when is delegation of decision- making appropriate? when is delegation of decision- making...

When Is Delegation Of Decision-When Is Delegation Of Decision-Making Appropriate?Making Appropriate?

Cardiothoracic Ethics Forum: Surgical Ethics Course Cardiothoracic Ethics Forum: Surgical Ethics Course AATS 95th Annual MeetingAATS 95th Annual Meeting

SeattleSeattleApril 25, 2015April 25, 2015

Thomas A. D’Amico MDThomas A. D’Amico MDGary Hock Endowed Professor and Vice Chair of SurgeryGary Hock Endowed Professor and Vice Chair of Surgery

Chief Thoracic SurgeryChief Thoracic SurgeryChief Medical Officer, Duke Cancer InstituteChief Medical Officer, Duke Cancer Institute

DisclosureDisclosure

Member, STS Standards and Ethics CommitteeMember, STS Standards and Ethics Committee

No conflicts related to this presentationNo conflicts related to this presentation

CaseCase

• A 76-year old woman with bone-only metastatic A 76-year old woman with bone-only metastatic breast cancer developed shortness of breathbreast cancer developed shortness of breath

• CT: complex left pleural effusion, recurrent after 2 CT: complex left pleural effusion, recurrent after 2 attempts of thoracentesis, cytology positiveattempts of thoracentesis, cytology positive

• No documentation in EMR of relief of SOBNo documentation in EMR of relief of SOB

• Thoracic Surgery is consulted and she undergoes Thoracic Surgery is consulted and she undergoes left VATS drainage of effusion, decortication and left VATS drainage of effusion, decortication and talc pleurodesistalc pleurodesis

CaseCase

• No complications in the immediate post-op period, No complications in the immediate post-op period, although her CXR is not improvedalthough her CXR is not improved

• POD #3, she develops mental status changesPOD #3, she develops mental status changes

• The chart from the current hospitalization does not The chart from the current hospitalization does not document document extent of disease extent of disease or or goals of caregoals of care

• She does have an Advanced Directive on the chart, She does have an Advanced Directive on the chart, but her status is not DNARbut her status is not DNAR

• She has never had a Palliative Care ConsultShe has never had a Palliative Care Consult

CaseCase

• No documentation that she has indicated which No documentation that she has indicated which of her 2 sons* has health care power of attorneyof her 2 sons* has health care power of attorney

• POD 5: Progressive respiratory distress, POD 5: Progressive respiratory distress, hemodynamic instability, and MS changeshemodynamic instability, and MS changes

• Family consultation with thoracic surgery care Family consultation with thoracic surgery care team and medical oncologist (who refuses team and medical oncologist (who refuses Palliative Care consultation): continue aggressive Palliative Care consultation): continue aggressive care, plan for Herceptin therapy. No DNARcare, plan for Herceptin therapy. No DNAR

CaseCase

• POD6: Respiratory arrest. Intubated and POD6: Respiratory arrest. Intubated and resuscitated, requiring inotropic supportresuscitated, requiring inotropic support

• POD 7-9: No improvement; unresponsivePOD 7-9: No improvement; unresponsive

• Palliative Care ConsultPalliative Care Consult

• POD 10: Conference with 1 son regarding the POD 10: Conference with 1 son regarding the specifics of the Advance Directive and what the specifics of the Advance Directive and what the patient would have wanted in this conditionpatient would have wanted in this condition

• POD 11: Meeting with both sons and pastor POD 11: Meeting with both sons and pastor

Opportunities for ImprovementOpportunities for Improvement

• The decision to operate was not based on The decision to operate was not based on objective evidence (? Improve SOB)objective evidence (? Improve SOB)

• The care team was not aware of extent of disease The care team was not aware of extent of disease or goals of careor goals of care

• The treating oncologist did not understand the The treating oncologist did not understand the benefit of Palliative Care consultationbenefit of Palliative Care consultation

• The Palliative Care team was restricted by the The Palliative Care team was restricted by the medical oncologistmedical oncologist

Unpredictable ObstaclesUnpredictable Obstacles

• The family disregarded the Advance DirectiveThe family disregarded the Advance Directive

• It was difficult to have a conference that included It was difficult to have a conference that included all of the surrogate decision-makersall of the surrogate decision-makers

