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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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4. Advance Directives - Planning
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The medical practitioner should not treat the disease but the patient who is suffering from it.
~ Maimonides
Documented Wishes
The Importance of Advance Directives and Durable Power of Attorney for Healthcare
It was a typical Wednesday morning at the local hospital when the nursing staff noticed something strange in the medical records of one of their patients, Mrs. Smith. Mrs. Smith had been admitted a few days prior for pneumonia, but the nursing staff noticed that there was no mention of an advance directive or durable power of attorney for healthcare in her medical records. This was a cause for concern, as the hospital was required by law to inform patients of their rights to make decisions about their medical care and inquire about advance directives.
The nursing staff immediately informed the attending physician, Dr. Johnson, who was surprised to learn that Mrs. Smith did not have an advance directive or durable power of attorney for healthcare. Dr. Johnson knew that it was his responsibility to educate his patients about their rights to make decisions about their medical care and ensure that their medical wishes were documented. He decided to speak with Mrs. Smith about her medical care wishes and to encourage her to create an advance directive and durable power of attorney for healthcare.
Dr. Johnson entered Mrs. Smith’s hospital room and introduced himself. He explained to Mrs. Smith that he wanted to speak with her about her medical care wishes and ensure that her wishes were documented. Mrs. Smith was hesitant at first, but Dr. Johnson reassured her that he was there to support her and ensure that her wishes were respected.
Dr. Johnson explained to Mrs. Smith the importance of advance directives and durable power of attorney for healthcare. He described how these documents could help ensure that her medical care wishes were respected and that the right decisions were made on her behalf in case she became unable to make her own decisions.
Mrs. Smith listened carefully and nodded her head in agreement. She understood the importance of these documents and agreed to create an advance directive and durable power of attorney for healthcare. Dr. Johnson provided her with the necessary forms and explained how to fill them out.
Mrs. Smith completed the forms and appointed her daughter, Sarah, as her medical decision-making surrogate. Dr. Johnson made sure that Mrs. Smith’s wishes were clear and that Sarah understood her role and responsibilities as a surrogate. He educated Sarah about the patient’s reasonable goals, values, and priorities, and explained how to make medical decisions that would maximize Mrs. Smith’s best interests using beneficence (do good) and nonmaleficence (do no harm).
A few days later, Mrs. Smith’s condition worsened, and she became unable to make her own medical decisions. Sarah was called upon to make medical decisions on her mother’s behalf, and she did so with confidence, using the patient’s reasonable goals, values, and priorities, as well as the principles of beneficence and nonmaleficence.
Thanks to Dr. Johnson’s intervention and Sarah’s diligent advocacy, Mrs. Smith’s medical wishes were respected, and she received the care that she wanted. This case was a wake-up call for the hospital staff, reminding them of the importance of educating patients about their rights to make decisions about their medical care and ensuring that their medical wishes were documented. It was a lesson that they would not soon forget.
Abstract
The Patient Self-Determination Act of 1990 mandates that all medical institutions receiving Medicaid or Medicare payments must inform patients of their legal rights to make decisions about their medical care, periodically inquire about advanced directives, document patients’ medical care wishes, and provide educational programs on patient self-determination. An advance directive (living will) and durable power of attorney for healthcare allow patients to self-determine their treatment preferences and establish a medical decision-making surrogate. The durable power of attorney is accompanied by professional responsibilities for both the practitioner and surrogate, with the surrogate obligated to use the patient’s reasonable goals, values, and priorities when making medical decisions. If these are not determinable, the surrogate must maximize the patient’s best interests using the principles of beneficence and nonmaleficence. The practitioner has a role in educating the surrogate on decision-making. The living will must be respected if it provides clear instructions, otherwise the decision-making authority goes to the surrogate appointed by the durable power of attorney.
**
Think
[4:1] Autonomy, or self-determination, is valued precisely because it is the patient who is considered to be in the best position to determine what their own subjective goals, values, and priorities are, which are the necessary conditions for determining what objective treatments will maximize the patient’s best interests.
