“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