…caring for patients with dignity and compassion mandates that nurses honor a patient’s wishes, even if they disagree with these wishes.
:: Advance Directives: Why Aren’t They Widely Used? ::
Please consider the following two scenarios. Are both cases simple to answer……or is there a case to consider more than just the patients wishes?
PATIENT A): You are looking after a 80 year old lady on the wards with a fractured neck of femur. She is otherwise fit and relatively healthy and has been living an independent and very active life.
She has an advance care directive (12 months old) stating that in the event of cardiac arrest she does NOT wish to be intubated or resuscitated.
Following a day of fevers she suddenly becomes hypotensive, loses consciousness and cardiac output.
The team have begun resuscitation a short time before you arrive and are discussing that there is a high probability that this patient might be rescued.
Would you respect her advanced care directive and advocate to withhold continuing advanced cardiac life support?
PATIENT B): You are looking after a 80 year old lady on the wards with a fractured neck of femur. She has multiple other co-morbidities, she has severe emphysema, Ca bowel with metastases to liver and bone and is an insulin dependent diabetic. She has a left hemiparesis following a stroke 6 months ago and has lived in a nursing home since then.
She has an advance care directive (12 months old) stating that in the event of cardiac arrest or severe illness she wishes full resuscitative interventions including ICU admission, inotropic support and intubation if necessary.
Following a day of fevers she suddenly becomes hypotensive, loses consciousness and cardiac output.
The team have begun resuscitation a short time before you arrive but are now discussing ceasing activity due to the poor prognosis.
Would you respect her advanced care directive and advocate for the provision of ACLS and intensive care interventions?
Are there any differences in your considerations of these two advance care directives?
I would have asked both patients what they wanted in such circumstances BEFORE it happened.
Failing that, in some states we are required by law to follow a valid AHD if one exists.
In reality, I would aggressively resuscitate the first patient and instruct the team to cease resuscitating the second.
Are we obliged to offer futile treatment, even if it’s in an AHD? I’m not altogether certain that we are (?).
No, not in the ACT. The law is a bit…. weird… here, in as much as even a legally valid AHD can be summarily over-ruled by family members, or two medical officers who concur on a given course of action.
I have to admit straight out that I do not work in acute nursing so it will never be a question I have to answer.However if a patient has made their wishes known, then they should be respected. In the end, we all have to die of something…and wouldn’t it have been great to have an active live till 80 and then pass away quickly.
At the hospitals that i have been at, you need to have the NFR re-written each hospital admission. What the patient has stated, providing that they understood what they were consenting to and understand that it may happen at any time, should be adhered to.
But when the discussion about NFR should be done, should be done in a private, calm manner, and done when the paitent is orientated and perhaps with family members. (not like i saw with a guy who had just been told that he had cancer ontop of being a new tetraplegic, and a poor prognosis… and it was kind of said.. do you want us to stick you in a ICU bed with lots of machines and things, or keep you comfortable… and not really given much choice…. he sadly died a few days later)