[4:2] This recognition resulted in Congress passing the patient Self-Determination Act of 1990, which mandates by federal law that all medical institutions that receive any Medicaid or Medicare payments must:
- 1. inform patients of their legal rights to make decisions concerning their medical care,
- 2. periodically inquire as to whether the patient has executed an advanced directive,
- 3. document in the medical records the patient’s medical care wishes, and
- 4. provide educational programs for staff, patients, and the community on ethical issues concerning patient self-determination and advance directives.
Assess
Patient: 1) Autonomy
[4:3] An advance directive, or a living will, is a preemptive act of a patient with decisional capacity to autonomously self-determine what treatment preferences they authorize under various conditions, and a durable power of attorney for healthcare (POA) establishes who is to serve as their medical decision-making surrogate if they were to ever be in a state of lacking decisional capacity. A durable power of attorney is durable because it only comes into effect once the patient loses decisional capacity and continues throughout that duration of time.
[4:4] Although the living will is the most direct communication from the patient as to what treatments the patient would or would not want to give informed consent to, the living will can also be the least helpful if the patient is unable to predict future events and changing desires. This can result in vague terms like “no heroic measures” or “no extraordinary care,” which in practice is virtually no better than saying nothing at all. This lack of contextual precision is where surrogate decision-making can make its helpful contribution.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[4:5] The durable power of attorney (POA) is accompanied with professional responsibilities for both the practitioner and the surrogate. As a matter of beneficence (do good) and nonmaleficence (do no harm), the practitioner must make sure that the surrogate is educated about how to make medical decisions for the patient. First, the surrogate decision maker is not to be making medical decisions for the patient using their own goals, values, and priorities. Second, the surrogate, or proxy, must make medical decisions that maximize the patient’s best interests—beneficence (do good) and nonmaleficence (do no harm), using the patient’s reasonable goals, values, and priorities. In other words, the surrogate decision maker must make medical decisions for the patient as if the surrogate were the patient themself making the decision. This is why the practitioner must include the surrogate in the patient’s health care discussions as much as possible before the patient loses their decisional capacity, especially when having direct discussions about the patient’s reasonable goals, values, and priorities. If the practitioner fully informs the surrogate of the circumstances and medical condition of the patient, and if the surrogate understands how to make decisions that will maximize the patient’s best interests, then this will typically avoid some of the inherent problems of vagueness and imprecision that frequently occur with living wills.
[4:6] However, if for some reason the patient’s reasonable goals, values, and priorities are not determinable, then the responsibility of the surrogate, in consultation with the practitioner, will be to maximize the patient’s best interests, using the moral principles of beneficence (do good) and nonmaleficence (do no harm).
Public Policy: 4) Justice
[4:7] The federal government enacted the Patient Self-Determination Act, which essentially makes every medical institution in the country responsible for:
- 1. enforcing the patient’s right to autonomously choose what medical care they will receive (Living Will),
- 2. who their surrogate will be (Durable Power of Attorney—POA), and
- 3. document the Living Will and Durable Power of Attorney in the electronic medical records (EMR).
Conclude
[4:8] Autonomous decisional authority is a universal patient right. Therefore, if there is a living will that provides clear and distinct instructions regarding a foreseen medical circumstance, then that living will must be respected. If there is no living will, or the living will is not clear for a particular circumstance, then the decision-making authority will go to whoever has been appointed to be the surrogate decision maker by the patient’s durable power of attorney (POA). When making medical decisions, the surrogate has the legal and moral obligation to use the patient’s reasonable goals, values, and priorities. In other words, the surrogate must make medical decisions as if they were the patient, which is not necessarily how the proxy might make decisions for themself. The practitioner has a vital role in educating the patient’s surrogate as to how the surrogate is to make medical decisions by using the patient’s reasonable goals, values, and priorities, and if those are not knowable, then by maximizing the patient’s best interests using beneficence (do good) and nonmaleficence (do no harm).
[4:9] In summary, advance directives are essential tools in respecting and upholding patient autonomy in medical care. Living wills provide guidance on the patient’s desired treatment, while durable power of attorney for healthcare appoints a surrogate to make decisions on their behalf when necessary. It is crucial for practitioners to educate patients and surrogates about their roles and obligations, ensuring that medical decisions are made based on the patient’s reasonable goals, values, and priorities or, when these are not known, in the best interest of the patient. By doing so, healthcare professionals can effectively support patients’ rights to self-determination and maintain trust in the medical profession.
