When Is Delegation Of Decision-Making Appropriate?

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When Is Delegation Of Decision-Making
Appropriate?

• Cardiothoracic Ethics Forum Surgical Ethics
  Course AATS 95th Annual Meeting
• Seattle
• April 25, 2015

Thomas A. DAmico MD Gary Hock Endowed Professor
and Vice Chair of Surgery Chief Thoracic
Surgery Chief Medical Officer, Duke Cancer
Institute
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Disclosure

• Member, STS Standards and Ethics Committee
• No conflicts related to this presentation

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Case

• A 76-year old woman with bone-only metastatic
  breast cancer developed shortness of breath
• CT complex left pleural effusion, recurrent
  after 2 attempts of thoracentesis, cytology
  positive
• No documentation in EMR of relief of SOB
• Thoracic Surgery is consulted and she undergoes
  left VATS drainage of effusion, decortication and
  talc pleurodesis

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Case

• No complications in the immediate post-op period,
  although her CXR is not improved
• POD 3, she develops mental status changes
• The chart from the current hospitalization does
  not document extent of disease or goals of care
• She does have an Advanced Directive on the chart,
  but her status is not DNAR
• She has never had a Palliative Care Consult

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Case

• No documentation that she has indicated which of
  her 2 sons has health care power of attorney
• POD 5 Progressive respiratory distress,
  hemodynamic instability, and MS changes
• Family consultation with thoracic surgery care
  team and medical oncologist (who refuses
  Palliative Care consultation) continue
  aggressive care, plan for Herceptin therapy. No
  DNAR

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Case

• POD6 Respiratory arrest. Intubated and
  resuscitated, requiring inotropic support
• POD 7-9 No improvement unresponsive
• Palliative Care Consult
• POD 10 Conference with 1 son regarding the
  specifics of the Advance Directive and what the
  patient would have wanted in this condition
• POD 11 Meeting with both sons and pastor

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Opportunities for Improvement

• The decision to operate was not based on
  objective evidence (? Improve SOB)
• The care team was not aware of extent of disease
  or goals of care
• The treating oncologist did not understand the
  benefit of Palliative Care consultation
• The Palliative Care team was restricted by the
  medical oncologist

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Unpredictable Obstacles

• The family disregarded the Advance Directive
• It was difficult to have a conference that
  included all of the surrogate decision-makers
• Delegation of decision-making was to the
  oncologist and pastor

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Common Delegation Of Decision-Making

1. Incompetent patients
2. Anesthetized patient in the OR
3. Unconscious patient in the ICU
4. Patients who request delegation
5. Children

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Capacity for Medical Decision-Making

• Possession of values and goals
• Ability to communicate and understand information
• The ability to reason and to deliberate about
  ones choices
• Presidents Commission for the Study of Ethical
  Problems in Medicine and Biomedical and
  Behavioral Research (1982)

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Incapacity

• May be periodic
• May be decision-specific
• May be reversible
• Not related to age, refusal of care, medical
  diagnosis, social status
• ? Level of education

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Surrogate Decision-Making

1. Directed Decision-Making (living will)
2. Delegated Decision-Making (power of attorney)
3. Devolved Decision-Making (default surrogate)
4. Displaced Decision-Making (court, guardian)
5. Deferred Decision-Making (physician)

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Living Will

• Less than 1/4 of adult patients have completed a
  living will
• Up to 1/2 of patients express strong desire to
  share decision-making
• As many as 3/4 of adults admit that they would
  prefer their health care providers to override
  their stated preferences from living will in
  favor of familys directly opposing preferences

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Surrogate Decision-Making

• AMA Opinion 8.081
• Competent adults may formulate, in advance,
  preferences regarding a course of treatment in
  the event that injury or illness causes severe
  impairment or loss of decision-making capacity
• These preferences generally should be honored by
  the health care team out of respect for patient
  autonomy

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Surrogate Decision-Making

• Patients may establish an advance directive by
  documenting their treatment preferences and goals
  in a living will or by designating a health care
  proxy (durable power of attorney for health care)
  to make health care decisions on their behalf

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Surrogate Decision-Making

• When there is evidence of patients preferences
  and values, decisions concerning the patients
  care should be made by substituted judgment
• Consider the patients advance directive (if
  any), the patients views about life and how it
  should be lived, how the patient has constructed
  his or her identity or life story, and the
  patients attitudes towards sickness, suffering,
  and certain medical procedures

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Surrogate Decision-Making

• If there is no reasonable basis on which to
  interpret how a patient would have decided, the
  decision should be based on the best interests of
  the patientbest promote the patients well-being
• Factors considered when weighing the harms and
  benefits of various treatment options include the
  pain and suffering associated with treatment, the
  degree of and potential for benefit, and any
  impairments that may result from treatment