• Delegation of decision-making was to the Delegation of decision-making was to the oncologist and pastoroncologist and pastor

Common Delegation Of Decision-MakingCommon Delegation Of Decision-Making

1.1. Incompetent patientsIncompetent patients

2.2. Anesthetized patient in the ORAnesthetized patient in the OR

3.3. Unconscious patient in the ICUUnconscious patient in the ICU

4.4. Patients who request delegationPatients who request delegation

5.5. ChildrenChildren

Capacity for Medical Decision-MakingCapacity for Medical Decision-Making

• Possession of values and goalsPossession of values and goals

• Ability to communicate and understand Ability to communicate and understand informationinformation

• The ability to reason and to deliberate about The ability to reason and to deliberate about one’s choicesone’s choices

President’s Commission for the Study of Ethical Problems in President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1982)Medicine and Biomedical and Behavioral Research (1982)

IncapacityIncapacity

• May be periodicMay be periodic

• May be decision-specificMay be decision-specific

• May be reversibleMay be reversible

• Not related to age, refusal of care, medical Not related to age, refusal of care, medical diagnosis, social statusdiagnosis, social status

• ? Level of education? Level of education

Surrogate Decision-MakingSurrogate Decision-Making

1.1. Directed Decision-Making (living will)Directed Decision-Making (living will)

2.2. Delegated Decision-Making (power of attorney)Delegated Decision-Making (power of attorney)

3.3. Devolved Decision-Making (default surrogate)Devolved Decision-Making (default surrogate)

4.4. Displaced Decision-Making (court, guardian)Displaced Decision-Making (court, guardian)

5.5. Deferred Decision-Making (physician)Deferred Decision-Making (physician)

Living WillLiving Will

• Less than 1/4 of adult patients have completed a Less than 1/4 of adult patients have completed a living willliving will

• Up to 1/2 of patients express strong desire to Up to 1/2 of patients express strong desire to share decision-makingshare decision-making

• As many as 3/4 of adults admit that they would As many as 3/4 of adults admit that they would prefer their health care providers to override their prefer their health care providers to override their stated preferences from living will in favor of stated preferences from living will in favor of family’s directly opposing preferences family’s directly opposing preferences


AMA Opinion 8.081AMA Opinion 8.081

•Competent adults may formulate, in advance, Competent adults may formulate, in advance, preferences regarding a course of treatment in the preferences regarding a course of treatment in the event that injury or illness causes severe impairment event that injury or illness causes severe impairment or loss of decision-making capacityor loss of decision-making capacity

•These preferences generally should be honored by These preferences generally should be honored by the health care team out of respect for patient the health care team out of respect for patient autonomyautonomy


• Patients may establish an advance directive by Patients may establish an advance directive by documenting their treatment preferences and documenting their treatment preferences and goals in a goals in a living willliving will or by designating a health or by designating a health care proxy (care proxy (durable power of attorney for health durable power of attorney for health carecare) to make health care decisions on their ) to make health care decisions on their behalfbehalf


• When there is evidence of patient’s preferences and When there is evidence of patient’s preferences and values, decisions concerning the patient’s care should values, decisions concerning the patient’s care should be made by be made by substituted judgmentsubstituted judgment

• Consider the patient’s Consider the patient’s advance directive (if anyadvance directive (if any), the ), the patient’s views about life and how it should be lived, patient’s views about life and how it should be lived, how the patient has constructed his or her identity or how the patient has constructed his or her identity or life story, and the patient’s attitudes towards life story, and the patient’s attitudes towards sickness, suffering, and certain medical proceduressickness, suffering, and certain medical procedures


• If there is no reasonable basis on which to interpret If there is no reasonable basis on which to interpret how a patient would have decided, the decision should how a patient would have decided, the decision should be based on the be based on the best interests of the patientbest interests of the patient…best …best promote the promote the patient’s well-beingpatient’s well-being

• Factors considered when weighing the harms and Factors considered when weighing the harms and benefits of various treatment options include the benefits of various treatment options include the pain pain and suffering and suffering associated with treatment, the associated with treatment, the degree of degree of and potential for benefitand potential for benefit, and any impairments that , and any impairments that may result from treatmentmay result from treatment


