Respecting Patient Rights

Basic Bioethics For Residents, CCF Residency Programs, November 28, 2000

I. Communicating with Patients and Families
II. Informed Consent: Empowering Patient Participation in Decision Making
III. Assessing Patients' Decisional Capacity
IV. Maintaining Patient Confidentiality
V. Honoring Patients' Advance Directives

V. Honoring Patients' Advance Directives

Advance Directives are legal documents in which patients' express their wishes about the kind of health care they want to receive should they become unable to make their own treatment decisions. There are two types of Advance Directives in Ohio:

Living Will
Durable Power of Attorney for Health Care

A Living Will is a legal document in which patients are able to state in advance their desire to receive or their desire to withhold life support procedures. Implementation of a Living Will requires meeting two conditions:

  • Two physicians document in the medical record that the patient is either in an irreversible coma or is suffering from a terminal illness, and
  • The patient is unable to make decisions for him/herself.

Any treatment that might be considered life prolonging or that artificially extends the dying process should be withheld or withdrawn. One caution is that Ohio law has special provisions that permit the withholding or withdrawal of artificial nutrition and hydration for patients who suffer from an irreversible coma.

A Durable Power of Attorney for Health Care is a legal document that allows patients to specify in advance who should make health care decisions for them should they become unable to make their own health care decisions. The individual named is called the "agent" or "attorney-in-fact" for the patient. The Durable Power of Attorney for Health Care document allows a patient to name an "agent" or "attorney-in-fact" with broad or specific powers to provide consent or refusal for any type of health care.

The Durable Power of Attorney for Health Care takes effect anytime the patient loses the ability to make his/her own health care decisions. Unlike the Living Will, the patient does not need to be terminally ill or suffering from an irreversible coma. For the Durable Power of Attorney for Health Care document to become effective, two physicians must document in the medical record that the patient in question has lost the capacity to make health care decisions.

Revocation: A Living Will or Durable Power of Attorney for Health Care can be revoked at any time and in any manner, e.g., by the patient simply tearing the Durable Power of Attorney for Health Care document, expressing orally the desire to revoke the document, or in writing by the patient. Health care professionals who witness such revocations should document them in the medical record.

CCF policy and procedures include asking the patient or family upon admission about the existence of Advance Directives. The existence of an Advance Directive is documented in the Demographic Sheet in the patient's medical record. Copies of Advance Directives should be placed on the medical record in the tabbed section for Advance Directives. Social Work maintains an additional copy of the Advance Directive. Physicians should always document the content of discussions about the patient's end-of-life desires or any expression of treatment preferences.

Questions about the applicability of Advance Directives or conflicts in their interpretation or implementation or other questions involving the withholding and withdrawing life-sustaining treatment can be referred to the Department of Bioethics (x4-8720, Pager #22512). Assistance for patients in completing Advance Directives is available from The Department of Pastoral Care (x4-2518) or the Department of Social Work (4-6552).

Do Not Resuscitate (DNR) Orders

Advance Directives are not DNR orders. DNR orders are written by physicians to indicate that a patient should not be resuscitated. The order may be written to reflect a patient's or surrogate's expressed wishes about resuscitation or because the patient will not benefit from resuscitation.

The Ohio "DNR Comfort Care" law created a standard protocol and forms of identification that can be honored throughout the State of Ohio.

Under Ohio law, the "DNR Comfort Care" protocol requires that health care professionals perform the following for a patient when the DNR Comfort Care protocol is activated:

Will:

  • Suction the airway
  • Administer oxygen
  • Position for comfort
  • Splint or immobilize
  • Control bleeding
  • Provide pain medication
  • Provide emotional support
  • Contact other appropriate health care providers such as hospice, home health, attending physician/CNP/CNS

Will Not:

  • Administer chest compressions
  • Insert artificial airway
  • Administer resuscitative drugs
  • Defibrillate or cardiovert
  • Provide respiratory assistance (other than that listed above)
  • Initiate resuscitative IV
  • Initiate cardiac monitoring

Three types of DNR Orders are allowed at CCF:

  1. DNR Comfort Care (DNRCC) orders permit comfort care only (the above protocol), both before and during a cardiac or respiratory arrest. This kind of order is generally appropriate for a patient with a terminal illness, short life expectancy, or little chance of surviving CPR.
  2. DNR Comfort Care - Arrest (DNRCC-Arrest) orders permit the use of all resuscitative therapies before an arrest, but not during or after an arrest. A cardiac arrest is defined as an absence of palpable pulse. A respiratory arrest is defined as no spontaneous respirations or the presence of agonal breathing. Once an arrest is confirmed, all resuscitative efforts should be stopped and (following the above protocol) comfort care alone initiated.
  3. DNR - Specified orders allow the physician to "tailor" the DNR order to the specific circumstances and wishes of the patient. For example, under this option the physician could specify "pharmacological code only," or "no defibrillation, or "do not intubate."

Options 1 and 2 (DNRCC, and DNRCC - Arrest) can be made portable, i.e., under Ohio law they can travel with the patient from one care setting to another. Option 3 (DNR - Specified) is not portable, but used only at CCF.

The attending physician should reassess patients admitted with a state-approved DNR order. The DNR order should be re-written to conform to CCF policy. If a patient survives to discharge, the DNR order should be re-written in accord with patient wishes and according to state-approved options. Transport personnel and the receiving facility must be notified about the DNR order.

The Ohio DNR Comfort Care regulations permit various means of identification to communicate the patient's code status:

  • A state-approved DNR Comfort Care form, signed by a physician or advanced practice nurse
  • A DNR necklace or bracelet
  • A DNR wallet card
  • A Living Will specifying that a DNR order should be written when the Living Will becomes effective.

In the CCF hospital, all patients with a DNR order will wear a hospital-style bracelet indicating the kind of DNR order written. A CCF DNR Order form entitled End of Life Decision Making is used for writing all DNR orders. A patient brochure about the DNR Comfort Care protocol is available. Prior to an invasive procedure and anesthesia, an existing DNR order should be re-assessed, when possible, with the patient or surrogate. A CCF Reassessment of Do Not Resuscitate Order During Invasive Procedures form should be completed by the ordering or primary staff physician.

Points to Remember

  • Advance Directives only take effect when the patient loses decisional ability. Before that time, the patient's current expressed wishes should be followed.
  • Advance Directives do not replace active communication with patients and their families.
  • Patients and families should be provided appropriate and sufficient information to make informed health care decisions. Patients' expressed preferences about health care treatments should be documented as they evolve in the course of treatment.
  • CCF policy supports the use of Advance Directives by patients, but does not require that any patient complete an Advance Directive as a condition for treatment.
  • Assessment of and attention to patients' spiritual needs is an important part of quality end-of-life care and should be a routine part of patient care.
  • Quality medical care also includes providing patients with the supportive atmosphere in which to reflect on end of life choices and to allow their wishes to be communicated to their health care providers and to their families.

Supplemental Reading

I. Communicating With Patients and Families Buckman R. How To Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: The Johns Hopkins University Press, 1992.

II. Informed Consent: Empowering Patient Participation in Decision Making Meisel A, Kuczewski M. "Legal and Ethical Myths About Informed Consent," Archives of Internal Medicine 1996; 156:2521-2526.

III. Assessing Patients' Decisional Capacity Agich GJ. "Can the Patient Make Treatment Decisions? Evaluating Decisional Capacity." Cleveland Clinic Journal of Medicine 1997; 64:461-464.

IV. Maintaining Patient Confidentiality Siegler M. "Confidentiality in Medicine - A Decrepit Concept," The New England Journal of Medicine 1982; 307:1518-1521.

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