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Legal & Ethical Considerations for Advance Care Planning And The Nurse's Role in Palliative and End‐of‐Life Care Across the Lifespan Plenary III: Legal & Ethical Considerations for ACP & PEOLC Patient Self-Determination Act of 19901 Mandates that patients must be queried Legal & Ethical Considerations about the existence of advance directives and that such advance for Advance Care Planning directives be made available to them if and Palliative End of Life Care they wish To make Patient Self-Determination Act LINDA GOBIS, JD, MN, RN reality, health care providers must CLINICAL ASSISTANT PROFESSOR themselves understand the act and its UNIVERSITY OF WISCONSIN OSHKOSH COLLEGE purposes and should be able to answer OF NURSING patients' questions. Advance Directives Are Challenging Individuals Who Should Consider Advance Directives The most challenging aspect of preparing an advance directive is assisting patients Patients who have no legally designated in identifying their preferences for surrogate or who could be denied the treatment. right—e.g., same sex partners WI Nursing Coalition Summit was held in Patients with unusual or highly specific 2012 to discuss the nurse’s role in preferences advance care planning and develop an Patients and families for whom the action plan for Wisconsin. existence of a document will reduce Create one form anxiety Standardized nursing role in advanced planning Disseminate advance directive information Self-Determination Natural Death Acts Patient self-determination involves the Natural death acts are written, legally right of individuals to decide what will or recognized advance directives but with will not happen to their bodies. statutory enforcement Competent adults have the right to Vary state to state forego treatment even if the refusal is Chapter 154 of the Wisconsin Statutes— certain death. Living Wills Advance directives can assist in Chapter 155 of the Wisconsin Statutes— clarifying a patient’s wishes for end of Power of Attorney for Health Care life decisions. 1 The Nurse's Role in Palliative and End‐of‐Life Care Across the Lifespan Plenary III: Legal & Ethical Considerations for ACP & PEOLC Living Wills Wisconsin Living Will2 Directives from competent individuals to Living Will only applies when a patient is medical personnel and family members diagnosed with either: regarding the treatment they wish to Persistent vegetative state—complete & receive when they can no longer make irreversible loss of cerebral cortex the decision for themselves Terminal condition—death imminent withhold or withdraw life-sustaining Does not allow for surrogate treatment from patients if they are ever decision-maker in a terminal state Wisconsin Living Will2 Power of Attorney for Health Care Allows patient refusal of life-sustaining Power of attorney for health care procedures for PVS: (PAHC) allows patients to appoint a Assistance in respiration surrogate or proxy to make health care decisions in the event that the patient Artificial maintenance of BP & heart rate lacks “capacity” to do so. Blood transfusion It is a common-law concept that allows Kidney dialysis one person to speak for another. Does not include pain meds, nutrition & hydration Allows refusal of feeding tubes for PVS & terminal condition. WI Power of Attorney for Health Care3 WI Power of Attorney for Health Care3 Applies when patient incapable of Limitations--agent cannot admit for managing health decisions (e.g. evaluate inpatient mental health treatment information; communicate decisions) Options: Incapacitated; not incompetent Admit to CBRF or nursing home Document only takes effect when patient Withdraw or withhold feeding tube meets criteria for incapacity Make decisions if patient pregnant Old age, eccentricity or physical disability Special provisions or limitations are insufficient Anatomical gifts Uses best interest standard Optional Addendum Allows for surrogate decision-maker 2 The Nurse's Role in Palliative and End‐of‐Life Care Across the Lifespan Plenary III: Legal & Ethical Considerations for ACP & PEOLC Decision Making for the Incapacitated or Incompetent Patient Who should decide? SEE LAST PAGE OF HANDOUT Guardian, adult designated in an advanced directive, surrogate What standard should be used? Best interest, substituted judgment Decision Making Capacity Capacity Evaluation Elements to determine decision making Medical evaluation of “capacity” to make capacity. The patient can: medical decisions: Understand the information given Two physicians or one physician and one psychologist Evaluate the consequences and make a Document decision-making capacity (i.e. decision results of evaluation) in medical record Communicate a decision Complete activation form (i.e. triggers Incapacity = patient