• Any quality of life considerations should be measured Any quality of life considerations should be measured as the worth to the individual whose course of as the worth to the individual whose course of treatment is in question, and not as a measure of social treatment is in question, and not as a measure of social worthworth

• One way to ensure that a decision using the best One way to ensure that a decision using the best interest standard is not inappropriately influenced by interest standard is not inappropriately influenced by the surrogate’s own values is to the surrogate’s own values is to determine the course determine the course of treatment that most reasonable persons would of treatment that most reasonable persons would choose in similar circumstanceschoose in similar circumstances


• Physicians should Physicians should recognize the proxy or recognize the proxy or surrogate as an extension of the patientsurrogate as an extension of the patient, entitled , entitled to the same respect as the competent patientto the same respect as the competent patient

• Physicians should provide advice, guidance, and Physicians should provide advice, guidance, and support; explain that decisions should be based support; explain that decisions should be based on on substituted judgment substituted judgment when possible and when possible and otherwise on the best interest principle; and offer otherwise on the best interest principle; and offer relevant medical relevant medical informationinformation and and opinionsopinions


• In general, physicians should respect decisions In general, physicians should respect decisions that are made by the appropriately designated that are made by the appropriately designated surrogate and based on the standard of surrogate and based on the standard of substituted judgment or best interestsubstituted judgment or best interest

• In cases where there is a dispute among family In cases where there is a dispute among family members, physicians should work to resolve the members, physicians should work to resolve the conflict through mediationconflict through mediation


• Physicians/ethics committee should uncover the Physicians/ethics committee should uncover the reasons that underlie disagreement and present reasons that underlie disagreement and present information that will facilitate decision-makinginformation that will facilitate decision-making

• When a physician believes that a decision is clearly When a physician believes that a decision is clearly not what the patient would have decided, not be not what the patient would have decided, not be reasonably judged to be in the patient’s best interests, reasonably judged to be in the patient’s best interests, or primarily serves the interest of a surrogate/third or primarily serves the interest of a surrogate/third party, an ethics committee should be consulted before party, an ethics committee should be consulted before requesting court interventionrequesting court intervention


• Physicians should encourage patients to document Physicians should encourage patients to document treatment preferences or to appoint a health care proxy treatment preferences or to appoint a health care proxy and discuss their values regarding health care and and discuss their values regarding health care and treatment in advancetreatment in advance

• Because documented advance directives are often not Because documented advance directives are often not available in emergency situations, physicians should available in emergency situations, physicians should emphasize to patients the importance of discussing emphasize to patients the importance of discussing treatment preferences with individuals who are likely treatment preferences with individuals who are likely to act as their surrogatesto act as their surrogates

Power of AttorneyPower of Attorney

AdvantagesAdvantages

1.1. Promotes AutonomyPromotes Autonomy

2.2. Avoids guardianshipAvoids guardianship

3.3. Cost reductionCost reduction

4.4. Takes pressure off Takes pressure off family membersfamily members

DisadvantagesDisadvantages

1.1. Lack of monitoringLack of monitoring

2.2. No standard of conduct No standard of conduct for agent (substituted for agent (substituted judgment, best interest)judgment, best interest)

3.3. Broad authorityBroad authority

4.4. ? Risks (Brooke Astor ? Risks (Brooke Astor Case)Case)

Advance DirectivesAdvance Directives

1.1. Most people do not have oneMost people do not have one

2.2. Forms may be difficult to understandForms may be difficult to understand

3.3. May change their mindMay change their mind

4.4. Health care providers may not be aware of Health care providers may not be aware of existence or locationexistence or location

5.5. Incorporation in EMR?Incorporation in EMR?

Advance Directives: AdvantagesAdvance Directives: Advantages

1.1. Starts communication regarding goals of care Starts communication regarding goals of care

2.2. Existence alone may cause care-givers to stop Existence alone may cause care-givers to stop and think before decision-makingand think before decision-making

3.3. Empowers the patientEmpowers the patient

4.4. Existence of a current Advance Directive is Existence of a current Advance Directive is more likely to lead to updated Directives, with more likely to lead to updated Directives, with age, co-morbidities, change in family structureage, co-morbidities, change in family structure

