Tse Chun Yan Outline Brief introduction Review 2 journal articles - - PowerPoint PPT Presentation

Tse Chun Yan

Outline

 Brief introduction  Review 2 journal articles  Brief discussion

In Hong Kong, for a mentally incompetent patient

 Decision on medical treatment normally made by

consensus building between the healthcare team and the family members in the best interests of the patient.

 Consensus building is sometimes not easy.

 A valid and applicable advance decision refusing

life-sustaining treatment (usually called an advance directive AD in Hong Kong) has legal status, and must be respected.

 Helps to reduce difficulties in decision-making.

To clarify terminology

 In other countries, advance directives may include:

 Advance decision refusing treatment

 Called “living will” in many countries.

 Appointing a healthcare proxy

 CPA for healthcare is one form of healthcare proxy.

 In Hong Kong, because a healthcare proxy currently

has no legal status, an AD is an “advance decision refusing treatment” (a “living will”).

To reduce difficulties in end-of-life decision-making

 Some would consider that signing an advance decision

refusing treatment would be adequate to reduce difficulties in end-of-life decision-making.

 Why bother to appoint a CPA with power to decide on

LST?

Hastings Centre Report 2004, 34(2): 30-42.

Authors

 Angela Fagerlin

 Co-Director of the Center for Bioethics and Social Sciences in

Medicine and Professor of Medicine at University of Michigan

 Carl E. Schneider

 Chauncey Stillman Professor for Ethics, Morality, and the

Practice of Law and Professor of Internal Medicine at University

• f Michigan

Discussion paper with over 100 references

 Key points:

 The policy to widely promote living wills has not

produced results and should be abandoned (main theme of the paper).

 Not against the use of living wills in special situations.  Prefers promoting durable power of attorney.

Why living wills fail

 Few people sign living wills despite wide promotion:

 Quoted a figure of 18%.

 People have difficulty in knowing what they will want:

 “An unspecifiable future confronted with unidentifiable

maladies with unpredictable treatments”,

 Compared to the rising standard for informed consent,

living wills are made without adequate information and without adequate analysis,

 People change their mind.

Why living wills fail

 People have difficulty to articulate what they want:

 Idea muddled in their mind  People have difficulty to write down in their own words

the complex instructions

 Standard forms are either too general or have too

specific questions.

 The healthcare team are not aware of the existence of a

living will:

 26% of medical records accurately record information

about the directives.

Why living wills fail

 Interpreters cannot analyze the AD instruction accurately:

 Quoted one randomized control trial showing that the

availability of a scenario-based or value-based AD does not help the predictability of patient preferences in other scenarios.

 Living wills do not alter patient care:

 Contents of AD were vague and difficult to apply to current

situation

 Difficulty to say whether the patient is terminally ill or

“absolutely, hopelessly ill”

 Objection by family members

The cost of programs to promote living wills

 The cost plainly outweighs the benefits, because the

“programs have failed”.

 The policy should be abandoned.

Not against the use of living wills in special situations, when

 The medical situation is plain  The crisis is imminent  The preferences are specific, strong, and delineable  Have special reason to prescribe their care

Prefers to promote durable power

• f attorney

 The choices that powers of attorney demand of

patients are relatively few, familiar, and simple.

 A regime of powers of attorney requires little change

from current practice,

 in which family members ordinarily act informally for

incompetent patients.

 Powers of attorney probably improve decisions for

patients,

 since surrogates know more at the time of the decision

than patients can know in advance.

Prefers to promote durable power

• f attorney

 Powers of attorney are cheap;

 they require only a simple form easily filled out with

little advice.

 Can be supplemented by legislation akin to statutes of

intestacy

 Statutes to specify who is to act for incompetent patients

who have not specified a surrogate.

Quick comments on the paper

 Emotive language was sometimes used. Discussion

was sometimes biased.

 However, the views raised are worthy of serious

reflection.

Journal of Pain and Symptom Management 2013, 46 (3): 355-365.

Qualitative study

 Participants: patients and surrogates with experience

• f making serious medical decisions:

 Patients: for themselves,  Surrogates: for others.

 Semi-structured focus groups, asking what activities

best prepared the participants for decision making.

 Thematic content analysis.

Themes identified

 Use of advance directives alone is not sufficient:

 Scenarios in AD are hypothetical  Decisions needed to be made are more than those

specified in the AD

 Identifying values based on past experiences and

quality of life:

 Use past experience and consider worst case scenarios  Focus on quality of life defined individually  Reevaluate over time

Themes identified

 Choosing a surrogate and verifying their understanding:

 Choice based on ability  May change over time  Need to prepare surrogate

 Considering whether to grant surrogates leeway:

 Patients want to grant leeway to surrogates,  allowing surrogates to be an advocate and to make best in-

the-moment decisions,

 though understanding that leeway is not always prudent.

Themes identified

 Informing family and friends about one’s wishes:

 To prevent conflict  To provide control for the patient and the surrogate

Overall discussion

 Advance decisions refusing treatment may not be

adequate or appropriate to cover all scenarios in end-

• f-life decision-making.

 In-the-moment decisions are important:

 Need to prepare the decision-makers.

 Prior expression of values and preferences and prior

discussion with family members would be helpful.

 Importance of ACP to involve family members and to

discuss values and preferences.

Overall discussion

 If there is worry about conflicts among family

members, it will be useful to delegate such a decision to someone he/she trusts, and who understands the values and treatment preferences of the patient.

 Thus, it is sometimes useful in Hong Kong to appoint a

CPA with power to decide on life-sustaining treatment.

Thank you!