Discussion w15 650

Q-1

A provider's obligation is to do no harm. Healing the patient from whatever ails them is a holistic healing process. Advanced directives are a large part of the healthcare process as well, and should be discussed earlier and more often than they actually are (House & Ogilvie, 2020); (White, 2019). Advanced directives are essentially the wishes of the patient when they were made when the patient was in a fully coherent mental state and was able to make their own decisions (House & Ogilvie, 2020); (White, 2019). These are the direct wishes of the patient to be followed when the patient themselves are either incapacitated or incoherent (House & Ogilvie, 2020); (White, 2019).

State and federal legislation affect advanced directives in the way that family members can override them when the patient is incapacitated as they are the next of kin or the emergency contact (House & Ogilvie, 2020). Each state has some variations to this loophole, but they mostly stay the same amongst the states (House & Ogilvie, 2020). Some believe that this loophole has arisen due to the massive increase in litigation especially in healthcare (House & Ogilvie, 2020).

There are many ethical dilemmas that occur when allowing for such a loophole and having advanced directives at the same time. A perfect example is from my work in an MSICU yesterday (2/17). I had a patient who coded last Sunday and was extubated Tuesday. The patient is no longer neurologically intact, now on dialysis, and we suspect an anoxic brain injury that has left the patient lethargic, drowsy, unable to follow commands, and opens his eyes to his name but does not track. The family originally brought in a Living will and Advanced Directive when the patient arrived that clearly stated DNR status and refusal of lifelong treatments. However, once the patient began to code, the wife rescinded everything. As healthcare professionals we are now stuck, as there is appropriate documentation to validate the DNR, but as the patient is now incapacitated the next of kin now has medical decisional making capacity. So at this point, she wanted everything done. Fast forward a few days to 2/17, I am explaining to the wife and sister that his prognosis is poor, dialysis isn't helping, his quality of life is how he is presenting now, and I even relayed the fact that the patient clearly said he did not want any of this. The wife acknowledged his advanced directive, but stated: "We need to do everything anyway".

The ethical dilemma has presented as such: we are going against the patient's wishes, especially with futile and end-of-life care, while the wife has the power and authority to change any medical decision that was made previously. We, as healthcare professionals, are now forced to prolong this patient's suffering out of fear of retaliation and litigation.

In my practice, I have always reasonably accommodated the patient's spiritual practices regardless of what they were. We have had sermons in the ICU patient's rooms, as well as celebrations of life, or spiritual rituals.

In my opinion, if that's what the patient wanted, then so be it, we have to respect their wishes, even if we don't agree with them. 

References:

House, S.A., Ogilvie, W.A. (2020). Advance Directives. StatPearls Treasure IslandStatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459133/

White, G. (2019). Do not postpone discussing advanced directives. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 191(28), E796. https://doi-org.lopes.idm.oclc.org/10.1503/cmaj.72212

Q-2

The grieving process is altered in patients who have dementia living with a spouse (Hovland, 2018). This is suspected because the outcome of dementia usually ends up being failure to thrive due to cognitive decline (Hovland, 2018). The spouse recognizes the end result, and pre-emptively begins to grieve as they become aware of the end result of the disease (Hovland, 2018). The stages of grief differ in each individual in terms of intensity, duration, speed, and accpetance to move onto the next stage (Hovland, 2018). Some people take it well, while others do not, and my need support from family, friends, or healthcare team members (Hovland, 2018).

The nurse practitioner can offer many options for support for both the patient and the spouse, especially once the information has been obtained of advancing metastatic cancer (Mughal, Azhar, Siddiqui, 2020). Palliative care, respite care, or hospice placement can be offered as the criteria is met for hospice placement with a life threatening illness, futile care, and/or failure to thrive (Mughal, Azhar, Siddiqui, 2020). The etiology of hospice admission could be either dementia, or the advanced metastatic cancer (Mughal, Azhar, Siddiqui, 2020). 

