DETERMINING PATIENT DECISIONAL CAPACITY AND IDENTIFYING SURROGATE DECISION MAKERS
The ED team should immediately identify the decision makers when a debilitated patient arrives in crisis to the ED. A patient with decisional capacity is one who has the mental ability to grasp and retain information about his or her condition, weigh risks and benefits, and demonstrate these abilities by verbalizing a medical decision27 (see chapter 303, "Legal Issues in Emergency Medicine," for a more detailed discussion of patient capacity). Table 299-4 lists phrases to aid meaningful communication with patients and families.28 If the patient lacks decisional capacity, then the patient's advance directive should be accessed and the named surrogate decision maker should be contacted as soon as possible. If none of these resources are available, then the closest family member(s) should be consulted regarding the plan of care. If no one is available to speak for the patient, then the treating physician should act in the patient's best interest. This may include an order to "do not resuscitate" the patient if it is clear that aggressive therapy would not be beneficial.
TABLE 299-4Key Communication Phrases28 ||Download (.pdf) TABLE 299-4 Key Communication Phrases28
Determining Decision-Making Capacity
Will you describe your current condition?
Tell me about the treatment options we have just discussed.
Explain to me why you feel that way.
Quality of Life
What symptoms bother you the most? What concerns you the most?
Has anyone talked to you about what to expect?
Do you have any sense of how much time is left? Is this something you would like to talk about?
Talking with Surrogate Decision Makers
These decisions are very hard; if [the patient] was sitting with us today, what do you think [he/she] would say?
Can you tell me why you feel that way?
It is not a question of whether we will care for your [loved one], but how we will care for them.
Then we will do everything possible to keep your [loved one] comfortable, but we won't be providing ineffective and burdensome therapies such as CPR or intubation.
Discussing Palliative Care or Hospice Referral
To meet the goals we've discussed, I've asked the palliative care team to visit with you; they are experts in treating the symptoms you are experiencing. They can help your family deal with the changes brought on by your illness.
Breaking Bad News—Death Pronouncement
I wish there is more we could have done; I'm very sorry for your loss. This has to be really difficult for you. Is there anyone I can call to be with you now?
Once the physician has determined the patient's decision-making capacity, chronic health status, a clinical diagnosis for the current visit, and a general understanding of the patient's care preference, the doctor and team are prepared to have an abbreviated family meeting with the decision maker(s) to discuss the approach to care. The physician must be clear in his/her own mind whether there is any available therapy that will restore the patient's health; have access to the advice of consultants, specialists, and the patient's primary care physician; and be prepared to issue honest, compassionate, and helpful recommendations based on his/her own assessment.
A productive approach to start such meetings is to ask the surrogate decision maker what he or she understands about the patient's past health and current condition (see Table 299-4). After patiently listening, the physician should share his or her insight into the patient's condition and prognosis while monitoring the family's reaction to determine whether the ED team and the family are in agreement. An example of a physician's opinion in a particular case follows: "Your mother's advanced medical condition cannot be cured, and her illness has made her defenseless against the bacteria in her own body. Treating her again and providing another round of intensive care will not bring her health or immune system back to normal, but may only prolong her suffering."
The next step is to ask the surrogate decision makers whether they know about the patient's values and preference for care, for example, how their mother would wish to be treated in the current circumstances. If the answer to that is unknown, ask how the surrogate decision makers would wish to be treated if they were in the same condition.
Based on the response to these questions, the plan of care should be negotiated and jointly affirmed. If the patient decision maker(s) indicate that they must have full resuscitative efforts despite your reservations, you can explore that thinking with them, although it would be best to provide symptom-blunting treatment (such as opiates) along with intubation or central line insertions.
Cultural difference should be taken into account when discussing treatment options with patients and families, including religious preferences. African Americans are more likely to select aggressive treatment options and less likely to select hospice care than non-Hispanic whites.29 Reasons cited for end-of-life preferences among African Americans facing these decisions include historical mistrust toward the healthcare system and the importance of spirituality.29
Do not resuscitate (DNR) is a medical order, like intubation, oxygen, or IV fluids. Although a DNR order can be written by the physician without the agreement of a surrogate or family member, the order must be in accord with state law and hospital policy. However, DNR status or other limitations of resuscitation should evolve directly from harmonious decisions reached at the family meeting. Code status orders should be written on every patient justifying the particular approach recommended. There is no ethical obligation to provide ineffective and burdensome care.30 Families are often grateful when a physician compassionately recommends treating a patient with comfort measures rather than prolonging his or her suffering with nonbeneficial interventions.
The Center for Ethics in Health Care at Oregon Health & Science University developed the Physician Orders for Life-Sustaining Treatment in 1995.31 Since then, the program has expanded to 13 states, with 21 more states currently developing similar programs. This brightly colored form allows a patient to effectively communicate his or her wishes and have those wishes documented as a transporTable medical order that is valid across all healthcare settings (ED, nursing home, community). The Physician Orders for Life-Sustaining Treatment form is helpful in initiating conversations about treatment preferences and can prevent unwanted resuscitations by EMS.31
Palliative care consultation services are likely available at your hospital and should be used just as you would any specialist consultation. ED consultation can provide assistance when conducting a family meeting or when access to an inpatient hospice or palliative care unit is needed. When symptom relief, medical decision making, or disposition and coordination of care are beyond your expertise or available time, a consult is appropriate. Notify the patient's attending physician of the consultation if time allows.32