A matter of ongoing ethical concern for nurses, doctors and other medical professionals is the need for clear guidelines when it comes to the decision to suggest that a patient or family consider filling out a DNR (Do Not Resuscitate) order. These kinds of advanced healthcare directives are becoming ever more common as our population ages. While it has been widely accepted that medical professionals should respect legally implemented end-of-life treatment preferences for those patients whose lives are drawing to a close for those who suffer a sudden and nonrecoverable illness, the technical and practical aspects of how these decisions are made can be a quagmire. In addition to the legalities involved in this decision, there is the question of ensuring that each patient is provided with ethically sound treatment that suits his or her needs. The following discusses as the Medical Treatment Directive Tool, referred to hereafter as the MTDT. The goal of this tool is to make it easier for nurses and physicians to approach the topic of DNR’s and to ensure that the patient’s wishes are fully adhered to regardless of their choice.
The MTDT serves a number of different purposes that go well beyond living will declarations and the standard power of attorney, which are often used for such purposes. Declarations in living wills are designed to make clear the individual’s desires with regard to treatment options for sustaining life if, at some point, the individual is comatose or terminally ill (Godkin, 2008). It can be used either when the patient is still lucid, or when a surrogate decision maker is required. By contrast, the living will refers to the future and is only in force if the individual is not able to make his or her own health care choices. As for power of attorney, this provides a family member or other individual with the authority to make health care decisions for the patient again though, this usually only goes into effect if the individual is deemed unable to make such decisions for his or herself.
As an alternative approach, the MTDT is designed to obtain the medical treatment objectives of the individual in question while they are still capable of responding, to create a medical order to that effect and to ensure that the patient’s wishes are honored later. While this tool can be used in conjunction with DNR orders and is principally aimed at helping medical professionals to determine when to carry out a DNR order, MTDT deals with more than just the decision not to resuscitate. After all, most patients are also concerned about quality of life issues and avoiding suffering.
The MTDT focuses on allowing patients to clearly lay out their personal choices regarding what levels of intervention they prefer as they are living out the final stage of their lives. In addition to addressing the question of CPR (Cardiopulmonary Resuscitation), this tool also provides for addressing other relevant health care questions in an end-of-life situation, such as what degree of intervention is acceptable in an emergency situation and what types of artificial nutrition methods, ventilation, hydration and antibiotics can be used (Nowarska, 2011). Allowing patients to make the decisions ahead of time through the use of the MTDT is empowering for them.
The MTDT is particularly useful because it will create greater standardization and broader consistency in how such cases are handled. In the best case scenario, the form based on the MTDT should travel with the individual patient wherever he or she goes. It should be with him or her in the hospital, in a nursing facility or at home. Thus, medical professionals can ensure that the patient’s care is entirely consistent. Furthermore, it makes it possible for the patient to reevaluate the healthcare and end-of-life decisions indicated on the document at any time.
Standard DNRs usually vary from one location to the next, since care facilities and hospitals are each going to have their own specific form, largely based on specific state laws and regulations on the subject. This means that standard DNR’s only apply to the particular facility in which they were originally generated. This inconsistency and variation in DNR forms inhibits the effective care of end life patients and causes them unnecessary suffering. For instance, duplicated orders or contradictory orders can interfere with the clear communication of the end-of-life patient’s true desires (Manalo, 2013).
It is important to point out that the MTDT is more than just a bureaucratic form that needs to be filled out. It has to be considered and employed as an important decision-making tool. In order for the MTDT to be fully effective, there has to be a straightforward and clear discussion of the nature and provisions between the medical professionals and the patient/surrogate. The objective of such conversations is to define the patient’s personal desires and long-term treatment decisions, taking into account the current condition of the patient. The quality and effectiveness of this conversation is essential to the successful use of the MTDT.
Obviously, the use of this tool will result in definitive medical orders in a standardized format and that the patient or the patient’s surrogate will ensure is contained in the individual’s medical records at home. However, this form in itself is only a small part of the overall process. One of the principal objections that some might have to such an approach is that the decisions regarding an individual’s end-of-life scenario might become less thoughtful and considered with such a form in hand. Nevertheless, this approach ensures a clear and definitive conversation with the patient and/or his or her surrogate in which that patient’s desires are directly recorded in a straightforward and easy to understand way. This represents a considerable improvement over previous practices in which a patient’s desires were often not considered (Nowarska, 2011).
The planning for the MTDT process should involve three steps:
Step Two: As the patient grows older, his or her family members or representatives will increase their involvement in the case and stand prepared to act if necessary.
Step Three: During the scenario laid out in the MTDT, its provisions will be carried out.
One of the principal criteria for determining if the above three-step and process should
begin is whether, in the minds of the patients, caregivers and position, there is a high likelihood or at least a reasonable chance that the patient in question might die in the upcoming year. If the answer is in the affirmative, then it might be time for the patient or his or her surrogate to engage in a conversation with medical professionals about an end-of-life scenario and the possibility of filling out the MTDT form. It should be noted though that the entire MTDT approach is intended for more than just those patients who are currently in a terminal end-of-life condition. Anyone advanced in years or who is in poor health might wish to specify the level and type of care that they prefer.
