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“Instructions on Current Life-Sustaining Treatment Options” Form: Objectives and Use
Jack SchwartzAttorney General’s Office
April 2008
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What’s the Key Issue? > 30,000 hospital and nursing home
deaths annually in Maryland Most after a chronic illness Most after a decision about medical
interventions Is there a good answer to the “Why”
question? Why are we pursuing this pathway, instead
of another?
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Good Answers to the “Why?” Question Because the patient chose this
pathway Told us so after informed consent
discussion Pointed the way in an advance directive
Because this pathway fits the patient’s values and beliefs
Because this pathway provides the best care, given the patient’s condition
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Bad Answers to the “Why?” Question Because Doctor X always does it
this way Because it’s too soon after surgery
for the patient to die Because Relative Y said she’d sue
us if we didn't We just went ahead, we don’t
really know why
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Care Planning and Delivery Steps Identifying issues for which decision
needed now Discussing goals/options with the right
decision maker Documenting decisions Writing physician orders All of these should be done, form or no
form LST Options form meant to improve existing
process
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Legal Framework Has Not Changed Types of advance directives Proxy standards
What would patient want, if known? Living will or similar advance directive is
direct evidence What is in patient’s best interest?
Surrogate authority Patient in terminal or end-stage condition,
PVS Physician authority
Medically ineffective treatment
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Terminal Condition Incurable No recovery even with life-
sustaining treatment Death “imminent”
No definition of “imminent” Medicare hospice criterion sometimes
used
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End-Stage Condition Progressive Irreversible
No effective treatment for underlying condition
Advanced to the point of complete physical dependency
Death not necessarily “imminent” Primarily advanced dementia, maybe other
diseases
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Persistent Vegetative State No evidence of awareness Only reflex activity, conditioned
response Wait “medically appropriate period
of time” for diagnosis One of two physicians who certify
PVS must be neurologist, neurosurgeon, or other expert re cognitive functioning
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What Is the LST Options Form? Standardized format re patient/proxy
preferences about current issues What decisions ought to be made now? Not another advance directive
Nursing homes must offer Other facilities may use Physician to sign
But, not a physician’s order; not an EMS/DNR Order
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Why the Form? Better planning when no advance
directive Better application of advance
directive to clinical situation More awareness of main goal of
care Better communication if patient
transfers
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LST Options Form and Advance Directives
AD LST Options
Capacity required?
Yes No
Locked into place after incapacity?
Yes No
Hypothetical, future issues?
Yes No
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Part A: Main Goal of Care Premise: specific treatment
preferences serve a goal, not ends in themselves
“What do you hope to achieve?”
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Part B: Advance Directive and Contact Information Attach prior or newly created
advance directives Provide contact information for
proxy Health care agent, if any Top-priority surrogates
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Part C: DNR Status Yes, attempt CPR No, allow natural death “No” answer is not a DNR order,
even after physician signs Should be implemented with
facility-specific or EMS/DNR Order
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Part D: Ventilator Yes, even indefinitely Yes, for a therapeutic trial
Time limit may be specified No
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Part E: Hospital Transfer Yes, for any indicated condition Yes, for acute injury only No
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Part F: Medical Workup Yes, all indicated tests
Treatment planned after diagnosis Limited tests only
Noninvasive, low risk No
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Part G: Antibiotics Yes Yes, but not by IV No, except if needed for comfort
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Part H: Artificially Administered Fluids/Nutrition Yes, even indefinitely Yes, for a therapeutic trial
Time limit may be specified Yes for IV fluids; no for nutrition No
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Part I: Other Treatment Issues as Specified Yes, even indefinitely or
repeatedly Yes, for an acute episode only No
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If LST Options Form Is Filled Out: Must travel with patient New attendings must consider
Starting point for discussion Can be basis for physician’s orders
Must be reviewed if material change in patient’s condition Clinical judgment about what = “material
change” But: loss of capacity = “material change”
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Related and Noteworthy: Ethical Framework Endorsed by State Advisory Council on
Quality Care at the End of Life, Attorney General’s Office
Intended to: Make explicit the process for quality care
delivery Can be adapted in facility policies
Identifies key steps and rationale for each http://www.oag.state.md.us
Click on “Health Policy” Click on “Ethical Framework”
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Additional Resources www.oag.state.md.us Click on “Health Policy”
Text of Health Care Decisions Act Summary, slide shows, algorithm LST Options form Explanatory Guides Advance directive materials Legal opinions and advice letters
“I am now thoroughly confused but better informed.”
Martin Dawes, BMJ 331 (2005): 362