End of life Decision making

Question 1

What are the three types of advanced directives in Texas?

Answer 1

• Directives to physicians
• Medical power of attorney
• Out-of-hospital DNR order

Question 2

It is ethically and legally permissible for a patient to ________life-sustaining treatment.

Answer 2

refuse

Question 3

What are the big 3 life sustaining therapies?

Answer 3

• ventilator
• dialysis
• artificial nutrition & hydration

Question 4

Advises physician about a person’s wishes for levels of treatment, in the event that person is:

Answer 4

(a) diagnosed with a terminal or irreversible condition and

(b) unable to make decisions

Question 5

What is a terminal condition?

Answer 5

Incurable condition caused by injury, disease or illness that according to reasonable medical judgment, will produce death within 6 months, even with life-sustaining treatment.

Question 6

What is an irreversible condition?

Answer 6

• A condition, injury, or illness that can never be cured;
• That leaves a person unable to care for OR make decisions for himself; AND
• Is fatal without life-sustaining treatment

Question 7

Mr. Z. is a motorcycle enthusiast and daredevil. Nevertheless, he is concerned about advance care planning and always keeps a copy of his Directive to Physicians (Living Will) right with him. This document states in no uncertain terms that he never wants to be intubated. One evening he has an accident and is brought to the closest ED. His living will and his wishes thereof are noted in his medical record. Mr. Z. has a possible closed head injury and his LOC and respiratory status start to deteriorate. If he is not intubated he will become severely compromised or even die. What should happen?

A. He should be intubated
B. He should not be intubated

Answer 7

A. He should be intubated

*we don’t think he is in a terminal or irreversible condition. Ventilator can be withdrawn when we are certain.

Question 8

What is considered out of hospital, with respect to a DNR?

Answer 8

-Community hospital, street, Emergency department, outpatient department

Question 9

Can surrogates refuse pain meds for patients?

Answer 9

No

Question 10

Mr. A is a 72 year patient with COPD; he also has some degree of dementia that manifests occasionally, usually in the evening. Mr. A’s wife is 68 years old and in good mental and physical health. He has three grown daughters. He has a friend who is his medical power of attorney. Who makes decisions for him?

A. His wife
B. His medical power of attorney
C. His three daughters
D. He does

Answer 10

D. He does

Question 11

Mr. A is a 72-year-patient with COPD; he also has severe dementia. Mr. A’s wife is 68 years old and in good mental and physical health. He has three grown daughters. His friend states he is the medical power of attorney. Who makes decisions?

A. His wife
B. His medical power of attorney
C. His three daughters
D. He does

Answer 11

B. His medical power of attorney

Question 12

Mr. G is a 52-year-old man admitted to the hospital with a severe bilateral stroke. He is unresponsive, unable to communicate, and tests show that he has severe anoxic brain injury. His physician recommends either doing a tracheotomy or shifting the goals of care to palliation (comfort care only; no aggressive therapies). Mr. G has no legal guardian and no Medical Power of Attorney. According to Texas law, who is his legal surrogate to make this decision?

A. His adult daughter who lives out of state.
B. His ex-wife who visits daily.
C. His girlfriend.
D. His clergyman.

Answer 12

A. His adult daughter who lives out of state.

Question 13

(T/F) For surrogate decision making, surrogates first make decisions in accordance with the patient’s best interest.

Answer 13

False

Explanation: Substituted judgment standard first; then comes best interest standard

Question 14

(T/F) A patient must be in a terminal or irreversible condition and lack decision making capacity in order for a medical power of attorney (MPOA) to be applicable.

Answer 14

False

Explanation: This is true for living wills but not for MPOAs. For the MPOA to be applicable, the patient must lack decision making capacity but he/or she does not need to be in a terminal or irreversible condition

Question 15

(T/F) Patients can refuse mechanical ventilation but not artificial nutrition and hydration.

Answer 15

False

Explanation: Patients can refuse any and all treatment.

Question 16

Ms. C is a 70-year-old woman who has advanced lung cancer with widespread metastases. She is currently dependent on mechanical ventilation and requires artificial nutrition and hydration. She is unable to participate in decision making. She has developed a life-threatening infection.

True or False: Surrogates can request that antibiotics be withheld on the basis of patient wishes.

True or False: If antibiotics are initiated, they cannot be withdrawn.

Answer 16

True

False

Explanation: There is no distinction (legally or ethically) between withdrawing and withholding LST. Both withdrawing and withholding are legally and ethically permissible.

Question 17

What is TADA section 166.046

Answer 17

Procedures for refusing to comply with patient/family request for inappropriate treatment`

Question 18

What is physiologic futility?

Answer 18

• Continued treatment is not reliably expected to produce its usually intended physiologic outcome.
• patient is gonna die no matter what you do

Question 19

What is functional/qualitative futility?

Answer 19

Cont’d treatment is reliably expected to be effective, but also to involve significant disease-related or iatrogenic morbidity, loss of functional status and, therefore, decreased capacity for qualify of life.

Question 20

What are the two components of Due process?

Answer 20

• Negotiate disagreements

- TADA 166.046

Question 21

What is brain death?

Answer 21

-ALL spontaneous brain function has stopped

Question 22

An 85-year-old man is admitted to the hospital with a severe bilateral stroke. He is unresponsive, unable to communicate, and tests show that he has severe anoxic brain injury. He is dependent on endotracheal intubation and mechanical ventilation. The attending physician believes that continuing aggressive treatment would not benefit the patient and would therefore be medically inappropriate. He has tried on several occasions to discuss this with the patient’s daughter (the patient’s only family member), but she insists that aggressive treatment continue. The attending physician has asked the hospital ethics committee to review the case in accordance with the Texas Advance Directives Act, Section 166.046.

If the ethics committee agrees that continuing aggressive treatment would be medically inappropriate, what should the attending do?

A. Discontinue the inappropriate interventions immediately.
B. Seek a second opinion from another attending physician.
C. Give the daughter 10 days to try to transfer the patient or come to grips with her father’s death with support from the health care team and then discontinue the inappropriate interventions
D. Seek legal counsel prior to discontinuing inappropriate treatments.
E. Give the daughter 48 hours to try to transfer the patient.

Answer 22

C. Give the daughter 10 days to try to transfer the patient or come to grips with her father’s death with support from the health care team and then discontinue the inappropriate interventions

Question 23

(Fischer, Kaplan, USMLE) An 80-year-old is admitted to the hospital with a massive intracranial bleed. He has been placed on the ventilator because of the respiratory failure associated with intracranial herniation. When you try to remove the ventilator, there are no respirations. The patient makes no purposeful movements. There is no pupilary reaction when you shine a light in his eyes. Corneal reflexes are absent. The medical team has conducted all appropriate tests and concluded that the patient suffered irreversible cessation of entire brain function. Which of the following is the most appropriate action regarding this patient?

A. Remove the ventilator
B. Make the patient DNR
C. Get a court order authorizing you to remove the ventilator
D. Invoke the futility policy

Answer 23

A. Remove the ventilator