**
4. Review Questions
1. Congress passed the Self-Determination Act of 1990 federally mandates that any institution that receives Medicaid or Medicare payments must:
2. A durable power of attorney is durable because a power of attorney:
3. Living wills can be the most direct patient communication, and they can also be the least helpful.
4. It is essential to select a trusted surrogate as the surrogate will be making medical decisions using their own goals, values, and priorities.
**
CORRECT! 🙂
[4:2] This recognition resulted in Congress passing the patient Self-Determination Act of 1990, which mandates by federal law that all medical institutions that receive any Medicaid or Medicare payments must:
1. inform patients of their legal rights to make decisions concerning their medical care,
2. periodically inquire as to whether the patient has executed an advanced directive,
3. document in the medical records the patient’s medical care wishes, and
4. provide educational programs for staff, patients, and the community on ethical issues concerning patient self-determination and advance directives.
Wrong 😕
[4:2] This recognition resulted in Congress passing the patient Self-Determination Act of 1990, which mandates by federal law that all medical institutions that receive any Medicaid or Medicare payments must:
1. inform patients of their legal rights to make decisions concerning their medical care,
2. periodically inquire as to whether the patient has executed an advanced directive,
3. document in the medical records the patient’s medical care wishes, and
4. provide educational programs for staff, patients, and the community on ethical issues concerning patient self-determination and advance directives.
Wrong 😕
[4:3] An advance directive is a preemptive act of a patient with decisional capacity to autonomously self-determine what treatment preferences they authorize under various conditions, called a living will, and who is to serve as their medical decision-making surrogate if they were to ever be in a state of lacking decisional capacity, called a durable power of attorney for healthcare (POA). A durable power of attorney is durable because it only comes into effect once the patient loses decisional capacity and continues throughout that duration.
CORRECT! 🙂
[4:3] An advance directive is a preemptive act of a patient with decisional capacity to autonomously self-determine what treatment preferences they authorize under various conditions, called a living will, and who is to serve as their medical decision-making surrogate if they were to ever be in a state of lacking decisional capacity, called a durable power of attorney for healthcare (POA). A durable power of attorney is durable because it only comes into effect once the patient loses decisional capacity and continues throughout that duration.
Wrong 😕
[4:4] Although the living will is the most direct communication from the patient as to what treatments the patient would or would not want to give informed consent to, the living will can also be the least helpful if the patient is unable to predict future events and changing desires. This can result in vague terms like “no heroic measures” or “no extraordinary care,” which in practice is virtually no better than saying nothing at all. This lack of contextual precision is where surrogate decision-making can make its helpful contribution.
CORRECT! 🙂
[4:4] Although the living will is the most direct communication from the patient as to what treatments the patient would or would not want to give informed consent to, the living will can also be the least helpful if the patient is unable to predict future events and changing desires. This can result in vague terms like “no heroic measures” or “no extraordinary care,” which in practice is virtually no better than saying nothing at all. This lack of contextual precision is where surrogate decision-making can make its helpful contribution.
CORRECT! 🙂
[4:5] The durable power of attorney (POA) is accompanied with professional responsibilities for both the practitioner and the surrogate. As a matter of beneficence (do good) and nonmaleficence (do no harm), the practitioner must make sure that the surrogate is educated about how to make medical decisions for the patient. First, the surrogate decision maker is not to be making medical decisions for the patient using their own goals, values, and priorities. Second, the surrogate, or proxy, must make medical decisions that maximize the patient’s best interests—beneficence (do good) & nonmaleficence (do no harm), using the patient’s reasonable goals, values, and priorities. In other words, the surrogate decision maker must make medical decisions for the patient as if the surrogate were the patient making the decision. This is why the practitioner must include the surrogate in the patient’s health care discussions as much as possible before the patient loses their decisional capacity, especially when having direct discussions about the patient’s reasonable goals, values, and priorities. If the practitioner fully informs the surrogate of the circumstances and medical condition of the patient, and if the surrogate understands how to make decisions that will maximize the patient’s best interests, then this will typically avoid some of the inherent problems of vagueness and imprecision that frequently occur with living wills.
