1. 1. Advanced Directives: When our wishes are not always what happens. Danielle M Smith HA 575 Legal and Ethical Perspectives Saint Josephs College of Maine
2. 2. What is a advanced directive ? Advance directives are legal documents that state the patients wishes when the patient becomes unable to speak for themselves. Advanced directives are created ahead of any medical incapacitation in order to ensure that the patient has the ability to make their own decisions when they are unable to do so. (Morrison, 2010)
3. 3. Types of Advanced Directives Living Will Durable Power of Attorney Surrogate Decision Maker Substitute Judgment Guardianship Health Care Proxy (Morrison, 2010)
4. 4. Living Will A living will is a legal document that discloses a persons individual needs and requests when unable to make competent decisions on their own. Living will should be validated by two witnesses that are not related to the patient. (Morrison ,2010) Decisions that a living will can address are: Life-support treatments such as mechanical ventilation , cardiopulmonary resuscitation (CPR) and life sustaining medications. Nutrition and hydrationfeeding tubes & artificial nutrition Guardianship or decision maker appointment Dialysis and organ donation (Advanced directives, 2014)
5. 5. Durable Power of Attorney A durable power of attorney is a legal device that permits one individual, known as a principle, to give to another person called the attorney-in-fact, the authority to act on his or her behalf (Morrison, 2010) The attorney-in-fact that is appointed is giving the responsibility to take care of banking, legal and real estate decision making for a specified amount of time that may be for a lifetime if needed. (Morrison, 2010) Issues with a durable power of attorney is the appointed attorney-in-fact is limited by their own knowledge of legal matter and finances, therefore leaving room for possible errors. (Morrison, 2010)
6. 6. Surrogate Decision Maker A surrogate decision maker is a agent who makes a choices for a patient when the person is unable to make them for themselves. A surrogate must follow the religious and moral beliefs when making a choice for the patient. Substituted judgment is a form of surrogate decision making where the surrogate attempts to establish what decision the patient would have made if the patient were competent to do so (Morrison, 2010).
7. 7. Guardianship and Health Care Proxy Guardianship is a process where the court system declares a patient incompetent for decision making and a legal guardian is appointed for managing financial, medical, and living decisions. Health Care Proxy is an appointed person to make health treatment decisions if the said person is unable to do so for themselves. (Morrison, 2010)
8. 8. Legal Rights of The Patient The Patient Self-Determination Act of 1990 protects the patients right to create an advanced directive and the right to make health care decisions including right to accept or refuse certain treatments. (Morrison, 2010) Health care institutions certified by Medicare and/or Medicaid must take steps to educate all adult patients and the larger community on their right to accept or refuse medical care. This law also directs facilities to inquire on admission whether a patient has made an advance directive, maintain policies and procedures on advance directives, and provide this information to patients upon admission. Organizations must comply with the PSDA in order to receive reimbursement through the Medicare and Medicaid programs (End of life care, 2014)
9. 9. Ethical Issues with Advanced Directives Determining that a patient is incompetent to make personal decisions is one of the first issues when addressing advance directives. Courts and medical personnel can assist in the determination of competency to make decisions. Ensuring that the patient has made their wishes known and that others are supportive of the patients choices is a second ethical hurdle when making life choices . Making sure that when the patient becomes unable to make choices the advanced directive will be followed is a top priority. When families do not agree with the decisions that the patient or proxy have made related to health care needs can pose a large problem for both the patient, healthcare providers and other family members. (Lark & Gatti, 1999)
10. 10. Ethical Case Study I work at a small community hospital intensive care unit (ICU) and this is a patient situation that we had come into out unit. A 76 year old women who called 911 related to shortness of breath (hx of copd). When EMS arrived the patient collapsed and was transported to our emergency room(ER). Once in the ER the patient was in respiratory failure and was orally intubated and placed on medications that helped to sustain the patients blood pressure and a naso- gastric tube was placed for gastric evacuation, medications and nutrition if needed. The patient was stabilized and transferred to my ICU. The patients lives at home and cares for her husband who is advanced stages of dementia, unfortunately he was unable to provide any contact information for additional family members at the time of admission. Once family was contacted they immediately stated that the patient was a Do Not Resuscitate (DNR) and that she should have never been placed on life support and they wanted the life support terminated yet they could not provide the hospital with a advanced directive that outlined the patients wishes. After several days of family meetings with the medical team (medical doctors, nurses and social services) the family was being told that she is not terminal and they still insisted on having the life support stopped against the doctors advice to keep the endo-tracheal tube to allow the patient to rest and regain pulmonary strength. The family continued to express that she would not have wanted this and the medical doctor decided to allow the patient to be removed from life support at the request of the family. The patient was not ready and did not oxygenate well and needed to be placed back on life support in order to sustain her oxygen levels, the family said no. The patient was placed on BI- PAP external ventilation and she eventually tired after approximately 10 days she did succumb to her illness and passed away.
11. 11. References Advanced Directive. (2015). Retrieved March 18, 2015, from http://www.winstonmedical.org/PatientsVisitors/AdvancedDirective.aspx Advance Directives: MedlinePlus. (2014, May 5). Retrieved March 18, 2015, from http://www.nlm.nih.gov/medlineplus/advancedirectives.html End of Life Care Manual. (2014). Washington state hospital association,. Retrieved March 17, 2015, from http://www.wsha.org/eol-fedstate.cfm Lark, J., & Gatti, C. (1999). Compliance with Advance Directives: Nursing's View. Critical Care Nursing Quarterly, 22(3), 65-71. Morrison, E. E. (2010). Ethics in health administration: A practical approach for decision makers (2nd ed., pp 121-159). Boston: Jones and Bartlett Publishers