WVUH Ethics Committee

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WVUH Ethics Committee Ethics Consultation
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• Palliative Care Consultation

Alvin H. Moss, MD Barb Mulich, RN, FNP, CHPN
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She wants to be a full code.

• A frail 96-yr old woman is admitted in pulmonary
  edema. She is known to have inoperable severe
  aortic stenosis and 3 HB treated with a
  pacemaker. She has had a recent MI. Prior to the
  MI, her EF was 15. This is her third
  hospitalization in six months. Shortly after
  admission, she becomes hypotensive and oliguric.
  She is started on a Levophed drip to keep her
  systolic pressure above 80 mmHg. She remains
  tachypneic. Workup reveals a new massive MI with
  troponin level of 4.5. Her BUN and Creatinine
  rise to 53 and 1.7, and a nephrology consultation
  is requested. Nephrology declines to dialyze the
  patient because she is too unstable. The family
  gets irate and requests dialysis, full code
  status, and mechanical ventilation if needed.
  They claim age discrimination. The patient is
  asking for CPR, but it is hard to determine her
  understanding secondary to her hearing deficit.
  What should you do?

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Ethics Consult orPalliative Care Consult?
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Objectives

• Provide an example of ethics consultation
• Identify the indications for an ethics
  consultation
• Present the most common reasons for ethics
  consultation
• Highlight the Advance Directive, Do Not
  Resuscitate, and Health Care Surrogate laws
• Present an example of palliative care
  consultation
• Introduce the Palliative Care Service and the
  CHIP DNR/comfort screen

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Indications for Ethics Consultation

• An impasse with the patient/family in medical
  decision making, i.e., there is conflict.
• Disagreement within the health care team about
  the appropriate management of a patient, i.e.,
  there is conflict.
• An unusual, unprecedented, or very complex case
  ethically.
• The patient lacks decision-making capacity and
  has no advance directive or identifiable
  surrogate to assist in decision-making for the
  patient.

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Most Common Reasons for Ethics Consultation

• Assistance with decision-making about the
  withdrawal of life support, especially when there
  is conflict
• Assistance with decision-making about CPR status,
  MV, and feeding tubes
• Interpretation of advance directives

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Decision-Making for Patients without Capacity

• Based on Advance Directives
• with MPOA representative if named
• according to the Living Will
• Based on Best Interests
• with MPOA representative if named
• with health care surrogate

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DiagramHealth Care Decision-makingfor Adults
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Does the patient have a medical power of attorney?

• If not, what should you do?

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(No Transcript)
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Would you be surprised if the patient died in the
next year?
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(No Transcript)
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The POST Form into West Virginia Code

• a STANDARD form
• LEGALLY recognized DNR identification
• legal PROTECTION--health care providers are not
  subject to civil or criminal liability for good
  faith compliance with or reliance upon POST
• protocol for interinstitutional TRANSFERS

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Use of POST Form

• Discharge of patients to
• Nursing Homes
• Hospice
• Home Health

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(No Transcript)
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Palliative Care Consultation
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I want to die at home.
A Palliative Care consult was requested for a 68
yr. old man w/ end-stage heart disease and CKD.
He was admitted 3 wks earlier for heart failure.
Each time he would get close to being discharged,
he got worse. The case manager suggested a
palliative care consult to the cardiologist. The
patient had been in the hospital four times in
the previous month. The pt had asked his wife
"why did you bring me in? The patient wanted to
die at home.
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I want to die at home.

• The patient was afraid of suffocating, but ready
  to die. Shortness of breath and swelling were
  main symptoms. The patient wanted to say good-bye
  to his brothers and sisters who were out of town.
  He lived with his wife and a daughter. The
  daughter was not reconciled to the patient's
  dying, requesting dialysis and home monitoring
  of O2 saturation. His wife was willing to honor
  the patient's wishes. What should you do?

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Aspects of Palliative Care

• Pain and symptom management
• Advance care planning
• DNR
• Advance Directives
• Psychosocial and spiritual support
• Cultural support

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Definition
Palliative care is comprehensive,
interdisciplinary care of patients and families
facing a chronic or terminal illness focusing
primarily on comfort and support.
Billings JA. Palliative Care. Recent Advances.
BMJ 2000321555-558.
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Curative / Remissive Therapy
Presentation
Death
Hospice
Palliative Care
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Reasons for Palliative Care Consultation

• pain and sx assessment and management
• assistance in making difficult decisions, usually
  about continued use or withdrawal of
  life-sustaining treatment
• assistance in planning for the most appropriate
  care setting to meet patient/family goals
• provision of psychosocial and spiritual support
  to patients, families, and the health care team

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(No Transcript)
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WHO 3-stepLadder
3 severe
Morphine Hydromorphone Methadone Levorphanol Fenta
nyl Oxycodone Adjuvants
2 moderate
A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodei
ne Tramadol Adjuvants
1 mild
ASA Acetaminophen NSAIDs Adjuvants
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CHIP Master Guide

• Comfort/Treatment Limits
• CPR status
• Treatment Limitations
• Comfort Measures
• Pain/Other Symptoms
• Spiritual/Emotional
• Hospice/Home Health
• Advance Directives/Surrogate

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Obtaining Consults

• CHIP
• Paging
• Ethics beeper 0857 M-F 8-430
• Paging operator nights/weekends for ethics advice
• Palliative Care beeper 0857 M-F
• 8-430

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www.wvendoflife.org

• Toll-free
• 1-877-209-8086

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www.wvendoflife.org

• Downloadable living will and MPOA
• Downloadable surrogate selection form
• Request DNR and POST forms
• Request Hard Choices for Loving People