GOC in Old Sick Patients-Fast

Elder Care is Sexy

Outline

• Medico-legal challenges
• Making compassionate recommendations
• SIM

Wine question

thanatophobia?

Thanatophobia

• fear of death
• "feeling of dread, apprehension or anxiety when one thinks about the process of dying, or ceasing to be"

Case

• 69 M from LTC
• PMHx: LB Dementia (severe), metastatic lung ca with bone mets
• cc-fever, delirium, hypotension, hypoglycemia, s/p aspiration event today

Details

• Prior DNR override
• Son from California wants 'everything' done
• Bedside assessment by MD-patient is dying, frail, cachectic.

Details

• 72/40, 105, t=39, 32, 88% RA, GCS 10, GLUC 2.9
• WBC 29/LACTATE 8/Na 117/Troponin 2.1
• CXR bilateral infiltrates

"I WANT EVERYTHING DONE FOR MY MOM"

You need time to effectively communication a plan

HOW DO YOU PROVIDE GOAL-CONCORDANT CARE?

SHARED DECISION MAKING

"AN INTERPERSONAL, INTERDEPENDENT PROCESS IN WHICH THE HEALTHCARE PROVIDER AND THE PATIENT RELATE TO AND INFLUENCE EACH OTHER AS THEY COLLABORATE IN MAKING DECISIONS ABOUT THE PATIENT'S HEALTHCARE"

ROLES

• PHYSICIAN-share medical knowledge and experience
• PATIENT/SDM-disclosing values and goals relevant to application of that knowledge

language pitfalls

• early use of DNR/code status
• withdrawal of care

EPEC-EM approach

• A-Advanced directive?
• B-make the patient feel Better
• C-Caregiver considerations
• D-Decision-Making Capacity?

Annals of Surgery 2016

• Formulate a prognosis
• CREATE A PERSONAL CONNECTION
• Establish a shared understanding of condition
• MAKE A TREATMENT RECOMMENDATION
• Affirm ongoing support for the patient and family

What are you obliged to do?

Treatment decision in Canada based on

• patient's known wishes
• best interests
• both

cmpa

• it's clear that a physician must respect a capable person's known wishes for EOL care/procedure/treatment
• LESS clear whether a patient or SDM has the right to demand a specific treatment

Royal College

• "Intractable disagreements are best viewed as arising from differing visions of what is best for the patient"

Institute of Medicine

• Obligation of MD:
• "Bringing to bear every possible resource to prolong active and healthy life and accepting death ONLY when it is felt to be INEVITABLE & then trying to mitigate its connection with suffering"

2013 Supreme Court

• Cuthbertson v. Rasouli
• physicians must obtain consent from the patient/sdm before life support can be withdrawn.
• ONT/YUK-disagreement, apply to Consent and Capacity Board

WITHDRAWING VS. NOT OFFERING

previously considered legally and ethically equivalent

Journal of Respirology 2015

• No case law in Canada that dictates that withholding/not offering CPR requires the consent of SDM.
• Physicians can ethically and legally not offer CPR.

Cefarelli v. Hamilton Health Sciences

• Ruling supported MD in 'No CPR' order despite an advanced directive stating wish for full code.
• Thus determined which treatments are to be offered is a matter of medical judgement

"EVERYTHING THAT WILL BE BENEFICIAL"