Wrong 😕
[4:5] The durable power of attorney (POA) is accompanied with professional responsibilities for both the practitioner and the surrogate. As a matter of beneficence (do good) and nonmaleficence (do no harm), the practitioner must make sure that the surrogate is educated about how to make medical decisions for the patient. First, the surrogate decision maker is not to be making medical decisions for the patient using their own goals, values, and priorities. Second, the surrogate, or proxy, must make medical decisions that maximize the patient’s best interests—beneficence (do good) & nonmaleficence (do no harm), using the patient’s reasonable goals, values, and priorities. In other words, the surrogate decision maker must make medical decisions for the patient as if the surrogate were the patient making the decision. This is why the practitioner must include the surrogate in the patient’s health care discussions as much as possible before the patient loses their decisional capacity, especially when having direct discussions about the patient’s reasonable goals, values, and priorities. If the practitioner fully informs the surrogate of the circumstances and medical condition of the patient, and if the surrogate understands how to make decisions that will maximize the patient’s best interests, then this will typically avoid some of the inherent problems of vagueness and imprecision that frequently occur with living wills.
4. Clinical Vignettes
1. Mr. Gabriel Ahmed, a 52-year-old network administrator is admitted and is informed of their rights to make decisions about their medical care. The practitioner periodically asks the patient if they have an advanced directive and documents their wishes in the medical records. The medical institution also regularly offers educational programs for staff, patients, and the community on ethical issues related to self-determination and advance directives. Which of the following best describes the legal requirement imposed on the medical institution?
2. Ms. Sofia Ali, a 62-year-old banker has a durable power of attorney for healthcare (POA) in case they ever lose decisional capacity. This document designates a surrogate to make medical decisions on their behalf if they are unable to do so themselves. What makes the durable power of attorney (POA) durable?
3. Mr. Caden Chen, a 68-year-old marketing professional has created a living will expressing their treatment preferences, but the document contains vague terms like "no heroic measures" or "no extraordinary care." This lack of specific instructions can make it difficult for healthcare providers to make decisions on behalf of the patient. How can a surrogate be helpful?
4. Ms. Leslie Hamilton, a 72-year-old retiree is diagnosed with a progressive, degenerative illness that will eventually result in a loss of decisional capacity. The patient has a durable power of attorney (POA) and appoints their spouse as surrogate decision maker. The patient has made it clear that they do not want any medical interventions that will prolong their life if they are in a persistent vegetative state, and documents that in the medical records. What is the primary responsibility of the practitioner when working with the surrogate decision-maker in this situation?
5. Mr. Griffin Singh, an 82-year-old retiree has been admitted with a serious illness and is unable to make decisions regarding their medical care. The healthcare team has discovered that the patient has a living will in place. The patient also has a durable power of attorney that appoints a surrogate decision-maker. Which of the following statements best describes the decision-making process in this situation?
Wrong 😕
Explanation: There are legal requirements imposed on medical institutions regarding patients' rights to make decisions about their medical care [4:2]. Informed consent and the right to make decisions about one's own medical care are fundamental principles in medical ethics and are protected by law. The medical institution has a legal obligation to inform patients of their rights and periodically inquire about advanced directives, as well as provide educational programs for staff, patients, and the community on ethical issues related to self-determination and advance directives. The documentation of the patient's wishes in their medical records is important but is not the only legal requirement imposed on the medical institution in this scenario [4:7].
CORRECT! 🙂
Explanation: There are legal requirements imposed on medical institutions regarding patients' rights to make decisions about their medical care [4:2]. Informed consent and the right to make decisions about one's own medical care are fundamental principles in medical ethics and are protected by law. The medical institution has a legal obligation to inform patients of their rights and periodically inquire about advanced directives, as well as provide educational programs for staff, patients, and the community on ethical issues related to self-determination and advance directives. The documentation of the patient's wishes in their medical records is important but is not the only legal requirement imposed on the medical institution in this scenario [4:7].
