END-OF LIFE ISSUES

[PART 1]

DR. RUKEVWE [RUKKY] ODJIMOGHO

Objectives
Withholding and withdrawal of medical treatment.

Know what advance directives are.

Know the types of advance directives and when they are

applied.

Know when to discuss advance directives with patients.

Know the steps to take to get advance directives.

Understand what DNR orders are and what it means

when they are put in place.

Fluid and Nutrition Issues

 WITHHOLDING
&
WITHDRAWING
MEDICAL TREATMENT
 Every competent adult patient has the
right to determine what treatments,
medications or medical procedures
he/she wants to receive or not receive.

There is no legal or ethical boundary

between withholding and withdrawing
medical treatment. Consequently, a
competent adult patient has the right to
start and stop a therapy when he/she
chooses, as long as he/she fully
understands the consequence(s) of the
decision.
 Note that this right holds even if the patient
will die from terminating the treatment (e.g.
dialysis, mechanical ventilation, HIV
medications, or blood transfusions). The
type or necessity of the treatment does not
take away this right from the patient.

Regarding withholding and withdrawing

medical treatment, psychiatric evaluation is
only necessary when underlying psychiatric
illness (e.g. schizophrenia) is suspected of
impairing judgment.
 However, if the patient is clearly in
his/her sound mind (with no
objective evidence of
incompetence), the patients
wishes should be followed.

Also remember that a patient can

refuse treatment for any reason
(e.g. on religious grounds).
 However, you are not to assume that
because someone is a member of a religious
group, the person automatically shares all
of its beliefs. When in doubt, ask questions.

The patients decision is always the focus

not religious practices.

Also keep in mind that treating a patient

WITHOUT consent carries the same legal
weight as assault and battery or any other
form of unwanted touching.
 ADVANCE
DIRECTIVES
Introduction
The best way to determine a patients
wishes is always to talk to the patient
directly.

If the patient is unconscious but will likely

be awake soon, and it is not an emergency,
wait for the patient to wake up.

Only consult a third party if the patient is

permanently inaccessible or the patient is
inaccessible and it is an EMERGENCY.
 If you cannot communicate with a
patient directly, then obtain the
patients wishes in the following order:

1. Subjective Standard (Advance

Directive)

2. Substituted Judgment

3. Best-Interest Standard
 SUBJECTIVE STANDARD
[ADVANCE DIRECTIVES]
Definition
An Advance Directive is a method by
which a patient makes provision for
health care decisions in the event of
becoming incapacitated or incompetent
to make them.

It is a way by which a patient

communicates his/her wishes for his/her
health care in advance of becoming
unable to make those decisions for
himself/herself.
 It is part of the concept of Autonomy.

Advance directives help the physician know

what the patients wishes are (in case of
incapacitation) so that the less accurate forms
of decision making (such as substituted
judgment) can be avoided.

Medicare regulations require hospitals to

provide patients with information about their
rights (under state law) to accept or refuse
recommended care, and to formulate advance
directives.
 In 1990, Congress passed the Patient Self-
Determination Act, requiring that all
hospitals and other health care facilities
receiving federal funds (such as Medicare
and Medicaid payments), ask patients at the
time of admission whether they have
advance directives.

If they do, patients are asked to submit

copies to the hospital (for documentation).

If they dont, they are to be given

information about advance directives.
 Advance directive documents may
have written instructions to give
boundaries to care. For example, a
patient may want to receive
antibiotics, but not want to receive
chemotherapy or dialysis.

Oral or written statements are

both valid.
 Decisions expressed to the
physician or to someone else are
also both valid.

And if the patient, over a period

of time, made multiple wishes or
statements regarding his/her
health care, the most recent
statement prevails.
Importance of Advance Directives
1. Advance directives show respect for patients by
allowing their preferences and values to guide
care (even when they can no longer make
informed decisions for themselves).

2. It relieves stress on family members (who may

be required to make decisions for them).

