Laws
Who makes decisions for incapacitated patient?
1) Court-appointed guardian, state appointed surrogate (for minors, elders, D.D.) 2) Durable Power of Attorney for health (type of AD, goes into affect when pt becomes incompetent) 3) Spouse of domestic partner 4) Adult children of patient (unanimous consensus of category) 5) Parents of the patient (unanimous consensus) 6) Adult brothers and sisters of the patient (unanimous consensus)
What does the Patient Self Determination Act specify?
1) HCPs must develop written policies concerning ADs. 2) They must ask all new patients if they have an AD and document the answer in the patient's chart. 3) Provide written material to patients regarding: Institutional policies relevant to these issues (such as an institutional policy to not perform abortions or not withdraw nutrition and hydration from PVS pts) and patients' rights under state law to prepare an AD. 4) Educate staff and the community served about advance directives 5) Ensure that patients are not discriminated against on the basis of whether or not they have an advance directive.
What are the Provisions of the Death with Dignity Act?
1) Must be a competent adult 2) Must be a Washington State resident 3) Determined by attending MD and consulting MD to be suffering from terminal disease 4) Voluntary request 5) A specific Process
What are the legal protections given by informed consent?
1) Rights of competent patients to refuse any and all therapies, including life sustaining therapies. 2) Rights of incapacitated patients to have a surrogate refuse any and all therapies, including life-sustaining therapies.
Two basic types of advance directives
1) Specify treatment preferences 2) Specify surrogate decision-makers 3) Many documents specify both.
Three types of evidence for surrogate decision making
1) Written Evidence (AD) 2) Verbal Evidence: conversations regarding therapy, conditions. 3) Relational evidence are accepted in WA state.
What is the process for Death with Dignity Act?
1) Written and oral initial request 2) Counseling by attending MD re: prognosis, hospice, counseling, someone in attendance (?), recommend nofigying next of kin, right to rescind, etc. 3) 15 day waiting period 4) 2nd oral request 5) 48 hours between written request and writing of Rx.
Standards for surrogate decision making
1) doing what the patient would have wanted. 2) Best interest standard
When was the Washington Death with Dignity Act enacted?
2009
Protection of HCP with regards to Death with Dignity Act
A person shall not be subject to civil or criminal liability or professional disciplinary action for participating in good faith compliance with this chapter. This includes being present when a qualified patient takes the prescribed medication to end his or her life in a humane and dignified manner.
Protection of HCP with regards to Death with Dignity Act (2)
A professional organization or association, or HCP, may not subject a person to censure, discipline, suspension, lossof license, loss of privileges, loss of membership, or other penalty for participating or refusing to participate in good faith compliance with this chapter.
What does CPR consist of?
ACLS protocols: chest compressions, intubation, meds.
Which types of evidence for surrogate decision making?
All 3 are accepted in WA state
Who does the Patient Self-Determination Act apply to?
All health care providers (hospitals, nursing homes, HMOs, hospice programs etc) that accept Medicare or Medicaid reimbursement.
Who can complete an advance directive?
Any competent adult.
What therapies can be withheld/withdrawn based on an AD under the WA state natural death act?
Any therapy. Specifically, life-sustaining therapies such as mechanical ventilation and artificially-provided nutrition and hydration.
How does a person obtain an Advance Directive?
Can obtain from many sources including the web, hospital, MD, clinic, etc.
Other names for POLST forms
Community based, portable or out-of -hospital DNR orders.
If the person should suffer a cardiopulmonary arrest, what should occur based on the Institutional Based DNR order?
Do not Begin CPR
If the person should suffer a cardiopulmonary arrest, what should occur based on the Out-of-hospital DNR orders?
Do not begin CPR
Specify surrogate decision-make AD
Durable Power of Attorney for Healthcare "Proxy Directives"
When do you need evidence of informed consent?
Entry to hospital, surgical procedure, discharge, deliveries, certain meds (chemo, trial, anti-psychotics, radioactive dyes), blood products, Imaging.
A do-not-resuscitate order means that the patient should be given only those therapies that promote comfort.
FALSE
A patient who is admitted to the emergency room after a motor vehicle accident always should be made a "no code" if the family member produces an advance directive
FALSE
A physician who decides to withhold cardiopulmonary resuscitation on the basis of futility is legally protected from a wrongful death suit in Washington State.
FALSE
A same sex domestic partner does not have the legal right to be at the patient's bedside and receive HIPAA protected information unless the patient has given explicit consent prior to losing consciousness.
FALSE
If 911 is called, the medics must perform cardiopulmonary resuscitation even if the person who has arrested has a portable DNR order such as a POLST form
FALSE
If a patient does not have a proxy directive or durable power of attorney for healthcare, the physician or ARNP can make healthcare decisions on behalf of the patient.
FALSE
If a patient does not have a written advance directive, life-sustaining therapies legally must be continued regardless of what the family says
FALSE
Legally and ethically, it is always better to withhold a therapy (such as mechanical ventilation) rather than try to withdraw it later because it is illegal to stop a therapy that is medically beneficial once it has been started
FALSE
The Patient Self-Determination Act requires that all patients in healthcare facilities that receive Medicare or Medicaid funding complete an advance directive.
FALSE
There have been many successful legal suits brought by families against physicians for withdrawing life-sustaining therapy from seriously ill patients where the family was initially in favor of withdrawal, but later changed their minds after the patient's death.
