Advance Care Planning
http://www.100md.com
《新英格兰医药杂志》
To the Editor: I read Gillick's article on advance care planning (Jan. 1 issue)1 with particular interest. When my husband had a cardiac arrest and fell onto my shoulder during a Pittsburgh Steelers football game on September 28, 2003, he did not have a response to cardiopulmonary resuscitation at the stadium. No airway was established for more than 20 minutes, and he had no spontaneous cardiac rhythm for about 45 minutes. He was placed on life support at the stadium and taken to a nearby hospital.
He had a "living will" requesting that there be no intervention in such a situation, and I had durable power of attorney for health matters. Pointing this out and requesting that life support be discontinued, I was told by the attending physician in the emergency room that, "legally," he could not do this for 6 to 12 hours. There is no such law in Pennsylvania. He also told me that if it were his mother or his wife, he would want life support to be continued. Of course, it was not his wife or his mother.
My husband never regained consciousness nor had any evidence of brain function. It took 29 hours for me and our children to have life support stopped. Why was his advance directive not respected? Why was my durable power of attorney ignored? I have no answers yet.
Dr. Gillick states that "advising patients to appoint a health care proxy . . . is all that physicians need to do . . . to enable their patients to be treated in accordance with their wishes." Doing all that was not enough for me and my husband. Everything was ignored. How do we educate our colleagues about their responsibility to respect these wishes regarding the end of life?
Jeanne M. Hanchett, M.D.
1020 Devon Rd.
Pittsburgh, PA 15213
References
Gillick MR. Advance care planning. N Engl J Med 2004;350:7-8.[Full Text]
To the Editor: We would like to clarify that New York law regarding surrogate decisions is not as restrictive as portrayed by Gillick. New York law permits an adult to name a health care agent who is authorized to make all health care decisions on behalf of the incapacitated patient. When the patient's wishes are known, the agent's decision should be based on those wishes. If the patient's wishes cannot be determined, the decision is based on the agent's judgment of the patient's best interests. The agent is not required to provide any evidence of knowledge of the patient's wishes. Rather, the agent is presumed to know the patient's wishes by virtue of the fact that the patient chose the agent. The only exception to this standard is for decisions about artificial nutrition and hydration, which require that the agent have reasonable knowledge of the patient's wishes.
In New York State, there are situations in which a surrogate may act even though the patient has not appointed a health care agent. A surrogate may make decisions to withhold or withdraw life-sustaining treatment on the basis of appropriate evidence of the patient's prior wishes.
New York law also provides that a do-not-resuscitate (DNR) decision can be made by a surrogate, selected from a hierarchical list of potential surrogates, after two physicians have determined that the patient is terminally ill or permanently unconscious or that resuscitation will be unsuccessful or unduly burdensome for the patient.
Tia Powell, M.D.
New York State Task Force on Life and the Law
New York, NY 10001
Dr. Gillick replies: In her letter, Dr. Hanchett describes how her husband's clearly stated wishes were callously disregarded after he sustained a cardiac arrest, despite his having prepared a living will and designated his wife as his health care proxy. She rightly points out that, in addition to broaching the subject of advance planning, physicians need to understand that they are bound to respect their patient's wishes and to be familiar with any special restrictions that are applicable in the state in which they practice. My article was an attempt to further these goals. More comprehensive approaches, such as the Physician Orders for Life-Sustaining Treatment (POLST) system in Oregon, have been dramatically successful in educating patients, emergency medical technicians, nursing-home staff, and physicians.1
I appreciate the elaboration of New York State's surrogate decision law provided by Dr. Powell. As I indicated in my article, a number of states place restrictions on the agent's power regarding life-sustaining treatment in general and artificial nutrition and hydration in particular. In most cases, the limitation consists of a requirement that the patient explicitly indicate that the decision-making authority vested in the surrogate includes the right to decide about life-sustaining treatment. In New York, a higher evidentiary standard is required for proxies to authorize the withholding or withdrawal of artificial nutrition and hydration, as Dr. Powell acknowledges. New York, like the majority of states, provides for substitute decision making even if the patient did not designate a surrogate, but the default proxy is constrained in ways that a chosen decision maker is not. In the example Dr. Powell gives, a request for DNR status may require that "two physicians have determined that the patient is terminally ill or permanently unconscious," whereas a proxy chosen by the patient could act in the event of decisional incapacity, regardless of the cause or prognosis.
