCP can be engaged to determine what the wishes of the patient are in determine what the wishes of the patient are in the following instances:the following instances: DNRDNR Artificial nutrition and hydrationArtificial nutrition and hydration Withholding and withdrawing treatment Withholding and withdrawing treatment

(ventilators, hemodialysis)(ventilators, hemodialysis)

What decisions can the What decisions can the surrogate make?surrogate make?

In a patient In a patient documenteddocumented not to have not to have decisional capacity, and where a HCP decisional capacity, and where a HCP was never identified and documented by was never identified and documented by the patient, the surrogate can the patient, the surrogate can ONLYONLY determine what the wishes of the patient determine what the wishes of the patient are in the following instance:are in the following instance: DNRDNR

Need consensus of all immediate family Need consensus of all immediate family membersmembers

ExamplesExamples

WRONG: “WRONG: “Family has decidedFamily has decided on comfort care. on comfort care. Will withhold all further treatments.”Will withhold all further treatments.”

WRONG: “No cancer workup WRONG: “No cancer workup per family’s wishesper family’s wishes.”.” RIGHT: “Medical team feels that any further RIGHT: “Medical team feels that any further

aggressive treatments would provide little or no aggressive treatments would provide little or no benefit to patient, and will cause increased benefit to patient, and will cause increased discomfort. Recommendation is to make patient discomfort. Recommendation is to make patient comfort care; comfort care; pt’s wife in agreementpt’s wife in agreement..

RIGHT: “Discussed plan of care with RIGHT: “Discussed plan of care with pt’s HCPpt’s HCP […]. […]. Will pursue aggressive treatments based on Will pursue aggressive treatments based on pt’s pt’s known and expressed wishesknown and expressed wishes.”.”

Avoid the “Salad Bar”Avoid the “Salad Bar”

Do not ask “Do you want us to do…?”Do not ask “Do you want us to do…?” DialysisDialysis IntubationIntubation AntibioticsAntibiotics PressorsPressors Blood transfusionsBlood transfusions Blood draws, etc. etc.Blood draws, etc. etc.

If the benefits to the patient outweigh the risks of the If the benefits to the patient outweigh the risks of the treatment, the treatment should be donetreatment, the treatment should be done

If HCP refuses, have them sign a refusal of treatment If HCP refuses, have them sign a refusal of treatment form; if surrogate refuses call Palliative Care, Risk form; if surrogate refuses call Palliative Care, Risk Management, or Patient RelationsManagement, or Patient Relations

How to discuss HCPHow to discuss HCP

““In New York, every patient needs a health In New York, every patient needs a health care proxy. If for some reason you are not able care proxy. If for some reason you are not able to speak for yourself, it gives a family member to speak for yourself, it gives a family member or close friend the legal authority to assist us in or close friend the legal authority to assist us in making medical decisions for you, based on making medical decisions for you, based on what they know of your wishes.”what they know of your wishes.”

““This is particularly important for you, Mr. This is particularly important for you, Mr. Smith, since you are not legally married to your Smith, since you are not legally married to your wife. If you would like her to make decisions for wife. If you would like her to make decisions for you, you have to fill out this form. Otherwise, you, you have to fill out this form. Otherwise, she will not be able to speak for you.”she will not be able to speak for you.”

DNR DNR

Do not resuscitateDo not resuscitate This is an end-of-life decision, and needs This is an end-of-life decision, and needs

to be addressed to be addressed beforebefore the end of lifethe end of life!!!!!! Every Every patient who is diagnosed with a patient who is diagnosed with a

chronic, life-limiting illness should have a chronic, life-limiting illness should have a DNR discussion with their doctorDNR discussion with their doctor

How?How?

Statements to avoid:Statements to avoid: ““What should we do if your heart stops?”What should we do if your heart stops?” ““Do you want us to do everything?”Do you want us to do everything?” ““CPR means that we will pound on your CPR means that we will pound on your

chest and break your ribs while we restart chest and break your ribs while we restart your heart, and stick a large tube down your your heart, and stick a large tube down your throat to breathe for you – do you want us to throat to breathe for you – do you want us to do that?”do that?”

““I think CPR would be futile for your loved I think CPR would be futile for your loved one.”one.”

How?, cont’dHow?, cont’d

Always make sure pt understands their Always make sure pt understands their diagnosis and prognosis prior to any diagnosis and prognosis prior to any DNR discussion.DNR discussion.

Helpful statements:Helpful statements: ““I need to discuss something very important I need to discuss something very important

with you regarding your further treatments. with you regarding your further treatments. Would you like anyone (family etc.) to be Would you like anyone (family etc.) to be present when we have this conversation, or present when we have this conversation, or would you like to defer this to your HCP?”would you like to defer this to your HCP?”

How?, cont’dHow?, cont’d

Helpful statements:Helpful statements: ““Considering that you have [Considering that you have [x, y, z diagnosesx, y, z diagnoses], ],

with a prognosis ofwith a prognosis of [[days to weeks, weeks to months, days to weeks, weeks to months,

monthsmonths],], I feel that performing CPR would I feel that performing CPR would cause you significant pain and distress, cause you significant pain and distress, while the chance of it being successful is while the chance of it being successful is slim to none. Therefore, I would recommend slim to none. Therefore, I would recommend a DNR order. However, I want to emphasize a DNR order. However, I want to emphasize that we will continue treating you in all the that we will continue treating you in all the other ways we have been doing.”other ways we have been doing.”

DNRDNR

Yellow: adult patient with decision making capacity; patient Yellow: adult patient with decision making capacity; patient gives verbal consentgives verbal consent

Blue: adult patient, therapeutic exception (“patient will Blue: adult patient, therapeutic exception (“patient will suffer immediate and severe injury from discussion of suffer immediate and severe injury from discussion of CPR”); needs signature of surrogateCPR”); needs signature of surrogate

White: adult patient, previously consented to DNR order; White: adult patient, previously consented to DNR order; needs consent of surrogate but no signatureneeds consent of surrogate but no signature

Pink: adult patient, without decisional capacity, that has a Pink: adult patient, without decisional capacity, that has a surrogate; needs signature of surrogate surrogate; needs signature of surrogate

Green: adult patient, without decisional capacity, without a Green: adult patient, without decisional capacity, without a surrogate; “medical futility”; 2 physician consentsurrogate; “medical futility”; 2 physician consent

Lavender: pediatrics onlyLavender: pediatrics only

DNR, cont’dDNR, cont’d

Once form is signed by family and / or Once form is signed by family and / or witness(es) and 2 attending physicians witness(es) and 2 attending physicians … enter DNR order… enter DNR order

Out of hospital DNR (community or Out of hospital DNR (community or nursing home) nursing home) white form; obtain white form; obtain verbal consent from surrogate, 2 verbal consent from surrogate, 2 attending physician signatures … enter attending physician signatures … enter DNR orderDNR order

DNI??DNI??

Not recognized in State of New YorkNot recognized in State of New York Medical decision: patient would / would Medical decision: patient would / would

not benefitnot benefit If patient / HCP does not want intubation, If patient / HCP does not want intubation,

must sign refusal of treatment formmust sign refusal of treatment form If surrogate, call a Palliative Care, Risk If surrogate, call a Palliative Care, Risk

Management, or Patient RelationsManagement, or Patient Relations