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Surrogate Decision-Making

• Any quality of life considerations should be
  measured as the worth to the individual whose
  course of treatment is in question, and not as a
  measure of social worth
• One way to ensure that a decision using the best
  interest standard is not inappropriately
  influenced by the surrogates own values is to
  determine the course of treatment that most
  reasonable persons would choose in similar
  circumstances

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Surrogate Decision-Making

• Physicians should recognize the proxy or
  surrogate as an extension of the patient,
  entitled to the same respect as the competent
  patient
• Physicians should provide advice, guidance, and
  support explain that decisions should be based
  on substituted judgment when possible and
  otherwise on the best interest principle and
  offer relevant medical information and opinions

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Surrogate Decision-Making

• In general, physicians should respect decisions
  that are made by the appropriately designated
  surrogate and based on the standard of
  substituted judgment or best interest
• In cases where there is a dispute among family
  members, physicians should work to resolve the
  conflict through mediation

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Surrogate Decision-Making

• Physicians/ethics committee should uncover the
  reasons that underlie disagreement and present
  information that will facilitate decision-making
• When a physician believes that a decision is
  clearly not what the patient would have decided,
  not be reasonably judged to be in the patients
  best interests, or primarily serves the interest
  of a surrogate/third party, an ethics committee
  should be consulted before requesting court
  intervention

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Surrogate Decision-Making

• Physicians should encourage patients to document
  treatment preferences or to appoint a health care
  proxy and discuss their values regarding health
  care and treatment in advance
• Because documented advance directives are often
  not available in emergency situations, physicians
  should emphasize to patients the importance of
  discussing treatment preferences with individuals
  who are likely to act as their surrogates

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Power of Attorney

• Advantages

• Disadvantages

1. Promotes Autonomy
2. Avoids guardianship
3. Cost reduction
4. Takes pressure off family members

1. Lack of monitoring
2. No standard of conduct for agent (substituted
   judgment, best interest)
3. Broad authority
4. ? Risks (Brooke Astor Case)

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Advance Directives

1. Most people do not have one
2. Forms may be difficult to understand
3. May change their mind
4. Health care providers may not be aware of
   existence or location
5. Incorporation in EMR?

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Advance Directives Advantages

1. Starts communication regarding goals of care
2. Existence alone may cause care-givers to stop and
   think before decision-making
3. Empowers the patient
4. Existence of a current Advance Directive is more
   likely to lead to updated Directives, with age,
   co-morbidities, change in family structure

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Physician Orders for Life Saving (POLST)

• Standardizing physician EOL orders to implement
  patients goals of care
• Requires exploring care goals abx, CPR,
  intubation, comfort
• MD orders in bright pink

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POLST Distribution in US
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Default Surrogates (Family)

• Priority of surrogates
• Scope of decision-making authority
• How are disagreements handled?
• Close friend vs family

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Deferring to the Physician

1. Spectrum of patient trust, from skepticism to
   trust to dependence
2. For surgery, varying degree in the use if
   decision-making aids
3. What are the barriers to communication?

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Barriers to effective EOL conversations

• 1040/1234 potential subjects (84.3) participated
• 29 participants development cohort
• Codes validated by analyses of responses from 50
  randomly drawn subjects from the validation
  cohort (n 996 doctors)
• 99.99 reported barriers to conduct EOL
  conversations, with 85.7 admitting it is very
  challenging, especially to pts of different
  ethnicity

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Barriers to effective EOL conversations

1. Language and medical interpretation issues
2. Religio-spiritual beliefs about death and dying
3. Doctors ignorance of pt cultural beliefs, values
4. Patient/family's cultural differences in truth
   handling and decision making
5. Patients limited health literacy
6. Patients mistrust of doctors and the health care
   system

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• Doctors rate the relative importance of the 6
  primary barriers to effective EOL conversations

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Role Reversal in the Conversation on Dying
https//www.youtube.com/watch?vvApg3qAn55sfeatur
eyoutu.be
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Summary

• The need for surrogate-decision making,
  especially at end-of-life, often complicates
  patient care
• Living Wills, Advance Directives, Health Care
  Powers Of Attorney, POLST all contribute to
  improving the decision-making process
• All are underused for a variety of reasons
• Talk to patients before operating on them

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Surrogate Decision-Making Issues

1. Patient Capacity
2. Health Care Power of Attorney
3. Advance Directive
4. Guardianship

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Capacity

• Must be judged according to a standard set by
  that persons own habitual or considered
  standards of behavior and values, rather than by
  conventional standards held by others
• Silberfield and Fish, When the Mind Fails (1994)