Advance Directives

 

Proxy directives: appoints someone to make decisions for maker in event of incapacity

Instructional directive: sets out specific instructions or principles of care

 

Proxy is someone names in an advance directive. Does not need to be close family member. The proxy should act with the patient's wishes and values in mind, not necessarily with the proxy's view of best interests.

 

Understanding what CPR is by the public:

2.7% knew success rate less than 10%

 

What are our goals?

sometimes giving a patient an autoomous choice is not good or fair: asking someone point-blank 'if your heart stops, what do you want us to do?" is not fair or good

 

 

clinician may decide not to discuss CPR with patient/family before documenting DNR, if patient clearly knows they are dying and the goal is cmfort during the last days...

this decreases the burden for patient/family, but can be seen as coercive etc

 

"no CPR orders should not be discussed in isolation, but rather in the context of goals and outcomes: survival, quality of life and function, etc

 

Preparing for End-of-Life Discussions

ensure you knows the clinical facts

ensure physical setting is good

recommended when illness trajectory is uncertain, in response to a patient/caregiver request, when patient ishes to be part of all decisions to be made

 

What to Say

"Withholding CPR does not mean we are giving up on you..."

"CPR will not help you; raher it will prolong suffering, which is not in line with our goals.."

 

Resources and References

Chest 2006 130:419 (Heyland)

Cantor et al, Arch Int Med (2003) 163: 2689-94

Clayton et al, Med J Aus Suppl. vol 186, no 12, 2007

 

 

Problems

Somewhat at odds with informed consent, as information about risks doesn't make its way to the patient.

Often, past wishes and current wishes can be at odds, especially as new conditions develop.

 

The hospital act