California tags treatment choices to transfers
Doctors required to assist in form’s completion
Elderly patients in California’s nursing homes and their loved ones now have a reasonable assurance that end-of-life treatment choices will indeed be honored. This confidence comes from the adoption earlier this summer of the Physician Documentation of Preferred Intensity of Treatment by the state’s highest physician’s group, the San Francisco-based California Medical Association (CMA), which includes more than 40 medical groups statewide.
"The idea of the form has been out there since the late 1980s," says Roger Purdy, executive associate of CMA and head of the group’s ethics committee that spearheaded the effort. "The problem was that it was not being used as intended."
In the form’s first section, physicians are now required to document that they have discussed treatment wishes with the patient. (See sample form, inserted in this issue.)
Previously, "the nursing home social service director or intake staff would hand the form to a family member, ask them to fill it out, and then the doctor would sign it later often without even reading it," says Terry Hill, MD, a nursing home medical director in Oakland, CA, who worked closely with Purdy to develop and implement the new form.
Many times the information on treated choices was sketchy at best.
CMA not only wanted state physicians to give clearer and more consistent attention to the wishes of these patients, it also wanted to keep them out of legal trouble.
"Patients may have had a do-not-resuscitate [DNR] order in the hospital or nursing home, but it wasn’t documented in the chart," Hill says. "The patient was transferred to another facility, and if life support was withheld or withdrawn, the state authorities would question why the decision was made. There was often no proof of ethical decision making."
Hill cautions that the new form is not a substitute for a pre-hospital DNR order, although it is transferred with the patient if that situation arises. The per-hospital DNR forms are recognized in California and many other states and allow for the specific choice of refusing resuscitation and other life-sustaining measures when emergency medical services staff are contacted and a patient is transferred to a hospital. (See related story on per- hospital DNR orders, Medical Ethics Advisor, September 1994, pp. 116-120.)
Rather, the preferred intensity of treatment form is an attempt to document the patient’s values and wishes about life-sustaining measures such as resuscitation, antibiotics, artificial nutrition, and even hospitalization itself, say Hill and Purdy.
Hill says, "This document is a guide for the physician to use when walking through these choices with the patient and the patient’s family."
The form also includes palliative care options under a section on the goals of care, and it strives to delineate some specific treatment choices and differing circumstances for their use. For example, the following statement describes palliative care as a choice: "If a palliative care approach is chosen, the primary goals of treatment will be to reduce suffering, promote comfort, and preserve dignity, with the understanding that these goals may require flexibility e.g. hospitalization for symptom control or use of antibiotics for an infection that is uncomfortable but not life-threatening."
Other documentation
When the patient is admitted to the long-term care facility, the new form also requires the additional step of documenting and attaching any court orders, such as those regarding guardianship, that may have a future impact on a medical treatment decision.
Hill says the new forms are being used by doctors in both the hospital and nursing home setting and have helped providers in both settings to make ethical decision making clearer. "The medical society serves as a multi-institutional ethics committee resource in the case of our preferred intensity of treatment initiative," he says.
Long-term care facilities often lack important ethical resources and struggle to make a variety of decisions that are different and more complex than those in less-acute settings.
Purdy recommends that other state medical societies look at ways that they can serve as an ethics resource to institutions in their regions. When it comes to treatment decisions, the long-term care facility remains subject to a host of state regulations that can intimidate its compliance with the known wishes of a patient.
In many states, including California, nursing homes can be cited for withholding or withdrawing life support without specific documentation, Purdy says. CMA physicians’ documentation of patient wishes in the new form has significantly decreased nursing homes’ reluctance to end treatment.
"Many of our nursing homes now look to us for guidance on other ethics issues, as well," Purdy says.
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