The idiosyncrasies of individual state laws, although important, should not cause us to lose sight of the impetus behind all forms of advance care planning: the need to provide medical care that is consistent with the patient's goals for care.
Muriel R. Gillick, M.D.
Harvard Vanguard Medical Associates
Boston, MA 02215
References
Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998;46:1097-1102.
He had a "living will" requesting that there be no intervention in such a situation, and I had durable power of attorney for health matters. Pointing this out and requesting that life support be discontinued, I was told by the attending physician in the emergency room that, "legally," he could not do this for 6 to 12 hours. There is no such law in Pennsylvania. He also told me that if it were his mother or his wife, he would want life support to be continued. Of course, it was not his wife or his mother.
My husband never regained consciousness nor had any evidence of brain function. It took 29 hours for me and our children to have life support stopped. Why was his advance directive not respected? Why was my durable power of attorney ignored? I have no answers yet.
Dr. Gillick states that "advising patients to appoint a health care proxy . . . is all that physicians need to do . . . to enable their patients to be treated in accordance with their wishes." Doing all that was not enough for me and my husband. Everything was ignored. How do we educate our colleagues about their responsibility to respect these wishes regarding the end of life?
Jeanne M. Hanchett, M.D.
1020 Devon Rd.
Pittsburgh, PA 15213
References
Gillick MR. Advance care planning. N Engl J Med 2004;350:7-8.[Full Text]
To the Editor: We would like to clarify that New York law regarding surrogate decisions is not as restrictive as portrayed by Gillick. New York law permits an adult to name a health care agent who is authorized to make all health care decisions on behalf of the incapacitated patient. When the patient's wishes are known, the agent's decision should be based on those wishes. If the patient's wishes cannot be determined, the decision is based on the agent's judgment of the patient's best interests. The agent is not required to provide any evidence of knowledge of the patient's wishes. Rather, the agent is presumed to know the patient's wishes by virtue of the fact that the patient chose the agent. The only exception to this standard is for decisions about artificial nutrition and hydration, which require that the agent have reasonable knowledge of the patient's wishes.
In New York State, there are situations in which a surrogate may act even though the patient has not appointed a health care agent. A surrogate may make decisions to withhold or withdraw life-sustaining treatment on the basis of appropriate evidence of the patient's prior wishes.
New York law also provides that a do-not-resuscitate (DNR) decision can be made by a surrogate, selected from a hierarchical list of potential surrogates, after two physicians have determined that the patient is terminally ill or permanently unconscious or that resuscitation will be unsuccessful or unduly burdensome for the patient.
Tia Powell, M.D.
New York State Task Force on Life and the Law
New York, NY 10001
Dr. Gillick replies: In her letter, Dr. Hanchett describes how her husband's clearly stated wishes were callously disregarded after he sustained a cardiac arrest, despite his having prepared a living will and designated his wife as his health care proxy. She rightly points out that, in addition to broaching the subject of advance planning, physicians need to understand that they are bound to respect their patient's wishes and to be familiar with any special restrictions that are applicable in the state in which they practice. My article was an attempt to further these goals. More comprehensive approaches, such as the Physician Orders for Life-Sustaining Treatment (POLST) system in Oregon, have been dramatically successful in educating patients, emergency medical technicians, nursing-home staff, and physicians.1
I appreciate the elaboration of New York State's surrogate decision law provided by Dr. Powell. As I indicated in my article, a number of states place restrictions on the agent's power regarding life-sustaining treatment in general and artificial nutrition and hydration in particular. In most cases, the limitation consists of a requirement that the patient explicitly indicate that the decision-making authority vested in the surrogate includes the right to decide about life-sustaining treatment. In New York, a higher evidentiary standard is required for proxies to authorize the withholding or withdrawal of artificial nutrition and hydration, as Dr. Powell acknowledges. New York, like the majority of states, provides for substitute decision making even if the patient did not designate a surrogate, but the default proxy is constrained in ways that a chosen decision maker is not. In the example Dr. Powell gives, a request for DNR status may require that "two physicians have determined that the patient is terminally ill or permanently unconscious," whereas a proxy chosen by the patient could act in the event of decisional incapacity, regardless of the cause or prognosis.
The idiosyncrasies of individual state laws, although important, should not cause us to lose sight of the impetus behind all forms of advance care planning: the need to provide medical care that is consistent with the patient's goals for care.
Muriel R. Gillick, M.D.
Harvard Vanguard Medical Associates
Boston, MA 02215
References
Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998;46:1097-1102.