Talking to Your Patients about Advance Directives Stephanie Reynolds, ACHPN Dawn Kilkenny, LCSW Palliative Care Department (Pager)

When?  On the first clinic visit, and anytime after that if there is a change in status.  Every time they are admitted to the hospital.

Why?  Patient autonomy: all patients with decision-making capacity are entitled to make their own decisions

Why? cont’d  If healthcare professionals do not initiate discussions regarding advance directives, this can result in:  Delays in treatment, while the families are struggling to determine what the patient’s wishes would be in certain situations  Conflicts between medical staff and families regarding goals of care  Patient and family distress, and dissatisfaction with care

Health Care Proxy  Allows a patient with decisional capacity to designate someone they know and trust to make medical decisions for them if they are not able to do so themselves  Legal document, witnessed by two people  Witnesses cannot be proxy or alternate  No need for lawyer or notary

Health Care Proxy, cont’d  With a HCP, the designated proxy is legally able to make medical decisions on behalf of the patient.  Without a HCP, the surrogate can only make a decision about DNR. If they feel that pt would have wanted withdrawal of treatments or are in conflict with the treatment team, notify Palliative Care, Risk Management, or Patient Relations.

What decisions can the HCP make?  In a patient documented not to have decisional capacity, the HCP can be engaged to determine what the wishes of the patient are in the following instances:  DNR  Artificial nutrition and hydration  Withholding and withdrawing treatment (ventilators, hemodialysis)

What decisions can the surrogate make?  In a patient documented not to have decisional capacity, and where a HCP was never identified and documented by the patient, the surrogate can ONLY determine what the wishes of the patient are in the following instance:  DNR  Need consensus of all immediate family members

Examples  WRONG: “Family has decided on comfort care. Will withhold all further treatments.”  WRONG: “No cancer workup per family’s wishes.”  RIGHT: “Medical team feels that any further aggressive treatments would provide little or no benefit to patient, and will cause increased discomfort. Recommendation is to make patient comfort care; pt’s wife in agreement.  RIGHT: “Discussed plan of care with pt’s HCP […]. Will pursue aggressive treatments based on pt’s known and expressed wishes.”

Avoid the “Salad Bar”  Do not ask “Do you want us to do…?”  Dialysis  Intubation  Antibiotics  Pressors  Blood transfusions  Blood draws, etc. etc.  If the benefits to the patient outweigh the risks of the treatment, the treatment should be done  If HCP refuses, have them sign a refusal of treatment form; if surrogate refuses call Palliative Care, Risk Management, or Patient Relations

How to discuss HCP  “In New York, every patient needs a health care proxy. If for some reason you are not able to speak for yourself, it gives a family member or close friend the legal authority to assist us in making medical decisions for you, based on what they know of your wishes.”  “This is particularly important for you, Mr. Smith, since you are not legally married to your wife. If you would like her to make decisions for you, you have to fill out this form. Otherwise, she will not be able to speak for you.”

DNR  Do not resuscitate  This is an end-of-life decision, and needs to be addressed before the end of life!!!  Every patient who is diagnosed with a chronic, life-limiting illness should have a DNR discussion with their doctor

How?  Statements to avoid:  “What should we do if your heart stops?”  “Do you want us to do everything?”  “CPR means that we will pound on your chest and break your ribs while we restart your heart, and stick a large tube down your throat to breathe for you – do you want us to do that?”  “I think CPR would be futile for your loved one.”

How?, cont’d  Always make sure pt understands their diagnosis and prognosis prior to any DNR discussion.  Helpful statements:  “I need to discuss something very important with you regarding your further treatments. Would you like anyone (family etc.) to be present when we have this conversation, or would you like to defer this to your HCP?”

How?, cont’d  Helpful statements:  “Considering that you have [ x, y, z diagnoses ], with a prognosis of [ days to weeks, weeks to months, months ], I feel that performing CPR would cause you significant pain and distress, while the chance of it being successful is slim to none. Therefore, I would recommend a DNR order. However, I want to emphasize that we will continue treating you in all the other ways we have been doing.”

DNR  Yellow: adult patient with decision making capacity; patient gives verbal consent  Blue: adult patient, therapeutic exception (“patient will suffer immediate and severe injury from discussion of CPR”); needs signature of surrogate  White: adult patient, previously consented to DNR order; needs consent of surrogate but no signature  Pink: adult patient, without decisional capacity, that has a surrogate; needs signature of surrogate  Green: adult patient, without decisional capacity, without a surrogate; “medical futility”; 2 physician consent  Lavender: pediatrics only

DNR, cont’d  Once form is signed by family and / or witness(es) and 2 attending physicians … enter DNR order  Out of hospital DNR (community or nursing home)  white form; obtain verbal consent from surrogate, 2 attending physician signatures … enter DNR order

DNI??  Not recognized in State of New York  Medical decision: patient would / would not benefit  If patient / HCP does not want intubation, must sign refusal of treatment form  If surrogate, call a Palliative Care, Risk Management, or Patient Relations