Wrong 😕
Explanation: A durable power of attorney for healthcare is a legal document that designates a surrogate decision-maker to make medical decisions on behalf of a patient in the event that the patient loses decisional capacity [4:3]. It is called "durable" because it comes into effect after the patient loses decisional capacity, and it stays in effect until the patient regains decisional capacity or until the patient dies [4:3]. This is different from a regular power of attorney, which becomes invalid once the person granting the power becomes incapacitated [4:3]. A durable power of attorney is an essential tool in ensuring that a person's wishes are carried out in the event that they become unable to make their own medical decisions [4:3].
CORRECT! 🙂
Explanation: A durable power of attorney for healthcare is a legal document that designates a surrogate decision-maker to make medical decisions on behalf of a patient in the event that the patient loses decisional capacity [4:3]. It is called "durable" because it comes into effect after the patient loses decisional capacity, and it stays in effect until the patient regains decisional capacity or until the patient dies [4:3]. This is different from a regular power of attorney, which becomes invalid once the person granting the power becomes incapacitated [4:3]. A durable power of attorney is an essential tool in ensuring that a person's wishes are carried out in the event that they become unable to make their own medical decisions [4:3].
Wrong 😕
Explanation: Surrogate decision-making can provide specific treatment preferences based on the patient's goals, values, and priorities, filling in the gaps left by vague terms in the living will [4:4]. A living will is a legal document that outlines a person's healthcare wishes in the event that they are unable to make decisions for themselves. However, if the living will contains ambiguous or unclear terms, healthcare providers may have difficulty interpreting the patient's wishes [4:4]. In such cases, a surrogate decision-maker can be helpful in providing additional information about the patient's goals, values, and priorities [4:4]. The surrogate can work with the healthcare team to help interpret the patient's wishes and make decisions that align with the patient's goals, values, and priorities [4:4]. While a surrogate may not be able to change the terms of the living will, they can provide valuable context and additional information to help ensure that the patient's wishes are being followed [4:4].
CORRECT! 🙂
Explanation: Surrogate decision-making can provide specific treatment preferences based on the patient's goals, values, and priorities, filling in the gaps left by vague terms in the living will [4:4]. A living will is a legal document that outlines a person's healthcare wishes in the event that they are unable to make decisions for themselves. However, if the living will contains ambiguous or unclear terms, healthcare providers may have difficulty interpreting the patient's wishes [4:4]. In such cases, a surrogate decision-maker can be helpful in providing additional information about the patient's goals, values, and priorities [4:4]. The surrogate can work with the healthcare team to help interpret the patient's wishes and make decisions that align with the patient's goals, values, and priorities [4:4]. While a surrogate may not be able to change the terms of the living will, they can provide valuable context and additional information to help ensure that the patient's wishes are being followed [4:4].
Wrong 😕
Explanation: The surrogate decision-maker is responsible for making healthcare decisions on behalf of the patient in the event that the patient becomes unable to make decisions for themselves [4:3]. It is the practitioner's responsibility to involve the surrogate in discussions about the patient's goals, values, and priorities and to educate the surrogate on how to make medical decisions that maximize the patient's best interests [4:5]. In this case, the patient has made it clear that they do not want any medical interventions that will prolong their life if they are in a persistent vegetative state, and this preference should be respected [4:8]. The practitioner should ensure that the surrogate is aware of the patient's wishes and is able to make decisions that align with those wishes [4:8]. The practitioner should also provide support and guidance to the surrogate as needed to help them make informed decisions that promote the patient's well-being [4:5].
CORRECT! 🙂
Explanation: The surrogate decision-maker is responsible for making healthcare decisions on behalf of the patient in the event that the patient becomes unable to make decisions for themselves [4:3]. It is the practitioner's responsibility to involve the surrogate in discussions about the patient's goals, values, and priorities and to educate the surrogate on how to make medical decisions that maximize the patient's best interests [4:5]. In this case, the patient has made it clear that they do not want any medical interventions that will prolong their life if they are in a persistent vegetative state, and this preference should be respected [4:8]. The practitioner should ensure that the surrogate is aware of the patient's wishes and is able to make decisions that align with those wishes [4:8]. The practitioner should also provide support and guidance to the surrogate as needed to help them make informed decisions that promote the patient's well-being [4:5].
