CIS: Surrogate decision making and advance directives

Question 1

•A 77 y/o female with Alzheimer’s disease is brought to the ED with abdominal pain. She is a resident of a nursing home and has a DNR bracelet. She is accompanied by her daughter, who is her durable POA (power of attorney) for healthcare. Her advance directive does not contain a living will. After assessment, you believe that she needs surgery, and her daughter is willing to consent to the surgery. The surgeon on call, however, does not want to take her to surgery because she’s DNR.

How do you handle?

Answer 1

DNR = If patient loses pulse then must let die.

Can perform surgery, dialyisis and other maintenance procedures. Thus, you should take steps to compel the surgeon or replace them.

Question 2

What are the components of an advanced directive?

Must you have both?

If only one, which should be priority?

Answer 2

1. Durable POA to make decisions if capacity is lost (proxy)
2. Living will

Need not have both.

Better to have the proxy, since living will cannot anticipate all end of life decisions that could arise.

Question 3

•The primary elements of decisional capacity which must be evaluated and documented are: _________________________________.

Question 4

•The difference between competence and decisional capacity is ___________________.

Question 5

•Minors may seek care independent of their parents in the following situations: ______________________________.

Question 6

•When competent patients with decisional capacity refuse treatment, the physician should ______________________________________.

Question 7

•When a competent pregnant woman with decisional capacity refuses treatment necessary to save her fetus, the physician should _________________________________.

Question 8

•A 77 y/o female with Alzheimer’s disease is brought to the ED with abdominal pain. She is a resident of a nursing home and has a DNR bracelet. She is accompanied by her daughter, who is her durable POA (power of attorney) for healthcare. Her advance directive does not contain a living will. After assessment, you believe that she needs surgery, and her daughter is willing to consent to the surgery. The surgeon on call, however, does not want to take her to surgery because she’s DNR.

If you complel the surgeon to proceed, or find a different surgeon, what should the surgeon do in preparation for surgery?

Answer 8

Discuss the risks of the procedure with the family/POA and explore the option of rescinding the DNR in advance of surgery.

Question 9

• The woman is eventually taken to surgery, but during surgery she suffers a massive CVA, which renders her comatose. Neurology consultation suggests that she will not recover any cognitive function and will most likely remain in a persistent vegetative state. At this point, her daughter requests that all forms of treatment, ie. IV’s, antibiotics, and tube feedings be withdrawn and the patient just kept comfortable.
• Can you ethically follow the daughter’s wishes?
• Is there a law in Colorado regarding this topic?

Answer 9

Under certain circumstances, yes. Predicated on the state requirements.

Colorado

In chart, Dr. must record the loss of capacity and make reasonable efforts to contact people with vested interest in the patient’s well being. These people must together decide upon a proxy.

Proxy may decide not to start or to stop tube feedings only when two doctors, (one neurologist and one neurosurgeon) agree that this would only prolong the vegetative state.

Question 10

What is the strongest standard for surrogate decision making?

Answer 10

Substituted judgement - expression of patient’s preferences (verbal or written)

Question 11

What can a surrogate not do?

Answer 11

Cannot make decisions based on their preferences. (Must attempt in good faith to make decisions based on the patients wishes)

Question 12

• A 55 y/o male with muscular dystrophy is brought to the ED with shortness of breath, fever and confusion. He is accompanied by his wife, two adult children, his sister, and a close friend. He has no Advance Directive or Durable POA for health care. You believe that he should be intubated and placed on a ventilator. All of the people who accompany this man agree with your recommendation.
• What is the first step?
• Can you proceed with intubation?

•What are your duties, in the state of Colorado, to establish a surrogate decision-maker?

Answer 12

Must determine if patient has decisional capacity.

If no previous directive on the matter, then yes.

Must inform the family that they must elect a proxy.