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Informed ConsentDNRAMA

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Title: Informed ConsentDNRAMA

1
Informed Consent/DNR/AMA

Thomas Genuit
Jason Weiner

2
Informed Consent/DNR/AMA

What does the Healthcare Decisions Act provide?
Patients have the right to
Informed participations in all healthcare
decisions
Accept / refuse any treatment
Formulate advanced directives / appoint agent to
make healthcare decisions
Physicians have the right to
Not provide medically ineffective therapy
What does the patient have to be to make
decisions?
Competent/capable
Informed
Who decides for patient that is
incompetent/incapable?
The patient surrogate

3
Informed Consent/DNR/AMA

What is required to make a voluntary, informed
decision?
Patient must be competent / capable of making
complex decisions
Physician must have given / patient must have
understood
Nature and prognosis of medical condition
Nature / purpose of proposed therapy, including
all reasonable alternatives and option of
foregoing therapy
Material risks of therapy, all reasonable
alternatives and of foregoing therapy
Patient must be free from coercion
What does competent/capable mean?
gt18 or emancipated minor
Ability to communicate adequately (yes, no,
questions, wishes)
Demonstrate cohesion of thoughts, understanding,
insight
Make decisions that is c/w what a reasonable
person would do

4
Informed Consent/DNR/AMA

Maryland law defines a competent individual as
a person who has not been determined to be
incapable of making an informed decision and is
At least 18 years old
A minor of any age who is married or is the
parent of a child, with respect to all matters
A minor who is at least 16 years old, with
respect to treatment of a mental or emotional
disorder by a physician, psychologist, or clinic
A minor of any age, but only with regard to the
following matters
Emergency treatment
Treatment for or advice about drug abuse,
alcoholism, venereal disease, pregnancy, or
contraception other than sterilization
Physical examination and treatment of injuries
from an alleged rape or sexual offense
Physical examination to obtain evidence of an
alleged rape or sexual offense
Initial medical screening and physical
examination connected with admission to a
detention center

5
Informed Consent/DNR/AMA

Except in the circumstances described above,
consent for treating a minor must be obtained
from the minors parent or guardian
Where, due to serious family hardship, a minor is
being cared for by another relative, Maryland law
authorizes the relative to consent so long as the
relative signs an affidavit as specified in the
statute
A patient may well be able to make an informed
decision about some basic questions even if the
patient is unable to address a more complex
medical issue
Accordingly, unless a patient is clearly unable
to make an informed decision about anything, a
physician should not simply find the patient
competent or incompetent, but should instead
assess the patients competence to make a
particular decision or type of decision

6
Informed Consent/DNR/AMA

Competent individuals decide for themselves
What to do if the patient is not competent?
If an advance directive containing patient
instructions has been adopted, the patients
instructions are to be followed
If the patient has named a health care agent, the
agents instructions are to be followed
If the patient has not appointed an agent, then
the statute provides a list of priorities for
surrogate decision makers

7
Informed Consent/DNR/AMA

Surrogates are to decide based on the patients
wishes, or, if the patients wishes are unknown,
the patients best interest
Surrogates may not authorize sterilization or
treatment for a mental disorder
Surrogates may not authorize withholding or
withdrawing of life-sustaining treatment unless
The attending and another physician have
certified that the patient is terminal or has an
end-stage condition, or
Two physicians, including one neurosurgeon or
neurologist, certify that the patient is in a
persistent vegetative state

8
Informed Consent/DNR/AMA

What is general/informed consent?
General consent
general agreement to admission, examination,
non-invasive tests, routine medical treatments,
laboratory tests (except HIV)
Face-sheet
Informed consent
Consent beyond general consent for treatment that
requires additional information, sufficient to
enable the individual to make a voluntary and
informed decision
Nature and prognosis of medical condition
Nature / purpose of proposed therapy, including
all reasonable alternatives and option of
foregoing therapy
Material risks of proposed therapy, all
reasonable alternatives and of foregoing therapy
What is an emergency situation?
Immediate risk to life or for serious health
impairment w/o therapy
Incapable patient/no decision maker available

9
Informed Consent/DNR/AMA

What is material risk?
Any risk that can be anticipated and is not very
uncommon/rare
Any severe risk (life, limb, serious health
imparirment) even if rare
What is an emergency situation?
Immediate risk to life or for serious health
impairment w/o therapy
Incapable patient/no decision maker available

10
Informed Consent/DNR/AMA

Who provides consent in Emergency situation?
HOC (Administrator on Call designee) unless even
minimal delay would cause serious harm
Pysicians responsibility
document nature of emergency
Efforts made to reach surrogate decision makers
As soon as feasible discuss nature of emergency
and treatment w. patient/surrogate
How long is consent valid?
Up to 30 days
Same hospitalization/admission
Unchanged patient condition / no unanticipated
significant health events

11
Informed Consent/DNR/AMA

When can a Consent be modified or Withdrawn?
At any time PRIOR to treatment rendered
By patient or same/higher decision maker
Original consent is voided must stay in
chartNew consent form must be obtained
If general consent is withdrawn
All care must stop and patient be discharged ?
comfort care
Physicians responsibility to document discussion
of consequences
Conflict resolution
Patient/decision maker vs. physician
Decision makers amongst themselves
Patient vs. decision makers

12
Informed Consent/DNR/AMA

What is DNR, AMA?
DNR refusal to consent to life sustaining
therapy CPRin case of cardiac/respiratory
arrest
AMA withdrawal of general consent
What must be done before withholding life
sustaining therapy i.e. DNR, WD based on
surrogate decision maker?
2 physicians must agree/document
Terminal illness w. imminent death including
futile medical care
Permanent vegetative state or
End stage progressive condition expected to
result in death within