3. Many patients also want to provide substantive

directives about their goals and values, or about
what life sustaining interventions they will want
to accept or reject.
Types of Advance Directives
There are three common types:

1. The Living Will

2. The Durable (or Medical) Power of

Attorney for Health Care and

3. Do Not Resuscitate (DNR) Order

There is the least common type called the

Five Wishes
Living Will
Oldest type of health care advance
directive.

It is a written form of advance directive

that outlines the care a patient would want
to receive if he/she becomes incapacitated
or incompetent.

This type of advance directive does not

require the input of a third party as it
explicitly directs or forbids actions, and it
only applies to end-of-life care.
 A living will can range from being an
extremely precise document (in which the
patient details the exact type of care
he/she wants or doesnt want), to being a
vague document that makes nonspecific
statements such as no heroic care.

Major challenge with the living will is that

most of the time, it lacks precision,
because the patient does not explicitly
state which tests and treatments he/she
wants for himself/herself.
 Most declarations instruct an
attending physician to withhold or
withdraw medical interventions from
its signer, if he/she is in a terminal
condition, and is unable to make
decisions about medical treatment.

Note that a Living Will would

overrule the wishes of the patients
family because it directly
communicates the patients wishes.
An Example of a Living Will
If I become unable, by reason of physical
or mental incapacity, to make decisions
about my medical care, as certified by two
physicians, let this document provide the
guidance and authority needed to make
any and all such decisions. If I am
permanently unconscious or there is no
reasonable expectation of my recovery
from a seriously incapacitating or lethal
illness or condition, I do not wish to be kept
alive by artificial means.
Durable Power of Attorney For
Health Care
This is a legal surrogate (appointed by a
competent patient), to make health care
decisions on his/her behalf, if the patient
becomes temporarily or permanently
unable to make such decisions.

Consequently, this advance directive

empowers a third party to make health
care decisions on the patients behalf.
 Note that the durable power of
attorney for health care (otherwise
known as the health-care proxy), only
makes HEALTH-CARE decisions for the
patient; not financial or other non-
health related decisions.

The health-care proxy speaks to the

physician on the patients behalf for all
treatments and tests, as well as
discusses issues of withdrawing and
withholding treatment, when the
patient is inaccessible.
 Thus, the health care proxy must be
chosen with great care, since the agent
will have great power and authority to
make health-care decisions on behalf of
the patient.

The proxy may be a relative or friend.

Most statutes require that this

appointment be made in writing,
although at least one state (California)
permits oral designation of the agent for a
limited period.
 The proxy speaks for the patient. And because
the patient chooses the proxy as his/her
representative, THE PROXY OVERRULES ALL
OTHER DECISION MAKERS (INCLUDING THE
PATIENTS FAMILY MEMBERS).

Furthermore, it is always expected that the

health-care proxy makes decisions based on
two parameters:
1. The patients directly expressed health-care
wishes; and

2. What the patient would have wanted if

he/she had decision-making capacity.
 Consequently, the health care proxys
decisions can be overruled if:

1) The patient tells you to do so OR

2) The health care proxys decisions are

in conflict with the patients Living Will
for an end-of life scenario.
 It is therefore extremely important that
the patient carefully discusses his/her
values, wishes, and instructions, with the
health care proxy, before, at the time,
and even after the document is signed.

It is also important that the health care

proxy be willing to exercise his/her power
and authority, to make certain that the
patients values, wishes, and instructions,
are respected.
DO NOT RESUSCITATE (DNR)/
DO NOT ATTEMPT
RESUSCITATION (DNAR)
Introduction
Cardiopulmonary resuscitation (CPR) is an
emergency procedure, that combines chest
compression (often with artificial ventilation), in an
effort to manually preserve intact brain function,
until further measures are taken to restore
spontaneous blood circulation, and breathing, in a
person who is in cardiac arrest.

Activities include:
1. Simple efforts such as mouth-to-mouth breathing
and chest compressions.
2. Breathing tubes to open the airway.
3. Electric shock to restart the heart (i.e.
defibrillation).
 A do not resuscitate or do not attempt
resuscitation [DNR/DNAR] order, is a medical
order written by a doctor, instructing health
care providers not to perform cardiopulmonary
resuscitation (CPR) if a patient stops breathing
or the heart stops functioning.