FALSE
When a patient has an advance directive for treatment preferences, you can assume that they would not want CPR if they should arrest
FALSE
At what level of legislation is the patient self-determination act?
Federal. Applicable in all 50 states.
Best Interests standard
If no information exists about what person would have wanted, surrogates should do what is in the patient's best interest.
When does the Institutional-based DNR "take effect" or apply?
Immediately
When does the out-of-hospital DNR "take effect" or apply?
Immediately
When was the Patient Self-Determination Act signed into law?
In November 1990, and became effective December 1991.
Other names for Advance Directives
Living wills, Directives to Physicians, Medical Directives.
Who can determine a patient's capacity?
MDs, PAs, ARNPs
Are HCPs ever the default for decision making?
NEVER, if the list runs out, patient will be given a court appointed guardian.
Does DNR mean "comfort care only?"
NO
Is a DNR the same thing as an AD?
NO
Is an AD necessary to have a DNR order written by a physician, ARNP, or PA?
NO
Should a patient with an AD be assumed to be a "no code" patient?
NO
Through the PSDA, are patients required to complete an advance directive?
NO
Through the PSDA, are patients required to give their HCP a copy of their AD?
NO
Does an Advance Directive represent informed consent?
NO. Document is a written statement of a person'swishes. Does not require disclosure of specific information of HCP and hence, does not represent an informed decision
Can some one else complete an AD for a patient?
NO. Even if the person is the patient's legal surrogate, they can't sign an AD for the patient.
Can patients be forced to leave the hospital AMA to be able to die at home?
NO. Section 4, WA State Natural Death Act
When does the advance directive "take effect" or apply?
Only after the patient has been declared terminal or is in a state covered under state law (PVS or coma)
Who signs an Advance Directive?
Only the person to whom it applies
How does a person obtain an Out-of-Hospital DNR Order?
POLST. Forms can be obtained only from a MD or ARNP care provider.
When should an AD be consulted in decision-making?
Patient MUST have lost decision-making capacity d/t a condition that is not reversible AND be in one of the following states: 1) Terminal condition 2) Irreversible coma or persisten vegetative state (non-terminal) 3) Particular situations specified in the AD by the individual patient.
What group most commonly uses the Death with Dignity Act?
People with ALS, White upper-middle class
How does a person obtain an Institutional-Based DNR Order?
Physician or ARNP writes as an order in the medical record.
What do POLST forms allow?
Portable DNR orders allow EMS (911) to respond to calls and offer assistance but NOT perform CPR or other unwanted procedures.
Specified content of informed consent discussion
Proposed treatment, anticipated results from tx, recognized possible alternatives forms of treatment, serious possible risks, complications, and anticipated benefits from proposed and alternative treatments, include non-treatment.
If the person should suffer a cardiopulmonary arrest, what should occur based on the advance directive?
Start CPR and evaluate situation when stabilized and communication is possible with the patient or their legal surrogate.
A competent patient can refuse life-sustaining therapies that his or her physicians believe would be of benefit to the patient.
TRUE
A lawyer does not need to be consulted to have a valid advance directive
TRUE
According to the Patient Self-Determination Act, it is legal to withdraw artificially delivered nutrition and hydration from a patient in a persistent vegetative state
TRUE
If a patient with a DNR order chokes on food, the nurse should do the Heimlich maneuver.
TRUE
Same sex couples, who have registered as domestic partners in Washington State, can make health care decisions for the other should either become mentally incapacitated and unable to make choices.
TRUE
T/F: An AD is a statement of a patient's preferences that may or may not include resuscitation preferences.
TRUE
T/F: An AD may help a physician, ARNP, PA or surrogate decide if a DNR order is the "right" decision
TRUE
What did the POLST form replace in 1995?
The old EMS No-CPR forms that are no longer available.
Who signs an Institutional-based DNR?
The physician or ARNP
Who signs an Out-of-hospital DNR Orders?
The physician or ARNP and the patient or their legal surrogate.
Who should have copies of an AD?
The proxy, primary health provider
At what level of law is legislation for informed consent determined?
The state level
What level of legislation regulates POLST forms?
The state level. Some states do not have a provision of out-of-hospital DNR orders.
Specify treatment AD
Usually refer to limiting therapy at the end of life but may request therapy.
What does a DNR specify?
Withholding cardiopulmonary resuscitation only.
Have there been successful lawsuits by families where patients receive life-sustaining or emergency therapy that had been explicitly refused?
YES
Does an Out-of Hospital FNR Orders represent informed consent?
YES. Form is signed by both the provider and the patient or the patient's legal surrogate. Form is written evidence that informed consent has occurred.
Should HCPs make every effort to help patients who wish to die at home to be transferred to home?
YES. Section 4, WA State Natural Death Act
Are physicians, nurses, and hospitals who participate in good faith in withholding or withdrawing life-sustaining therapy, immune from civil, criminal or professional conduct sanctions?
YES. Section 5 WA State Natural Death Act
Can an AD be rescinded at any time or any reason?
YES. This is to make sure patient don't fear it and know they can change their mind.
Does an Institutional-Based DNR order represent informed consent?
Yes: Order results from a discussion between MD or ARNP and the patient or legal surrogate. Like any other order for treatment, informed consent should have occurred prior to writing the order. Has to be re-written every time they come to the hospital.
Process of informed consent
communication- discussions should be ongoing
Product of informed consent
sign consent form (written evidence), when it is necessary is dictated by institutional policies.