Substitute Decision Making: Intentions & Limitations and - PowerPoint PPT Presentation

Substitute Decision Making: Intentions & Limitations and Illinois POLST Presented by: Birgitta Sujdak Mackiewicz, PhD OSFHC Saint Francis Medical Center & Children’s Hospital of Illinois, University of Illinois College of Medicine, Peoria, and POLST Illinois

Objectives • Define decisional capacity and informed consent • Differentiate between giving informed consent and expressing a preference • Identify limitations for Surrogate Decision Makers/Guardians with regard to life sustaining treatment • Review POLST form

Decisional Capacity and Informed Consent • Decisional Capacity is the “ability to understand and appreciate the nature and consequences of a decision” (755 ILCS 40) A patient may lack capacity if they are unable to: 1. Express or communicate a choice or preference 2. Appreciate their situation & its consequences 3. Understand & process relevant information 4. Give reasons or support for his or her decisions 5. Demonstrate evidence of risk/benefit reasoning about treatment & discharge decisions 6. Arrive at a clear decision 7. Remember a decision or choice which they recently made

Decisional Capacity and Informed Consent • Informed consent is a process which ordinarily involves communication between a patient/legal decision maker & physician & includes the following elements: • The patient’s diagnosis & prognosis if known; • The purpose & nature of the proposed treatments or procedures; • The risks, benefits & consequences of proposed treatments or procedures; • The risks & benefits of reasonable alternatives, including no treatment at all. Bemski, K.M. (2006)

Decisional Capacity and Preferences • Decisional capacity can wax and wane and is assessed in light of a particular decision. • Patients with Guardians may be capable of making some decisions. • Those who lack capacity for particular (or all) decisions may still have strong preferences and values. These should be elicited if they are unknown and the patient included in decisions as possible and appropriate. • Ethical dilemmas occur where there are values in tension: • Respect for patient preferences vs. patient’s best interest • Respect for patient independence/autonomy vs. patient safety

Decisional Capacity and Preferences • The role of a substitute decision maker is to give informed consent, to understand the options, benefits/risks, etc. • Patient preferences may be overridden if there is justification. • Not overriding patient preferences may actually be disrespectful and/or harmful to the patient. • The substitute decision maker IS the person responsible for making the decision. Otherwise what is their role? • It may seem easier to override preferences with regard to non- medical decisions or medical decisions that are not end of life decisions. • Exquisite care should be taken in making end of life decisions.

Decisional Capacity and Preferences • A patient who lacks decisional capacity may say they want CPR or “everything done” when this could be harmful, not aligned with their values, not in their best interest, or simply not beneficial. • A patient’s previous expression of preferences and values may no longer reflect the current situation. (If a patient had capacity at one time the same holds true with regard to their earlier decisions and statements.)

Decisional Capacity and Preferences • Health Care Professionals do have the patient’s best interests in mind, but they may use clumsy or offensive language suggesting that a patient doesn’t have a good quality of life. Give them the benefit of the doubt, educate, speak up, and be an advocate. • When presented with a decision ask, “What do you hope to achieve by that?” Or, “On what are you basing that recommendation?” Or “What are you trying to say when you say you don’t recommend X because the patient won’t have quality of life?” • Articulate goals and values and ask what treatment course is most likely to achieve those goals. Recognize that some goals may be unattainable.

Substitute Decision Makers • Power of Attorney for Health Care may make any decision the patient could make with no limitations, unless patient has indicated limitations. The POA should use knowledge of patient wishes, values, and goals. When these are unknown POA utilizes substituted judgment or the best interest standard. 755 ILCS 45 • Health Care Surrogate may make health care decisions on behalf of a patient who lacks decisional capacity (using knowledge, substituted judgment, and best interest). They may not make end of life decisions unless the patient has a qualifying condition. Only then are empowered to consent to withhold or withdraw life-sustaining treatment. 755 ILCS 40/1

Life Sustaining Treatment • "Life-sustaining treatment" means any medical treatment, procedure, or intervention that, in the judgment of the attending physician, when applied to a patient with a qualifying condition, would not be effective to remove the qualifying condition or would serve only to prolong the dying process. Those procedures can include, but are not limited to, assisted ventilation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs, antibiotics, and artificial nutrition and hydration. 755 ILCS 40

What about CPR/DNR? • Cardiopulmonary Resuscitation (CPR) is not considered life sustaining treatment as it is provided when a patient is in full arrest. A patient who is in full arrest has died. • CPR seeks to restore life, not sustain it. • Thus, a Surrogate, including a guardian, may consent to a DNR order regardless of whether there is a qualifying condition. • However, OSG requires that there be a qualifying condition present for a DNR when the guardian is a state guardian. • DNR =/= Do Not Treat. It only applies when the patient’s heart and breathing have stopped.

Qualifying Condition "Qualifying condition" means the existence of one or more of the following conditions in a patient certified in writing in the patient's medical record by the attending physician and by at least one other qualified physician: (1) "Terminal condition" means an illness or injury for which there is no reasonable prospect of cure or recovery, death is imminent, and the application of life- sustaining treatment would only prolong the dying process. 755 ILCS 40

Qualifying Condition (2) "Permanent unconsciousness" means a condition that, to a high degree of medical certainty, (i) will last permanently, without improvement, (ii) in which thought, sensation, purposeful action, social interaction, and awareness of self and environment are absent, and (iii) for which initiating or continuing life-sustaining treatment, in light of the patient's medical condition, provides only minimal medical benefit. 755 ILCS 40

Qualifying Condition (3) "Incurable or irreversible condition" means an illness or injury (i) for which there is no reasonable prospect of cure or recovery, (ii) that ultimately will cause the patient's death even if life-sustaining treatment is initiated or continued, (iii) that imposes severe pain or otherwise imposes an inhumane burden on the patient, and (iv) for which initiating or continuing life-sustaining treatment, in light of the patient's medical condition, provides only minimal medical benefit. 755 ILCS 40

Qualifying Condition • The determination that a patient has a qualifying condition creates no presumption regarding the application or non-application of life-sustaining treatment. It is only after a determination by the attending physician that the patient has a qualifying condition that the surrogate decision maker may consider whether or not to forgo life-sustaining treatment. In making this decision, the surrogate shall weigh the burdens on the patient of initiating or continuing life-sustaining treatment against the benefits of that treatment. 755 ILCS 40 (emphasis added)

POLST: Practitioner Orders for Life Sustaining Treatment • POLST is VOLUNTARY. It cannot be required for admission or treatment. • A tool for patients, POAs, and Health Care Surrogates that documents the results of a discussion with a medical provider about goals of care. • A medical order that documents wishes for treatment at this point in time; provides guidance to emergency medical personnel; usually completed in a medical setting • Is designed for those who with advanced illness or very frail – at any age. “ Would you be surprised if the patient died within the next year ?” • May also be used when DNR order is desired in tandem with life sustaining treatment.

POLST Form 3 Primary Medical Order Sections A. CPR for Full Arrest • Yes, Attempt CPR • No, Do Not Attempt CPR (DNR) B. Orders for Pre-Arrest Emergency • Full Treatment • Selective Treatment • Comfort Focused C. Medically Administered Nutrition • Acceptable • Trial Period • None

POLST • POLST is not intended for persons with chronic, stable disability, who should not be mistaken for being at the end of life. • Exceptions: may be considered for patients for whom CPR could cause disproportionate harm or on whom CPR would not work. • Can be signed by the patient’s decision maker if the patient lacks decision-making capacity. • POLST may be revised or revoked at any time. Should be reviewed regularly.