THE ETHICS OF ADVANCE DIRECTIVES
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1 THE ETHICS OF ADVANCE DIRECTIVES PATSY TREECE, RN, MN HARBORVIEW MEDICAL CENTER DIVISION OF PULMONARY, CRITICAL CARE AND SLEEP MEDICINE
2 FINANCIAL DISCLOSURE I have nothing to disclose
3 ADVANCE DIRECTIVE DEFINITION A directive made in advance of losing decisional capacity Advance = Before Directive = Wishes Seems so simple.
4 TYPES OF ADVANCE DIRECTIVES Living Will POLST- Physician orders Life Sustaining Therapy DPOAHC- Durable Power of Attorney for Healthcare
5 ETHICAL PRINCIPLE BEHIND ADVANCE DIRECTIVES Autonomy- the right of an individual to determine their own path Also: Beneficence- to do good Non-maleficence- to avoid harm
6 ETHICAL THEORY SUPPORTED BY AD Utilitarianism- the right thing to do is the thing that produces the most good for the most number of people
7 TROUBLESOME WATERS AD only applies when the patient lacks decisional capacity Decisional capacity can wax and wane- how do we know what the patient really wants? For example an advance directive says no ventilator and the patient seems confused but is experiencing dyspnea and asking for help breathing. Which is the authentic wish? Is it ethical to ask a short of breath person if they want to be rescued at the moment of crisis? AD generally only covers CPR, ventilation, antibiotics and tube feedings. What about dialysis?
8 DECISIONAL CAPACITY ISN T THE ONLY PROBLEM AD applies in a terminal state or in a state of permanent unconsciousness Ask 2 doctors to define each of these terms and you will have 2 different definitions
9 TERMINAL STATE Hospice eligible if 6 months to live, what if we predict they have 7 months if they are on the vent, getting dialysis and tube feeds? Do we continue aggressive interventions?
10 PERMANENT UNCONSCIOUSNESS A permanent vegetative state is defined as a state of unconsciousness that lasts at least 6 months Does that mean I have to stay on the vent for 6 months if I said I didn t want it?
11 IF A PERSON CAN T MAKE DECISIONS FOR THEMSELVES There are 2 ways to make decisions for another Substituted judgement- if a preference was ever stated (can be written or verbal) Best interest- typically errs on the side of preserving life We have to educate families about this- what THEY want is not how decisions should be made.
12 SURROGATE DECISION MAKERS In Washington we have a hierarchy Guardian Spouse Adult Children Parents Siblings No aunts, uncles, grandparents or cousins are LNOK in Wa unless made DPOA
13 HARD TO FOLLOW AN AD IF YOU ARE NOT THE ONE WHO COMPLETED IT WITH THE PATIENT Life and death decision- how informed was the patient when they completed the AD? Was the POLST completed during a 15 minute visit about something else? What are the patients values and goals? How can we help meet them? Documentation of the details of the conversation goes a LONG way in helping to understand the true wishes of the patient
14 SO FAR ASSUMPTION HAS BEEN AD LIMITS TREATMENT; WHAT IF THEY WANT AGGRESSIVE TX? Chose yes to CPR, Vent, tube feedings but has a terminal condition or may be actively dying What role does justice play? Are we obligated to continue treatment when it seems as if it is only prolonging the dying process? What about a refractory GI bleed? How many units of blood can they have?
15 ETHICAL ADVANCE DIRECTIVES Discuss all possibilities that are able to be predicted ie- SOB for COPD pt Explain how ACLS components work together- TV CPR is better than real life Document discussion- think of it as a process, not a one time task, talk about goals, values Revisit document from time to time Discuss DPOA, encourage pt to discuss wishes with them, should not be a secret document Make sure it s in the chart and not in a lawyer s office
16 ETHICAL ADVANCE DIRECTIVES Assess decision-making capacity at different times of day, get a referral for assessing DMC Treat delirium aggressively to try to re-establish DMC
17 Conclusions
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