This implies that if a patient is in

cardiopulmonary arrest, the health care
provider does not perform chest compressions,
neither does he/she attempt electrical
cardioversion, or administer acute anti-
arrhythmic medications.
 This order allows the patient choose whether
or not he/she wants CPR, in the event of an
emergency.

Note that it is specific for CPR. It does not

affect other treatments (such as dialysis, pain
medications, etc).

Consequently, there is no need for the

patient to reverse the DNR order in order to
administer non-CPR related treatments (e.g.
dialysis or admission to the intensive care
unit).
 Keep in mind that DNR discussions should be had
during the first meeting with the patient.

The physician should take the initiative in

bringing up the topic and not wait for the patient.

And when having the discussion with your

patient, avoid using jargons (for instance, dont
ask your patient, What are your do not
resuscitate wishes? ).

Also, be specific in your questions (e.g. If your

heart stops beating, do you want me to?)
Types of DNR Orders
1) DNR Order With No Qualifiers
This implies no cardio or pulmonary
resuscitations.
Usually stated as no heroic care or
measures.
Note however that the treatments the
patient agreed upon, would continue,
including new treatments that may be
required (e.g. dialysis).
2) Partial DNR Order
Two subtypes:
i) Pulmonary DNR implying no
respiratory support;

ii) Cardio DNR implying dont restart

the heart.
 Note that a patient can still be intubated
and maintained on a ventilator, with a
DNR order in place; but if the patient
loses his pulse, the doctor cannot
intubate the patient, because then it
would be considered part of the Code or
resuscitative/CPR management.

However, if this patient remains alive

and has advancing lung disease, the
patient can still be intubated. In this
case, the doctor would only defer CPR if
the patient were DNR.
 Note also that the physician writes
the DNR order after obtaining the
patients wishes (either directly from
the patient or using substituted
judgment or best-interest standard).

Unlike other medical interventions,

CPR is initiated without a
physicians order. However, you
need a physicians order to withhold
CPR.
Justifications for DNR/DNAR
1. Patient refuses CPR
Competent, informed patients might not want CPR.
Such informed refusals should be respected.

2. Surrogate refuses CPR

The surrogates decisions should however be based on
the patients preferences or best interests.

3. CPR is futile in a strict sense

E.g. if doing CPR has no pathophysiological rationale,
cardiac arrest occurs despite maximal treatment or
CPR has already failed in the patient.
DNR Guidelines
1. DNR orders should be documented in the written
medical record.

2. DNR orders should specify the exact nature of the

treatments to be withheld.

3. Patients, when they are able, should participate in

DNR decisions. Their involvement and wishes should
be documented in the medical record.

4. Decisions to withhold CPR should be discussed with

the health care team.

5. DNR status should be reviewed on a regular basis.

Language of DNR
Code:
A call for CPR efforts.

In the hospital, a code would usually contain

all the elements of advanced cardiac life
support, which includes oxygenation,
ventilation, cardiac massage, electroshock as
necessary, and emergency drugs.

These are sometimes announced as Code

Blue or some other designation, to signal the
emergency team of the need to respond.
No Code:
This implies DNR.

In previous times, the charts

were often labeled with devices
such as Red Tags or Purple
Dots to designate DNR status.
Special Setting
Anesthesia for Surgery and Invasive
Procedures
If patients with DNAR orders undergo surgery or
invasive procedures, their physicians should
discuss how the DNAR orders will be interpreted
perioperatively.

Plans should be documented clearly in the medical

record.

Similar considerations apply to DNAR orders in

radiology departments, where medications might
lead to cardiopulmonary arrest that is easily
reversed.
Five Wishes
A less common United States advance
directive, created by the non-profit
organization, Aging with Dignity.

It has been described as the "living will with a

heart and soul.