In terms of actually offering these options to the spouse, careful conversations would need to be had regarding what hospice is, what they do, and what they can offer (Mughal, Azhar, Siddiqui, 2020). I usually begin this conversation with the idea that the goal now has changed from treating and curing, to making the patient as comfortable as possible. A common question I usually get asked in the MSICU is "well how long will it take?" as in how long will it take for the patient to expire, and I usually answer "Only God knows, and all we can do is what the patient wants us to do". However, I also explain that if the patient persists for an extended time, hospice lasts up to 6 months in Florida, and can be extended at any time. Also, I am sure to mention that if they need a break, or begin suffering from caregiver fatigue, that hospice offers respite care as well, where the patient can be moved into the hospice home and the fmaily member can take a break. I belive that the patient being comfortable is just as important as the family members involved being able to take care of themselves as well. 

Usally these conversations are difficult to begin, but once the explanation process starts, it ususally sets in with teh family members that this si the best course of action tso theeir loved one can die with dignity.  

 

 

References:

Hovland, C. (2018). Welcoming death: Exploring pre-death grief experiences of caregivers of older adults with dementia. Journal of Social Work in End-of-Life & Palliative Care, 14(4), 274–290. https://doi-org.lopes.idm.oclc.org/10.1080/15524256.2018.1508538

Mughal, S., Azhar, Y., Siddiqui, W.J. (2020). Grief Reaction. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK507832/

Q-3

Providers must address the advance directives to their patients to determine the future medical care when the patient becomes incapable of making medical decisions. Advance Directives are described as the legal mechanisms that reinforce the fundamental professional and moral responsibilities of health care providers and institutions to promote and to protect patient autonomy, welfare, and dignity (Armstrong & Silverman, 2017, p. 224). There are two types of advance directives namely the living will and the health care proxy. The living will is also known as instructional directives that define the type of decision that should direct the patient’s care. The second type of advance directive is the health care proxy that is often called a durable power of attorney for health care. It is an individual that is selected by the patient to make decisions.

Some states have a state-authorized portable order. State-authorized portable orders are described as a specialized form of an identifier such as a do not attempt to resuscitate bracelets or necklaces that are authorized by state law or a state medical director that translates to the patient’s preference regarding specific life-sustaining treatment decisions into portable medical orders (National Archieves and Records Administration, 2020). Oregon’s Physician Orders for Scope of Treatment (POST) and New York’s Medical Orders for Life-Sustaining Treatment (MOLST) are some of the examples of the state- authorized portable orders that aim to make the patient's desire more easily available to emergency medical personnel (National Achieves and Records Administration, 2020). Some of the ethical or spiritual dilemmas that patients and families encounter during these discussions are unethical experimentation, life-prolonging treatment, life-sustaining treatment, and medical orders of end-of-life care. For example, providers support that each person has the right to determine what medical treatment they will receive including what life- sustaining treatment should be provided if an individual has a terminal issue. Providers need to ensure that they know the current state laws, living wills and durable power of attorney, they are considerate of the patient’s cultural beliefs and practice and should discuss the issue of life- sustaining measures with each of their patients before medical emergency happens or before institutionalization to prevent ethical dilemma during end-of life care.

 

 

 

 

 

 

References:

Armstrong, K. & Silverman, R.D. (2017). Medical- Legal Concepts: Advance Directives and Surrogate Decision Making. S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer (Eds). The Principles and Practice of Hospital Medicine 2nd edition (pp. 224-230). Mcgrawhill education.

American Academy of Family Physicians (2020). Ethics and Advance Planning for End-of-Life Care. Retrieved from https://www.aafp.org/about/policies/all/ethics-advance-planning.html

National Archives and Records Administration, (2020). Federal register: Informed consent and advance directives. Retrieved from https://www.federalregister.gov/documents/2020/05/27/2020-10264/informed-consent-and-advance-directives