Friday, May 23, 2008

The Problems with Advance Directives, Inappropriate Care and A Solution

Only about 20% of Americans have executed an advance directive and only about half of these have discussed their wishes with their physician. (1) Without one, most hospitals and nursing homes assume that the patient wishes every conceivable means of medical therapy, even if inappropriate for that particular patient. Another problem with advance directives is that it asks the person to make a decision about what type of care would be wanted at some time in the future. However, one could not possibly know what the clinical situation will be at that time.

My solution is a new style of hospital admission form. The advantages of this form and its benefit to patients, families and our society include:

1. This form would be completed at each hospital and nursing home admission and would serve as a fresh and timely advance directive. The patient/family can make a much more rational decision about which therapies are not wanted. Because admission to a hospital or nursing home is an extremely stressful time for the patient and family, the medical team can facilitate the completion of an up to date advanced directive with the patient/family at that time.

2. During the discussion about the form upon admission to the hospital or nursing
home, the physician can clarify the fact that only beneficial care can be administered but that the patient/family retains the right to refuse any or all offered treatments (if of age and sound mind). This eliminates, as much as possible, the potential of delivering inappropriate care.

3. The form would be adopted by Congress to be used for all Medicare and Medicaid patients and would create a legal framework for the appropriate care committee system. See March 1, 2008 post about Appropriate Care Committees.

4. Using this form would eliminate cardiopulmonary resuscitation (CPR) by default – that is performing CPR whether it would benefit the patient or not. CPR - the restarting of heartbeat and breathing - was first developed in the early 1960s, before Medicare, when the hospital patient population was much younger. So it was reasonable to be automatically initiated whenever there was a cardiac arrest because the patients had a more reasonable chance of survival and recovery. However, the hospital population is now much older and many are in an end-of-life situation. Despite this change in demographics the custom still remains to automatically attempt CPR, even in patients with end-stage disease despite great discomfit to the dying patient. This occurs unless a specific order is written to avoid the procedure. My proposed admission form would correct this problem by making cardiopulmonary resuscitation an ordered event to be used only in the appropriate circumstance. This would save many thousands of patients a great deal of discomfort and preserve billions of dollars of resources.

5. I have copyrighted this form so that I could insure that it be used in a constructive manner.

6. Because of the importance of this form to the reintroduction of rationality to our medical system I am asking all of you who visit my blog to download the introductory letter and the form and fax them to your Congress Person and Senators. Download the letter and the form here.
Teno J, Lynn J, Wenger N, et al. Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self Determination Act and the SUPPORT Intervention. SUPPORT Investigators Study to Understand Prognosis and Preferences for Outcomes and Risk of Treatment. Journal of the American Geriatrics Society 1997;45:500-507 (PMID 9100721)

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