The MTDT permits each individual to clearly state his or her specific goals with regard to end-of-life care. Furthermore, it ensures that they will be provided with guidance in translating their specific objectives about their care into legal medical orders that can be used in emergencies. For instance, an elderly individual who wishes to sign a DNR might also indicate on the MTDT form that he or she desires for treatment and intervention in certain circumstances but more limited approaches in other circumstances. This procedure reduces the chance that a patient will receive care that he or she does not desire. It also avoids the dual assumptions that are so common in end stage care that anyone would want to receive aggressive treatment in order to live as long as possible or that an individual in the difficult last stages of life would rather avoid any intervention.
As suggested above, the MTDT process should begin with a conversation between the medical professional and the patient. In those instances in which the patient no longer has the ability to consider their healthcare options or communicate their desires regarding these options, the conversation should take place between the medical professional and the patient’s surrogate. The initiator of the conversation can be any of these individuals. In fact, the ideal situation is one in which all of the individuals involved work as a team to arrive at the best result. This conversation is a vital part of the MTDT and absolutely essential to its ultimate success. Failure to engage in this way negates the whole purpose of the MTDT.
In order to create the MTDT document in a way that clearly expresses the patient’s wishes, the medical professionals have to begin by having a frank and open discussion of the individual’s present medical situation and condition, as well as the most probable prognosis for the patient, the various treatment options, the probable outcomes of those treatments, the types of intervention that are available and the level and type of intervention that the patient actually wants. For the most part, this conversation is principally the responsibility of the doctor involved, but an Advanced Practice Registered Nurse (APRN) can work with the patient and the doctor to evaluate the patient’s personal priorities and goals in light of the medical information the doctor or the patient’s APRN provides. That way they can arrive at the best possible option for the patient.
Since the medical needs of any patient are going to change over time the treatments being considered will have to change as well, which means that the doctor, APRN, and patient will have to maintain an ongoing discussion about these options. This will allow the patient to clearly express and record his or her preferences. If this communication does not occur, providers cannot guarantee that they are properly documenting the patient’s wishes or implementing those wishes over time. The MTDT approach of ongoing conversations means that the patient will understand any changes in his or her medical decision and the informed when making decisions regarding treatment. This has the added benefit of engendering in these patients greater confidence in the medical professionals working with them.
The result of these discussions are medical orders that are recorded on the MTDT form. These medical orders can be reviewed at a later date and updated if necessary. Should such changes be required, all that is necessary is for the doctor or APRN to work with the patient to decide on a new course and to write new medical order on an updated form. If the patient has lost the mental ability to take part in this process, the person they granted a power of attorney to will take part in the discussion and will sign the MTDT form for the patient. This person acting as the patient’s agent is of course limited in the actions they can take by the laws of the state. If the patient lacks the capacity to make these decisions but has failed to establish a power of attorney, then the state must establish a default surrogate to act on the patient’s behalf. Naturally, it is preferable for the patient to choose the person who will act as his or her agent, rather than leaving it to the authorities.
This last point is an important one, since the medical options available to patients and medical professionals are limited by laws and regulations of the state in question. This places limitations upon the MTDT itself. These limitations will most likely change over the years with new medical advancements and with new research. Broadly speaking, there are three types of treatments addressed on the form. The first section deals with CPR and the patient deciding whether he or she wants CPR to be performed. If the decision is no, the MTDT can act as a DNR order. In the following section of the family, the patient or an agent with power of attorney will decide the medical intervention levels that he or she finds acceptable. The patient can choose full treatment options, which may include ventilation, intubation and placement in a hospital’s intensive care unit. Otherwise, the patient might choose to place limitations on these interventions, such as choosing to avoid either the intensive care unit or highly invasive treatments. The third type of treatment the form addresses is the decision to choose comfort care alone.
In conclusion, it is important for the patient to have as much control over his or her healthcare decisions for as long as possible. While DNR orders and similar approaches have existed for some time and place limitations on what positions, nurses and other medical professionals can do for patient, these documents are rather restricted in nature. The MTDT can be an all-inclusive documentation of a patient’s wishes, evolving as that patient’s medical situation changes over time. It also helps with the vital decision making process. The use of this tool would not only ensure that the patient’s wishes are respected in a number of areas regarding his or her health, it would also reduce the chance that treatment mistakes would be made.
References
Godkin, D. (2008). Living will, living well: Reflections on preparing an advance directive. Edmonton: University of Alberta Press.
Manalo, M. C. (2013). End-of-Life Decisions about Withholding or Withdrawing Therapy: Medical, Ethical, and Religio-Cultural Considerations. Palliative Care: Research & Treatment, (7), 1-5.
Nowarska, A. (2011). CPR vs. DNR in the context of palliative care. Advances In Palliative Medicine, 10(3/4), 89-94.