13
Informed Consent/DNR/AMA

What is cardiac/respiratory Arrest requiring CPR?
Absence of measurable pulses or
Absence of cardiac electric activity or
Absence of spontaneous respiration
What is involved in CPR?
All measures of Basic and Advanced Cardiac Life
Support
Boutique/Custom codes make NO sense are
malpractice
Slow code
Chest compressions or drugs only
No intubation during code

14
Informed Consent/DNR/AMA

What is not covered by DNR order?
Respiratory distress requiring intubation/mechanic
al ventilation
Hypotension requiring pressor therapy
Transfer to higher level of care ICU
ALL other care needed by patient
For these and other conditions a specific care
plan outside of a DNR order must be established
Do not Use the term DNR/DNI?
Unless separate DNR order and care plan for
respiratory distress has been established

15
DNR/Informed Consent/AMA

What is the efficiency of CPR?
Restoration of circulation
Survival to discharge
Neurologic sequelae

70 ? 25-35 ? lt 25 ? lt10-15
25-50 30 - 30 - 30
Initial survival/restoration of circulation In
hospital chance of re-code Mild/moderate/severe
CNS damage
16
DNR/Informed Consent/AMA

What do you need to communicate?
When the patients heart gives out / when he
or she dies(not when his/her heart stops )
we need to determine if we are going to attempt
to revive (not do you want us to attempt
to restart the heart )
you do not need to make a decision now
but we will need to have a decision by
Time for questions
Involvement of other family, clerical support,
PMDs
Reestablish surrogate role of decision makers
No one wants to loose a relative / friend
There is no right or wrong
What would/did the patient the patient say
Assure decision makers
That DNR does not affect other therapy
That DNR can be suspended/withdrawn at any time

17
Informed Consent/DNR/AMA

Who is responsible for DNR order?
Qualified attending physician
Must sign order lt 24 hours
Must assure adequacy of discussion /
documentation
How long is it valid?
Until withdrawn or suspended or
Until patient transferred to other care area or
Until unforeseen medical event changes the
condition of the patient significantly
What to do for OR/procedures?
Temporary suspension must sign order
No suspension must document alternate care plan

18
Informed Consent/DNR/AMA

The Maryland Health Care Decisions Act sets out
two circumstances in which a physician may
decline to prescribe or render medical treatment
to a patient
Physician determines the treatment to be
ethically inappropriate (Unfortunately, there is
no definition for the term ethically
inappropriate)
Medically ineffective treatment to a reasonable
degree of medical certainty, will neither prevent
or reduce the deterioration of the health of an
individual nor prevent the impending death of an
individual (If a medical procedure would improve
or maintain the patients quality of life or
avert a dying process, it should not be deemed
medically ineffective)

19
Informed Consent/DNR/AMA

What happens when the patient/family disagrees?
The Act does not require the physician to provide
the procedure or treatment simply because the
patient or authorized proxy insists it be done
The health care provider should inform the
patient or proxy of their refusal to treat and
make the patient or proxy aware of the
opportunity to request a transfer to another
health care provider/institution
Pending a requested transfer, the health care
provider is legally required to comply with the
patient /proxys instruction only if a failure to
comply with the instruction would likely result
in the death of the patient

20
Informed Consent/DNR/AMA

What is Living despite a fatal illness?
Illness that will predictably cause the patients
death but for which interventions can still be
offered with a meaningful chance of prolonging
the patients life
Heavily affected by the physicians assessment of
prognosis, patients in this category must make
their own decisions
Physician can not act as independent decision
maker
Life-sustaining procedures are not medically
ineffective

21
Informed Consent/DNR/AMA

What is Actively dying?
Interventions can not reverse a decline that will
soon end in death
The course of the disease has foreclosed the goal
of seeking to prevent impending death
Any procedure with the purpose of preventing
death can be considered medically ineffective
However, if the patient/authorized proxy
disagrees with the physician, we must go through
the transfer procedure described earlier.

22
Informed Consent/DNR/AMA

What is AMA?
Any attempt by patient to leave hospital against
medical advice withdrawal of general consent
What are physicians responsibilities?
Establish patients competency/capability to
understand all consequences and make informed
decision
Assure that there is no
Coercion by family members/friends, etc
Socioeconomic situations that can be resolved
through social work/case management
Document all discussions, incl.
Nature, prognosis and likely course of disease,
Consequences of not administering adequate
therapy
Offer/help establish F/U, self or other
physician
Provide essential medications
through involvement of social work/case
management

23
Informed Consent/DNR/AMA

What is SW/Case managements responsibility?
Assure that there is no
Coercion by family members/friends, etc
Socioeconomic situations that can be resolved
through social work/case management
Contact family (if patient is competent must
obtain consent to contact family)
Offer/help establish F/U
Provide essential medications
Have patient sign AMA form
What are responsibilities for suspected abuse /
minors?
Contact protective services
Minors can not be discharged w/o signature of
guardian/parent

24
Informed Consent/DNR/AMA

Who can reasonably be detained?
Confused / disoriented patients
Emotionally disturbed patients who may be danger
to self or others
Suspected abused/neglected patients
Minors, when wishes of parents may cause
immediate danger to health or life of patient
Patients for whom hospital has initiated court
petition for appointment of guardian
Who is responsible for petition?
Attending physician of record
Psych consult should be obtained for
confused/disoriented, emotionally disturbed
patients lt 24 hours
Protective services should be involved for all
cases of suspected abuse, neglect and potential
danger to minors