June 7, 2014

Advance Directives Are Simpler Than We Make Them

Last week I posted a scenario to illustrate ethical frameworks.  The scenario is a common one, which EMS providers will confront many times in their career.  What is interesting to me is that I used it as an ethical scenario, but it may have illustrated to me poor understanding of advance directives among EMS providers.

You respond to a cardiac arrest to find a pulseless and apneic 65 year old male.  There are six or eight of his family members around, as well.  The patient has a valid DNR, but the entire group of family members say to work him.  What is the right thing to do?  

On one side, the DNR says to pronounce him.  On the other side, there are a whole bunch of upset people who want you to work him.  They are going to get even more upset if you don’t.  Plus, death is the irreversible choice.  It is the option that you can’t come back from.  What is the right answer?

The right answer is to pronounce the patient.  I cannot say that more clearly.  Pronounce. The. Patient.

The reason for that is based on the four main ethical principles of medicine.  Beneficence is having the welfare of the patient as your main goal.  Nonmaleficence is avoiding harm and avoiding ineffective treatments.  Justice is the act of ensuring your skills are evenly spread through society - not just caring for rich people only, for example.  Finally, autonomy is the ethical principle that holds that people should be allowed to make their own decisions about what medical care they do and don’t receive.

Autonomy is the primary principle in this case.  People are allowed to choose what care they receive (and don’t receive).

Advance directives are instructions that are given while a patient is able to make decisions, but are held for the future when they can’t decide.  Advance directives include living wills as well as various do-not-resuscitate forms.  Living wills are more complex forms that have extensive choices about enteral feeding, antibiotics, proxy decision makers, and that kind of thing.  They can get up to 20 pages or so (which makes them a pain in the ass for prehospital providers).  The good news is that they usually have a page that hits the high points, like an executive summary for CPR instructions.  But that is not what I am talking about here.

Do-not-resuscitate forms have various versions.  In Colorado, the most common form that I have been seeing recently is the MOST form.  I love that it has Yes CPR/No CPR right at the top where it is easy to find.  Anyway, with CPR directives, there is a spot at the bottom for a physician signature - this shows that a provider discussed the options with the patient, they were competent decision makers regarding their care, and the listed choices are the patient’s choices.  

Notice what the form doesn’t have: A spot for daughters, sons, grandchildren, and so on to sign.  Because nobody cares what they think in this case.

An adult decision maker doesn’t need anyone’s permission to institute advance directives.  They don’t need to tell anyone else.  They don’t need to discuss it with anyone else.  Many patients don’t discuss these decisions with most of their family members.  They may feel it is a private decision.  They may feel that the family members would disagree with their decision.  They may feel that the discussion would be uncomfortable and best avoided.  Whatever their reason is, I don’t care.  The guiding principle for me is the same - people are allowed to choose what care they receive and don’t receive.

They have a form that tells me what they have decided that they want, after a discussion with their primary care provider explaining their options.  The PCP signed off that the patient was making a rational decision.  All of that, along with what their decision is, is contained in the DNR form.  So show me a CPR directive, MOST form, or other DNR-type paperwork and I will call for a time of death.*

It is uncomfortable when you are the one to tell them, but family members can’t rescind a DNR form.

Oh, yeah, that brings me to another discussion point.  Durable medical powers of attorney.  “I’m his power of attorney, and I say to do everything you can to save him!”  The only person that can rescind an advanced directive in Colorado** is the person who made it.  So a POA can rescind the DNR, but only if they are the ones who made the decision and signed the form.  If the patient made the decision, signed the DNR, then made their kid DMPOA, then croaked - sorry, the patient is the only one who can take the DNR back. The DNR takes precedence over the power of attorney.  The only way a POA can rescind the DNR is if their signature is the one that is on the bottom of it.

*Technically, a MOST form is a way to lay out medical orders.  Medical orders can be changed by another medical provider.  But the MOST orders do clearly communicate the patient’s wishes, which should be honored - even when it makes their family members really sad.  My opinion is that you will be best off when you focus on the patient’s documented wishes.  Don’t complicate a call when you don’t have to.

**All of this is for Colorado.  Each state has their own specific statutes and forms.  I don’t know about different states or other countries.  Google it, baby.

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