There is good evidence that, for a significant percentage of patients, medical treatment near the EOL substantially deviates from the patient's wishes, even when the patient has timely executed an AD that complies with state
law. Improving this situation presents an opportunity for productive interprofessional collaboration in which the contributions of legal, ethical, clinical, and social expertise to the delivery of excellent medical care will be essential.
Mrs. P is an 85-year-old, severely demented widow who was admitted to a nursing home from a hospital about 2 years ago. She had been hospitalized for treatment of a hip fracture incurred in an automobile accident when she was still driving. She now also suffers from chronic lymphocytic leukemia and hypertension. Before the hospitalization that led to her present nursing home admission, Mrs. P had lived in an apartment with a cousin with whom she has maintained close contact.
Mrs. P seemed to do well in the nursing home, even though her dementia became progressively more severe. She paces and talks to herself a lot. She periodically needs blood transfusions to control her leukemia. During these transfusions, Mrs. P cannot understand what is happening and sometimes vigorously resists the procedure despite the best efforts of facility staff, who are dismayed by her consternation, to calm her. Before administering the transfusion, it is necessary to give her a sedative and then physically hold her in bed while the procedure is begun. Otherwise, Mrs. P would remove the transfusion apparatus.
A year before the accident that began this chain of events, Mrs. P had gone to a legal aid office and executed advance medical directives. One document was a DPOA for health care naming the cousin as Mrs. P's decision-making agent if necessary. The other document was an instruction directive (living will) stating, among other things, “If I ever become unable to make and express my own treatment wishes, I do not want medical interventions that prolong my life if I have an incurable or irreversible terminal disease.”
The nurses are upset when they have to restrain Mrs. P to transfuse her. Mrs. P's physician is apprehensive about potential negative legal consequences if the transfusions are discontinued at this point.
What should the physician and nursing staff do regarding Mrs. P?
Are the physician's legal apprehensions well-founded?
■ Do Mrs. P's ADs help or hinder the decision-making process?
■ What could have been done differently in the drafting of Mrs. P's ADs?
Would the writing of a POLST have helped with the decision-making process in this case? When, where, and by whom might a POLST have been written?
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