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PubMed1998

Field experience with prehospital advance directives.

STUDY OBJECTIVE: Some states have enacted legislation authorizing EMS providers to adhere to prehospital advance directives (ADs) in the terminally ill. This study was conducted to assess EMS providers' knowledge of and experience with prehospital ADs. METHODS: An anonymous survey was conducted of 142 EMS providers employed by a local, private ambulance service in the northeastern United States. The survey was administered during a 2-month period from January to March 1995. RESULTS: Of 142 participating providers, 106 (74.6%) completed questionnaires. Respondents included EMTs (61. 3%), paramedics (33.9%), and chair van operators (4.8%). The majority (58.6%) had at least 5 years of field experience. Almost all respondents (93.4%) were familiar with ADs, usually do-not-resuscitate orders. Most providers (78.3%) consider ADs before implementing extraordinary life support measures in terminally ill patients. Few (28.0%) have implemented prehospital ADs without medical control. The most commonly reported objections to withholding life support measures were fear of legal consequences, personal difficulty withholding care they are trained to provide, and ambiguity in the ADs received. Nearly all respondents (96.7%) support enactment of prehospital AD statutes. CONCLUSION: Most prehospital care providers recognize the need to withhold resuscitative care in terminally ill patients who have prepared ADs. However, a sizable minority fail to consider prehospital ADs as a routine part of their practice. The majority of our respondents support enactment of prehospital AD statutes to minimize confusion and provide legal authorization to limit resuscitation.

Advance Directives↗
PubMed2005

Esophageal manometry and pH monitoring: gastroenterologists' adherence to published guidelines.

GOALS: To determine whether gastroenterologists use esophageal manometry (EM) and esophageal pH recording (pHR) in accordance with published guidelines. STUDY: Questionnaires were mailed to 900 randomly selected gastroenterologists nationwide. Each questionnaire requested demographic information and contained 11 case scenario-based questions, followed by a choice of management options. RESULTS: A total of 275 completed questionnaires (30.6%) were returned. 63.6% and 64.4% of respondents were aware of published guidelines regarding the use of EM and pHR, respectively. The majority of respondents ordered EM appropriately: 1) to confirm a suspected diagnosis of achalasia (97.1%); 2) to establish a diagnosis of connective tissue disease (89.7%); 3) as part of the preoperative evaluation for anti-reflux surgery (74.6%); and 4) to ensure the proper placement of pH probes (69.4%). EM was rarely ordered for the initial workup of noncardiac chest pain. The majority of responding gastroenterologists would order pHR for the evaluation of: 1) endoscopy-negative patients being considered for anti-reflux surgery (79.1%); 2) patients with recurrent GERD symptoms after anti-reflux surgery (62.5%); 3) endoscopy-negative patients with GERD symptoms refractory to proton pump inhibitor (PPI) therapy; and 4) patients with extraesophageal manifestations of GERD that are refractory to PPI therapy (88.7%). CONCLUSIONS: The majority of gastroenterologists in our study order EM and pHR in accordance with published guidelines. However, EM appears to be used less than expected for preoperative evaluation before anti-reflux surgery and for ensuring the proper placement of pH probes. In addition, the use of pHR to evaluate persistent GERD symptoms after anti-reflux surgery was less than anticipated.

Adult↗
PubMed2006

Patient-centered informed consent in surgical practice.

OBJECTIVES: To review the medical, ethical, and legal basis of the doctrine of informed consent for surgery and its complications, particularly for an incapacitated patient who requires a surrogate decision maker; to discuss the elasticity of the consent doctrine, whether surgical consent encompasses consent for surgical complications, and emphasize the importance of communication and shared decision making in the context of the patient-surgeon relationship; and to discuss patient and surrogate refusal of treatment, standards of surrogate decision making, barriers to effective communication, the role of the hospital ethics committee in resolving disputes over treatment, and how to reconceptualize surgical consent in the context of patient-centered medicine. DATA SOURCES: We reviewed PubMed citations for informed consent in surgery, patient-physician communication, shared decision making, patient-centered medicine, and consent guidelines published by specialty societies, particularly the American College of Surgeons and the Society for Critical Care Medicine. STUDY SELECTION: We selected articles in which issues of consent for surgical treatment were discussed or measured. DATA EXTRACTION: We extracted data relevant to questions of consent in surgical practice. DATA SYNTHESIS: We studied qualitative aspects of the consent doctrine. CONCLUSIONS: Surgical consent is not an event or a signature on a form but is an ongoing process of communication that continues throughout preoperative, perioperative, and postoperative care. In the context of patient-centered medicine, consent is best conceptualized as shared decision making with patients or their surrogates.

Advance Directive Adherence↗
PubMed1998

Do not resuscitate orders--managing the dilemma.

The status of DNR orders (or equivalent declarations) in patients undergoing surgery will continue to present considerable challenges for both healthcare providers and patients, or their alternate decision makers. It is essential that all parties understand the specifics of each DNR order, focusing not only on the actual content of the order or declaration but also on the context in terms of location, timing and circumstance. The principle of "respect for persons" should guide, inform and shape the approach followed with each patient. Meaningful dialogue and "negotiation" will be required. Make no assumptions! The "required reconsideration" of pre-existing DNR orders should be the basic approach followed. There is no single "solution" for all DNR-related issues in the peri-operative period. What may appear obvious to the anaesthetist may be viewed entirely differently by the patient, or even by other members of the care giving team. There is no justification for either the automatic suspension or the automatic continuation of DNR orders in patients undergoing surgery. A patient-specific and situation-specific approach and "solution" is required. Similar principles will apply in acute care settings other than the operating room. Full engagement by health care workers in the processes addressing these issues should be a personally enriching experience.

Advance Directive Adherence↗
PubMed2006

Managed death in a PACE: pathways in present and advance directives.

OBJECTIVES: To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes. DESIGN: Interventional prospective cohort (pre- and post-). SETTING: Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO. PARTICIPANTS: Enrolled PACE participants. INTERVENTION: A documentation tool that captures both present and advance directives in a framework of "pathways," blending goals of care with typical procedure-oriented directives. MEASUREMENTS: Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death. RESULTS: Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant. CONCLUSION: Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life's end, and increased compliance with participants' wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.

Activities of Daily Living↗
PubMed2006

Managed death.

Explore the source record for details and available documents.

Advance Care Planning↗
PubMed2004

Precedent autonomy and subsequent consent.

Honoring a living will typically involves treating an incompetent patient in accord with preferences she once had, but whose objects she can no longer understand. How do we respect her "precedent autonomy" by giving her what she used to want? There is a similar problem with "subsequent consent": How can we justify interfering with someone's autonomy on the grounds that she will later consent to the interference, if she refuses now? Both problems arise on the assumption that, to respect one's autonomy, any preferences we respect must be among that person's current preferences. I argue that this is not always true. Just as we can celebrate an event long after it happens, so can we respect someone's wishes long before or after she has that wish. In the contexts of precedent autonomy and subsequent consent, the wishes are often preferences about which of two other, conflicting preferences to satisfy. When someone has two conflicting preferences, and a third preference on how to resolve that conflict, to respect his autonomy, we must respect that third preference. People with declining competence may have a resolution preference earlier, favoring the earlier conflicting preference (precedent autonomy), whereas those with rising competence may have it later, favoring the later conflicting preference (subsequent consent). To respect autonomy in such cases we must respect not a current, but a former or later preference.

Advance Directive Adherence↗