not capable of PAHC) making a medical decision. Contact agent listed in power of attorney document Confirm agent’s willingness to serve as surrogate decision-maker Standards in Life-Threatening Two Decision Making Standards Situations The best interest standard allows a If patient's preferences are known, then person to determine what one thinks the standard one applies in life- would be in the best interest of an threatening situations is that of incompetent adult and then pursue that substituted judgment. plan of care. If preferences are not known, then Substituted judgment is the standard becomes one of best interests subjective determination of how, if a on behalf of patient. person were capable of making opinions and wishes known, he or she would have chosen the right to refuse. 3 The Nurse's Role in Palliative and End‐of‐Life Care Across the Lifespan Plenary III: Legal & Ethical Considerations for ACP & PEOLC Practical Problems with Burden on Surrogates Advance Directives Shift in medicine from paternalism to Lost advance directives abdication Unclear statement of wishes Early bioethics cases = physician paternalistically overrode patient’s wishes Surrogate unaware of selection to forego treatment Surrogate does not wish to follow Now = physicians frequently do not directive provide recommendations Health care provider does not wish to Making treatment decisions has emotional follow directive effect on many Surrogates Advance directives comparison Chart Stress Guilt over decisions made Doubt re: whether made right decision Right to Forego Treatment Right to Forego Treatment Competent adults also have the right Incompetent and incapacitated adults to forego treatment even if the refusal also have the right to forego treatment is certain death. even if the refusal is certain death. Right to refuse intervention Right to refuse intervention Examples: feeding tube, blood products Examples: feeding tube, blood products Right to withhold/withdraw life Right to withhold/withdraw life sustaining treatment (aka right to die) sustaining treatment (aka right to die) Examples: ventilator, left ventricular Examples: ventilator, left ventricular assist assist device (LVAD), pacemaker device (LVAD), pacemaker Someone else has to make decision for them In re Quinlan (1976)4 Cruzan Case (1990)5 First case to decide all patients have Nancy Cruzan was involved in a motor right to withdraw, even if incapacitated vehicle accident in 1983 Karen Ann Quinlan was 21; became Started on life support and eventually unconscious after party where consumed went into permanent vegetative state combination of drugs and alcohol Parents requested discontinuation of Stopped breathing twice for 15 minutes fluids & hydration or more After multiple appeals, the court EMTs called and taken to hospital ultimately allowed the father to decide to Progressed into permanent vegetative withdraw fluids and hydration state and kept alive on a ventilator 4 The Nurse's Role in Palliative and End‐of‐Life Care Across the Lifespan Plenary III: Legal & Ethical Considerations for ACP & PEOLC Cruzan Case (1990)5 Wisconsin Cases Key points from case: In re: L.W. (1992)6 All patients have the right to withdraw Facts: 79 year old chronic schizophrenic, life sustaining treatment, even if in and out of group homes, had corporate incapacitated. guardian. She had a cardiac arrest, Artificial nutrition and hydration is progressed into permanent vegetative considered medical treatment that may state (PVS) and was ventilator be refused. dependent. Withdrawing life sustaining treatment is Decision: Guardian has authority to not homicide or suicide. consent to withdrawal of life sustaining treatment (LST), without court approval, if withdrawal is in the individual’s best interest. Wisconsin Cases Wisconsin Cases In re: Edna M.F. (1997)7 In re: L.W. (1992)6 Facts: 71 year old in late stage Alzheimer’s Factors to consider: dementia. Patient was close to PVS, but Degree of humiliation exhibited some minimal responses. Her guardian was her sister & best friend. Sister Dependence wanted to discontinue tube feedings. Past Loss of dignity resulting from condition & statement re: treatment preferences = “I treatment would rather die of cancer than lose my mind.” Life expectancy Decision: When an incompetent individual is Prognosis with or without treatment not in a persistent vegetative state, it is not in the person’s interest to withdraw life Options sustaining treatment, unless there is clear evidence that it would be in the person’s best interest. State’s Interest The state can override right to refuse, Wisconsin forego, or withdraw medical treatment Supreme in certain considerations: Court Case Preserving life if no terminal illness Homicide convictions
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