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N450 - Goals of Care and Ethical Issues at the EOL (1).
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N450 - Goals of Care and Ethical Issues at the EOL (1).
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N450 - Goals of Care and Ethical Issues at the EOLMortality and Ethics - ANS-- Ethics is a formal method for studying moral questions.
- Morality refers to social conventions about acceptable and unacceptable behavior and may
vary by culture.
- Nurse considers many views; apply ethical decision-making principles when conflicts occur
Goals of Care - ANS-- To protect a persons right to make choices
- To provide care that matches older adults' and families' goals and values
- To guide everyday clinical decisions and actions
- To ensure appropriate resource allocation
Patient Self-Determination Act 1991 - ANS-- Purpose of the law: to ensure the rights of
individuals "to accept or refuse medical or surgical treatment"
- Requires health care institutions to inform individuals about their right to participate in
decisions about their health care, including the right to make advance directives
- also right to advanced directive
Advance Directives - ANS-- Written instructions to a health care provider before the need for
medical treatment. Allows informed consent when no longer able to give consent.
- In an AD, you can refuse or consent to future treatment.
- DNR - allow natural death
- Power of attorney - gives someone else the power to make choice for you
- Tissue organ or body donation are considered advanced directives
Types of Advance Directives - ANS-- Living Will: care wanted under certain circumstances (e.g.,
CPR)
- Durable Power of Attorney for HealthCare; designated healthcare proxy (DPOA-HC)
- The Five Wishes: Aging with Dignity advance directive program
- POLST: physician orders that specify treatment decisions
Advance Directives: Imperfect Tools - ANS-- Low rates of completion
- Difficulties in thinking about "what if?" situations
- Lack of communication with and among health care providers
- Uninformed or biased surrogate decision-makers
**They are only in effect if they are in the providers hands - if not then it is not worth anything**
Discussing Values & Treatment Goals- Five Wishes - ANS-- The person I want to make
decisions if I cannot - names a person
- The kind of medical treatment I want or don't want
- How comfortable I want to be
- How I want people to treat me
, - What I want my loved ones to know
Approaches to Decision Making: Outline Scenarios and Treatment Options - ANS-- Health
Conditions - Coma, Dementia, Stroke, Terminal Illness
- Treatment Options (includes discussion of risks/ benefits and probable outcomes of therapy) -
CPR/Mechanical Ventilation, Dialysis, Diagnostic Tests, Hospitalization, ABX, Blood
transfusions, Tube feedings/IV fluids, Pain management, comfort care
Physicians' Orders for Life Sustaining Treatment (POLST) - ANS-- AKA MOLST
- Started in Oregon in 1991, now a national movement
**Not a living will just a doctor's orders**
- is a MD order for tx preferences - medical record and checks off pt. wants
- Can be applied across care settings - transferable
- Studies show that having a POLST form decreases unwanted treatment and enhances
symptom management at EOL
Ideally, the Older Adult who makes the decision is.... - ANS-- Is mentally capable of making
decisions
- Is fully informed about his/her disease, prognosis, and treatment choices
- Decides freely without feeling coerced
- Decides based on his/her values and priorities
- Need to determine if pt is capable or not
Establishing "Capacity" - ANS-- Incapacitated does not equal Incompetent
Incapacity determined by a process:
- Demonstrated inability over time to make decisions that create a significant risk of personal
harm
- Criteria in legal document (e.g., AD)
- Informed Consent - Determination is not based on medical diagnosis, age, poverty,
eccentricity, age, education level or personality
Competency V. Capacity - ANS-- Capacity is the clinical (caregiver or HCP) determination to
make informed decisions
- Competency is determined by the courts - presumption that the person has mental ability to
execute legal tasks - this is all or none
General Approaches to Maximizing Capacity - ANS-- Optimizing nutrition, sleep, bowel function,
managing incontinence
- Identifying and treating depression
- Monitoring & minimizing medication use
- Treating coexisting diseases, e.g., diabetes, COPD
- Correct sensory deficits
- Having a known and trusted person facilitate the discussion
- Conducting the discussion at a time of day when the older adult is likely to be most alert
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