Advanced Directives: When our wishes are not always what happens. Danielle M Smith HA 575 Legal and Ethical Perspectives Saint Joseph’s College of Maine
Transcript
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. 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. Types of Advanced Directives Living Will Durable Power of
Attorney Surrogate Decision Maker Substitute Judgment Guardianship
Health Care Proxy (Morrison, 2010)
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. 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. 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. 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. 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. 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. 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. 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