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Archive for the ‘Nursing Home’ Category

Withholding Life Sustaining Treatments in the ED at EHC

Hi folks,

As some of you may know, the recently passed Family Health Care Decision Act allows the withholding and withdrawing of life sustaining treatments in patients who lack capacity, even in the absence of a health care proxy.

This is an enormous step forward for palliative care.

However, the procedure to do this is rigorous and exacting. I have gone through HHC’s 30 page policy and I have created a 3 page summary. It is absolutely critical that we follow all of the steps completely. If we half-ass this, I am sure there will be greater administration involvement. Once that happens, it becomes more difficult to give our patients the palliative care they deserve. Please, please comply with HHC’s policy.

Scott

Withholding Life Sustaining Treatments under FHCDA

Question 1- Does the patient have capacity to make the decision on the particular life sustaining therapy?

An attending physician must make the initial determination that the patient lacks decision-making capacity.
The note should include language similar to: I have determined, to a reasonable degree of medical certainty, that the patient lacks the ability to understand and appreciate the nature and consequences of proposed health care, including the benefits and risks of and alternatives to proposed health care, and lacks the capacity to reach an informed decision.

A concurring attending must make the same determination and document it in the chart as well.

If mental illness is the cause of the lack of capacity, one of the two attendings must be BC/BE in Psych or Neurology.
If mental retardation or developmental delay is the cause of the lack of capacity, call risk management to get involved.
If the patient has any ability to comprehend, you must tell them of the decision that he or she lacks capacity. If the patient objects to the determination of lack of capacity, call risk management and do not continue.

Question 2 – Did the Patient State His or Her Wishes Previously?

Statements that are acceptable for this purpose are:
A Living will
Written statement regarding their wishes
Prior medical orders pertaining to the particular life sustaining treatment (DNR or DNI signed at the same.) Document the nature of these prior statements, and if possible include a copy in the chart. If the patient stated their wishes in one of the above forms, the attending can honor them. If the patient did not state their wishes, then a surrogate will make the decisions regarding life sustaining treatment.

Notify the surrogate (if one is available) of the prior statement of wishes, if the surrogate objects, call risk management.

Question 3- Is there a surrogate who is reasonably available, competent, and willing to serve?

Search for one person from the following list who is reasonably available, willing and competent to serve as surrogate: (The list goes from highest to lowest priority class)
1. A guardian authorized to decide about health care pursuant to Mental Hygiene Law (Call risk management before making any decisions using a guardian)
2. Spouse, if not legally separated from the patient, or a domestic partner;
3. A son or daughter eighteen years of age or older;
4. A parent;
5. A brother or sister eighteen years of age or older;
6. A close friend. A close friend is any person, eighteen years of age or older, who is a close friend of the patient, or a relative of the patient (other than a spouse, adult child, parent, brother or sister), who has maintained such regular contact with the patient as to be familiar with the patient’s activities, health, and religious or moral beliefs. Such person must write and present a signed statement to that effect to the attending physician. This statement should be added to the chart.

Patient Objection to Choice of Surrogate
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to the choice of surrogate, the patient’s objection must prevail until Risk Management becomes involved.

Surrogate Designation of Another Surrogate
If the surrogate designates any other person on the surrogate list, such person designated will be the authorized surrogate, provided no one in a class higher in priority than person designated objects. If there is such an objection or disagreement, the attending physician must promptly refer the matter to Risk Management.

Document the surrogate in the chart.

Question 4 – Is there a situation which would allow a surrogate to make decisions to withhold or withdraw life-sustaining treatment?

In order for a surrogate to withhold or withdraw life sustaining treatments, one of the following must be satisfied:
1. If the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
2. If the patient is permanently unconscious, the attending physician determines with the independent concurrence of another attending physician that the treatment would be an extraordinary burden to the patient.
3. If the patient has an irreversible or incurable condition, as determined by the attending physician with the independent concurrence of another attending physician, the provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or extraordinarily burdensome under the circumstances.

If the decision revolves around the provision of artificial nutrition or hydration (unlikely in the ED), then you should consult risk management.

Duty to Give the Surrogate Information
Health care providers must provide the surrogate information necessary to make an informed decision, including information about the patient’s diagnosis, prognosis, the nature and consequences of proposed health care, and the benefits and risks and alternatives to proposed health care.

Expression of Decisions
The surrogate must express a decision to withhold or withdraw life-sustaining treatment either orally to the attending physician or in writing.

Documentation
Three conditions above was present as a progress note. The concurring attending must write the same sort of note as a progress note.

Patient Objection to Surrogate’s Treatment Decision
Notwithstanding a determination that an adult patient lacks decision-making capacity, if the patient objects to a health care decision made by a surrogate the patient’s objection prevails until a determination is made by risk management.

Standard Forms
If the decision revolves around DNR, the surrogate should sign a DNR form. If the decision concerns intubation, vasopressors, dialysis, etc.; then documentation should be done in a progress note by the attending and the concurring attending.

Health care decisions for adults without available, willing, and competent surrogates

***Consult Risk Management for these decisions***

Written by reuben

November 1st, 2010 at 9:55 pm

Jewish Home Admissions

Written by reuben

September 11th, 2009 at 5:00 pm

Posted in Nursing Home