Stella Prejean, of the Lafayette, Louisiana, palliative care team, and Connie Boyd, Lafayette’s executive director, offer their guidance on advance care planning.
Making medical decisions for someone else during a time of crisis can be a prescription for errors. It’s important to know and document a patient’s wishes prior to a medical event.
I remember a patient who had end-stage COPD and was in the emergency room in acute respiratory distress. Although she had an advance directive instructing no intubation, her distressed family requested the procedure.
Medical personnel gathered the family and explained the patient’s wishes and how she had relieved them from the burden of that decision by signing an advance directive document. Intubating would have denied the patient’s wishes, so the family agreed to abide by them.
A 68-year-old male nursing home resident had completed a POST (Physician Orders for Scope of Treatment) document indicating he didn’t ever want a feeding tube, given his advanced Alzheimer’s Disease. It also indicated that he didn’t want to be intubated, but did want CPR. Unfortunately, his document was not signed by the physician, so when he experienced respiratory arrest in the emergency room, the patient was subsequently intubated.
Without the physician’s signature on his POST document, it was deemed invalid and because no family members were present, his wishes were not honored. Ensuring that advance directive and the other documents have been properly completed is an important step toward making sure an individual, such as these patients, gets the care that will honor their wishes.
But appropriate documents are only part of advance care planning. The process also ensures that decisions are reached based on the premise that the patient fully understands the choices in planning their care.
Making informed treatment decisions involves examining such things as:
- One’s own understanding of their medical condition, potential complications and potential gaps.
- Prior experiences with family or friends with serious illnesses.
- Understanding life-sustaining treatments during medical emergencies including the benefits and risks with CPR, mechanical ventilation or tube feeding.
- Goals for treatment (comfort care, trial treatments, full intervention) or any associated fears and worries.
- Documents that provide specific instructions for end-of-life care, such as a living will, do-not-resuscitate order or a POST (Physician Orders for Scope of Treatment) form, a physician-signed order form which puts into action treatment preferences for patients who are nearing the end of their lives.
When those key discussions don't happen and a medical crisis occurs, the perils and pitfalls become evident, particularly for those already under extreme pressure.