Physician Orders for Life Saving (POLST)Physician Orders for Life Saving (POLST)

• Standardizing physician EOL orders to Standardizing physician EOL orders to implement patients’ goals of careimplement patients’ goals of care

• Requires exploring care goals: abx, CPR, Requires exploring care goals: abx, CPR, intubation, comfortintubation, comfort

• MD orders in bright pinkMD orders in bright pink

POLST Distribution in USPOLST Distribution in US

Default Surrogates (Family)Default Surrogates (Family)

• Priority of surrogatesPriority of surrogates

• Scope of decision-making authorityScope of decision-making authority

• How are disagreements handled?How are disagreements handled?

• Close friend vs familyClose friend vs family

Deferring to the PhysicianDeferring to the Physician

1.1. Spectrum of patient trust, from skepticism to Spectrum of patient trust, from skepticism to trust to dependencetrust to dependence

2.2. For surgery, varying degree in the use if For surgery, varying degree in the use if decision-making aidsdecision-making aids

3.3. What are the barriers to communication?What are the barriers to communication?

Barriers to effective EOL conversationsBarriers to effective EOL conversations

• 1040/1234 potential subjects (84.3%) participated1040/1234 potential subjects (84.3%) participated

• 29 participants : development cohort 29 participants : development cohort

• Codes validated by analyses of responses from 50 Codes validated by analyses of responses from 50 randomly drawn subjects from the validation cohort randomly drawn subjects from the validation cohort (n= 996 doctors)(n= 996 doctors)

• 99.99% reported barriers to conduct EOL 99.99% reported barriers to conduct EOL conversations, with 85.7% admitting it is very conversations, with 85.7% admitting it is very challenging, especially to pts of different ethnicitychallenging, especially to pts of different ethnicity

Barriers to effective EOL conversationsBarriers to effective EOL conversations

1.1. Language and medical interpretation issuesLanguage and medical interpretation issues

2.2. Religio-spiritual beliefs about death and dyingReligio-spiritual beliefs about death and dying

3.3. Doctors’ ignorance of pt cultural beliefs, valuesDoctors’ ignorance of pt cultural beliefs, values

4.4. Patient/family's cultural differences in truth handling Patient/family's cultural differences in truth handling and decision makingand decision making

5.5. Patients’ limited health literacy Patients’ limited health literacy

6.6. Patients’ mistrust of doctors and the health care Patients’ mistrust of doctors and the health care systemsystem

Doctors rate the relative importance of the 6 primary barriers to Doctors rate the relative importance of the 6 primary barriers to effectiveeffective EOL conversations EOL conversations

Role Reversal in the Conversation on DyingRole Reversal in the Conversation on Dying

https://www.youtube.com/watch?v=vApg3qAn55s&feature=youtu.be

SummarySummary

• The need for surrogate-decision making, The need for surrogate-decision making, especially at end-of-life, often complicates patient especially at end-of-life, often complicates patient carecare

• Living Wills, Advance Directives, Health Care Living Wills, Advance Directives, Health Care Powers Of Attorney, POLST all contribute to Powers Of Attorney, POLST all contribute to improving the decision-making processimproving the decision-making process

• All are underused for a variety of reasonsAll are underused for a variety of reasons

• Talk to patients before operating on themTalk to patients before operating on them

Surrogate Decision-Making: IssuesSurrogate Decision-Making: Issues

1.1. Patient Capacity Patient Capacity

2.2. Health Care Power of AttorneyHealth Care Power of Attorney

3.3. Advance DirectiveAdvance Directive

4.4. GuardianshipGuardianship

CapacityCapacity

Must be judged according to a standard set by that Must be judged according to a standard set by that person’s own habitual or considered standards of person’s own habitual or considered standards of behavior and values, rather than by conventional behavior and values, rather than by conventional standards held by othersstandards held by others

Silberfield and Fish, Silberfield and Fish, When the Mind Fails When the Mind Fails (1994)(1994)

when is delegation of decision- making appropriate? when is delegation of decision- making...

Documents

palliative care consult

palliative care consultation

aggressive care

goals of care

palliative care consult

thoracic surgery care

condition pod

improved pod