CORRECT! 🙂
Explanation: A living will is a legal document that outlines a person's healthcare wishes in the event that they are unable to make decisions for themselves [4:4]. If the living will provides clear instructions, the healthcare team should rely on those instructions to guide their decision-making [4:8]. In this situation, if the living will is available and provides clear instructions, the healthcare team should follow those instructions to the best of their ability [4:8]. However, if the living will is unclear or does not provide specific guidance, the healthcare team should consult with the patient's surrogate decision-maker to determine the best course of action based on the patient's best interests [4:8]. The healthcare team should make every effort to ensure that the patient's reasonable goals, values, and priorities are respected for the maximization of the patient’s best interest [4:5].
Wrong 😕
Explanation: A living will is a legal document that outlines a person's healthcare wishes in the event that they are unable to make decisions for themselves [4:4]. If the living will provides clear instructions, the healthcare team should rely on those instructions to guide their decision-making [4:8]. In this situation, if the living will is available and provides clear instructions, the healthcare team should follow those instructions to the best of their ability [4:8]. However, if the living will is unclear or does not provide specific guidance, the healthcare team should consult with the patient's surrogate decision-maker to determine the best course of action based on the patient's best interests [4:8]. The healthcare team should make every effort to ensure that the patient's reasonable goals, values, and priorities are respected for the maximization of the patient’s best interest [4:5].
**
4. Cases: 4a, 4b, 4c*
Instructions
1. Read Prompt, 2. Think, Assess, & Conclude (TAC), then 3. Select an answer that mirrors the TAC conclusion.
Note: After success, select each of the wrong answers to understand why each of them is wrong.
4a
An adult patient, unable to communicate for themself, is admitted to the ICU in the end stages of small-cell-lung-cancer (SCLC), a particularly aggressive form of lung cancer. The spouse and family want the practitioner to do everything possible. A friend of the patient, estranged from the spouse and family, presents a recently signed and witnessed durable power of attorney, authorizing the friend to be the surrogate decision maker. The friend tells the practitioner to stop all medical treatment other than hydration, nutrition, and pain management.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
4b
A patient fills out a living will and states explicitly that they never want to be on a heart-lung machine under any condition. The living will is included in the medical records. Shortly after that, a medical emergency occurs in which the patient will need to be temporarily on a heart-lung machine to get through the emergency; then, the patient will be able to live everyday life.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
4c*
A patient with metastatic pancreatic cancer is admitted to the hospital with shortness of breath. The patient does not have decisional capacity. The patient’s youngest offspring, who holds the medical power of attorney, makes the patient DNR. The patient’s eldest offspring disagrees with this decision. What should be done?
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
Wrong 😕
A. The spouse and family have the ultimate authority to be the patient’s surrogate decision-makers, especially when withdrawing life-sustaining treatment.
The patient’s expressed consent has the most authority, then the durable power of attorney (POA), then the state listed order of surrogates.
Wrong 😕
B. Under these conditions, it is professional due diligence to get a court order for institutional risk-management purposes.
The patient’s expressed consent has the most authority, then the durable power of attorney (POA), then the state listed hierarchical order of surrogates which is basically the same for all states. Court order will only be needed if the practitioner believes that the surrogate was not making decisions based on the patient’s reasonable goals, values, and priorities and was inconsistent with the medical standards of care.
Wrong 😕
C. It is never morally permissible for a practitioner to withdraw life-sustaining treatment as that will abrogate the patient-practitioner relationship and be a form of active euthanasia.
Patients have the equal authority to: accept treatment, deny treatment, and withdraw from treatment; otherwise, no patient would be willing to experiment with various treatment options if all options were permanent.
CORRECT! 🙂
THINK (Question)
Does the patient’s friend with the POA have the authority to insist that aggressive treatment be withdrawn?
ASSESS
- • Patient Autonomy (informed consent)
The patient’s autonomous decision was to appoint the POA to make decisions on their behalf if and when they were to lose decisional capacity. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
As with all surrogate decision-making, the practitioner should do all possible to help all the parties of interest come to a consensus or understanding of what the patient would wish to have done under these circumstances using the patient’s goals, values, and priorities. - • Public-Policy Justice (be fair)
Congress passed the Patient Self-Determination Act of 1990, which mandates by federal law that all medical institutions that receive any Medicaid or Medicare payments must:
1. inform patients of their legal rights to make decisions concerning their medical care,
2. periodically inquire as to whether or not the patient has executed an advanced directive,
3. document in the medical records the patient’s medical care wishes, and
4. provide educational programs for staff, patients, and the community on ethical issues concerning patient self-determination and advance directives.
