Definitions
Advance care planning: Process enabling individuals to define goals and preferences for future medical care, discussed and documented prior to loss of decision-making capacity.
When patients & families request that “everything” be done
- Understand what “everything” means
- “Every treatment with even the slightest possibility of benefit” (rare)
- “Everything that you, as my physician, feel is worthwhile”
- “Everything to relieve symptoms, even though it may shorten life”
- Communicate prognosis
- Use clear & direct language (“Your mother is dying”)
- Maintain consistent messaging
- Avoid discussing minutiae of management
- Propose a philosophy of treatment
- Offer medical recommendations with appropriate limits to therapy
- Discuss what will be done before covering what will not be done
- Illustrate how the recommendations support the patient’s values
- Support emotional response
- Validate emotions & invite conversation (“What is the toughest part of this for you?”)
- Reaffirm commitment to caring for the patient no matter what happens
- Negotiate disagreements
- Review understanding & seek common ground
- Seek external input for persistent, unresolved conflict (eg, from ethics committee)
Limitation of life-sustaining treatment
- Core Principles:
- Patient Autonomy: Competent adults have the absolute right to refuse any life-sustaining treatment (LST); withholding = withdrawing (ethically and legally identical).
- Capacity vs. Competence: Capacity is a dynamic clinical determination (must understand, appreciate, reason, and express a choice); depression or psychiatric illness does not automatically invalidate capacity.
- Principle of Double Effect: Giving high-dose IV opioids/sedatives to relieve refractory pain or dyspnea is ethical and legal, even if it unintentionally hastens death.
- High-Yield Clinical Situations:
- Brain Death: Formal brain death is legal death; mechanical ventilation can be discontinued without surrogate consent.
- Advanced Dementia: Percutaneous endoscopic gastrostomy (PEG) tubes do not prolong life or prevent aspiration; the correct answer is assisted oral feeding.
- Terminal Extubation: Premedicate with IV opioids/benzodiazepines for air hunger; discontinue paralytic agents beforehand to prevent conscious paralysis.
- Family-Physician Conflict: If family demands non-beneficial/futile care, first hold a multidisciplinary family conference to explore values, followed by a hospital ethics committee consult.
- Unrepresented Patient: If no capacity, no surrogate, and no AD exist in an emergency, treat under implied consent in the pt’s best interest.