It was originally introduced in 1996, as a

Florida-only document, combining a living
will and health care power of attorney, in
addition to addressing matters of comfort,
care and spirituality.
Wish 1: The Person I Want to Make
Health Care Decisions for Me When I
Can't an assignment of a health care
agent (also called proxy, surrogate,
representative, or health care power of
attorney).

Wish 2: The Kind of Medical Treatment I

Want or Don't Want This section is a
living will a definition of what life
support treatment the patient wants or
doesnt want.
Wish 3: How Comfortable I Want to Be
what type of pain management the patient
would like, personal grooming and bathing
instructions, and whether he/she would like
to know about options for hospice care,
among others.

Wish 4: How I Want People to Treat Me

speaks to personal matters, such as whether
the patient would like to be at home,
whether he/she would like someone to pray
at his/her bedside, among others.
Wish 5: What I Want My Loved Ones to
Know - deals with matters of
forgiveness, how the patient wishes to
be remembered, and final wishes
regarding funeral or memorial plans.
SUBSTITUTED JUDGMENT
 This refers to a decision by someone who knows
the patient well enough to make the best guess
as to what the patient would want to do.

Note that it is not what the patient said to a

third party (as that would be classified as an
advance directive).

In the clinical vignette, consider the people

presented and determine who will best know
the patients wishes.

Next of kin is not the criteria but who can best

determine the patients wishes.
 If the clinical vignette clearly describes
someone who best knows the patient, that
person should be consulted for substituted
judgment.

If there is no clear description, then consult

the patients next of kin in the following
order:
a) Spouse;
b) Children of legal age (i.e. 18 years and above);
c) Other relatives (e.g. parents);
d) Close friend;
e) Caregiver.
BEST-INTEREST
STANDARD
 Where an advance directive or substituted
judgment cannot be obtained, the physician is
then required to act in the patients best
interest.

This means that the physician is to do what is

most beneficial for the patient, putting aside
personal and even religious beliefs.

The physician is to make the decision. In

practice, there may be need to work with the
Hospitals Ethics Committee in making the
decision, but for exam purposes, dont.
In Summary
To determine a patients wishes, follow
this order:

1. Talk to the patient directly

2. Use Subjective Standard (i.e. advance
directives e.g. living will, durable power
of attorney for health care and DNR
order)
3. Use Substituted Judgment
4. Use Best-Interest Standard
 FLUIDS
AND
NUTRITION ISSUES
 The artificial administration of fluids and
nutrition (e.g. feedings or fluids
administered by nasogastric, gastric, or
jejunostomy tube placement), is a medical
procedure and treatment that can be
accepted or refused by a competent adult
patient in exactly the same manner as any
other treatment.

Forcible insertion of an artificial feeding

device, into a competent adult patient,
against his/her wish, is ILLEGAL &
UNETHICAL.
 If there is n0 underlying psychiatric
impairment that may be responsible
for the patients refusal, his or her
wishes should be respected, even if it
will lead to the death of the patient.

If there is an underlying psychiatric

impairment, then psychiatric
consultation is advised.
 To determine a patients directive
regarding fluids and nutrition issues,
follow this order:

1. Talk to the patient directly

2. Use subjective standard (i.e. advance
directives e.g. living will, durable power
of attorney for health care)
3. Use substituted judgment
4. Use best-interest standard
References
1. Resolving Ethical Dilemmas: A Guide For Clinicians, 3rd Edition,
By Bernard Lo.

2. Clinical Ethics: A Practical Approach to Ethical Decisions in

Clinical Medicine, 6th Edition, By Albert R. Jonsen, Mark Siegler
& William J. Winslade.

3. Becker Professional Education Behavioral Science,

Epidemiology and Biostatistics, Version 2.3.

4. Ethics of Health Care: A Guide For Clinical Practice, 2nd Edition,

by Raymond S. Edge & John Randall Groves.

5. www.patientsrightscouncil.org/site/advance-directives-
definitions/

6. https://www.nlm.nih.gov/medlineplus/ency/patientinstructions
/000473.htm