CONCLUDE
The person with the POA has the legal authority to be the patient’s surrogate for making medical decisions per the medical standards of care and the patient’s goals, values, and priorities.
Wrong 😕
A. It is never permissible to second guess a Living Will.
A living Will is only as good as the patient’s ability to predict future events. That is why it is so important to know the patient’s reasonable goals, values, and priorities, as that is the foundation of decision-making.
CORRECT! 🙂
THINK (Question)
What does a practitioner do when a Living Will may not be what the patient intended?
ASSESS
- • Patient Autonomy (informed consent)
An advance directive is a preemptive act of a patient with decisional capacity to autonomously self-determine what treatment preferences they authorize under various conditions. Although the living will is the most direct communication from the patient as to what treatments the patient would or would not want to give informed consent to, the living will is the least helpful if the patient cannot predict future events and changing desires. Patients often use vague terms like “no heroic measures” or “no extraordinary care,” which is virtually no better than saying nothing. - • Practitioner Beneficence (do good) & Nonmaleficence (do no harm)
Living Wills must be recognized as disclosing a patient’s wishes under particular circumstances. If the patient delineated such a circumstance, then comply. If the circumstance is such that the patient highly likely did not have such a circumstance in mind, then to follow the Living Will could be against the patient’s wishes. If the latter, then the practitioner should provide the medical standards of care in this medical emergency. - • Public-Policy Justice (be fair)
The federal government enacted the Patient Self-Determination Act, which essentially makes every medical institution in the country responsible for:
1. enforcing the patient’s right to autonomously choose what medical care they will receive (Living Will),
2. who their surrogate will be (Durable Power of Attorney—POA), and
3. document the Living Will and POA in the electronic medical records (EMR).
CONCLUDE
If it is doubtful that the patient had such a circumstance in mind when making the Living Will, then the practitioner should follow the accepted standard of medical care.
Wrong 😕
C. If the rejection of treatment options is recorded in the medical record, then under no condition should the treatment be provided.
The patient’s global rejection of treatment options can be incorrect if they fail to predict the future situation that the patient then finds themself in. The practitioner’s goal is to provide treatment options that align with the patient’s reasonable goals, values, and priorities per the medical standards of care.
Wrong 😕
D. Living Wills are not a helpful tool for securing informed consent.
Although Living Wills can sometimes be naive, they can be a beneficial tool for communicating the patient’s reasonable goals, values, and priorities and for direction for treatment options under particular circumstances.
Wrong 😕
A. Get a court order before complying.
The court has already determined that a durable power of attorney - POA, authorizes that person to make medical decisions per the patient’s reasonable goals, values, and priorities.
Wrong 😕
B. Until consensus is reached, delay the DNR.
Although it is essential for the practitioner to encourage discussion & consensus and to inquire why there are disagreements, the youngest offspring has the POA, the legal authority to make the patient DNR.
Wrong 😕
C. Comply with the older offspring’s decision not to make the patient DNR.
Although the eldest son has traditionally had decision-making authority, in this case, the patient has chosen the youngest son to have the durable power of attorney (POA), with all the conferred decision-making authority per the medical standards of care.
CORRECT! 🙂
THINK (Question)
Does the family member with the POA have decisional authority?
ASSESS
- • Patient Autonomy(informed consent)
The POA is an extension of patient autonomy if incapacitated. - • Practitioner Beneficence (do good) &Nonmaleficence (do no harm)
The practitioner needs to make sure that decision-making for the patient be done in accordance with the patient’s reasonable goals, values and priorities. The practitioner should inquire as to why there is disagreement, encourage the interested parties to come to a consensus or understanding, and if there is still disagreement then the legal authority for decision-making is the POA. - • Public-Policy Justice (be fair)
The person with the POA has the legal authority to be the surrogate.
CONCLUDE
The family member with the POA has decisional authority.
