Feasibility and Acceptability of an mHealth ACP Tool in Primary Care

With only 7% of Medicare beneficiaries having completed Advance Care Planning with their physicians, engagement in Advance Care Planning in the clinical setting has been historically low. This study investigated the feasibility of introducing the Koda Health Advance Care Planning software platform in the primary care setting, and whether patients would engage in advance care planning through this medium. The Koda platform is a video-driven, web application that guides patients through advance care planning concepts, including values and quality of life exploration, surrogate decision maker selection, life-support treatments, and advance directive completion. The study was completed over a six-month period in two primary care clinics in the Houston, Texas area. Inclusion criteria were age 55 or older, English-speaking, and capacity for medical decision making. 339 patients met eligibility criteria and had a median age of 73 (range 59-89). All participants were offered the platform, and 262 (77%) created an account and began planning for their care. Of the patients that created an account, 87% completed all ACP steps on the platform and 72% identified a surrogate decision maker. The median time spent on the platform was 18 minutes. The Koda platform appears to be a useful tool for patients and providers to improve engagement in advance care planning and improve surrogate decision maker identification. Further research is needed to understand whether the Koda platform aids in providing goal-concordant care.

Continue with ICU care – she is a spiritual being

This case study discusses a dispute between the healthcare team and the patient’s surrogate decision maker at a cancer centre. While the healthcare team deemed further care to be futile, the patient’s husband argued that they should continue to try to reverse his wife’s acute decline. This case study illustrates the inertia and moral distress that can result when there are differences between patients/surrogates and the healthcare team in their goals for intensive care. The issues of moral distress and an inability to make decisions were addressed by involving an ethics consultant, and by creating institutional mechanisms to address end-of-life issues at an earlier stage

Requests for futile or inappropriate interventions near the end of life

Patients and families may, at times, request interventions that clinicians believe to be either futile or potentially inappropriate. Futile interventions are those that simply cannot accomplish the intended physiological goal. Requests for futile interventions are uncommon, and when a patient or surrogate decision maker requests an intervention that is futile, the clinician should decline the request and carefully explain the rationale for the refusal. More commonly, a patient or surrogate decision maker may request an intervention that the clinician believes to be potentially inappropriate. Potentially inappropriate interventions are those that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Conflicts can often be avoided through excellent communication; however, when conflicts arise and a mutually agreeable solution cannot be reached, such requests should be managed by a fair dispute resolution process. Five leading international, multidisciplinary, critical care organizations have published guidance for handling such disputes in the intensive care unit setting. Although the multi-organization futility statement was developed for use in intensive care units, the definitions and process can be employed in a multitude of healthcare settings and should form the basis of handling such requests in palliative medicine.

568 Ethical Challenges in the Pregnant Burn Patient

Introduction Classically, ethics in pregnancy have revolved around abortion. However, there are numerous issues that require attention including the fetus as a patient, the mother’s autonomy and medical treatment of the pregnant patient amongst others. These are further complicated when the pregnant patient has sustained a traumatic or burn injury. Although there are numerous case reports of managing the pregnant burn patient, there is a paucity of literature that focuses on the ethical challenges in the pregnant patient. Methods We report the case of an 18-year-old engaged female who sustained 60% total body surface area full-thickness burns. She was found to be 6 weeks pregnant with a viable fetus on ultrasound. The pregnancy was not planned, but desired. During the early portion of the hospitalization, she was found to lack capacity for both complex medical decision making and assigning of a surrogate decision maker. Furthermore, her mother only intermittently had custody of the patient when she was a minor, complicating whether she would be the best surrogate decision maker. Medical treatments that would significantly decrease morbidity and mortality would have had a negative impact on the viability of the fetus. Morning sickness compromised the nutrition care of the patient. Ethical issues that arose included capacity for complex medical decision making, the mother’s autonomy, surrogate decision making and whether a surrogate decision maker can make decisions regarding the fetus, the fetus as a patient, and medical interventions of the pregnant patient. Later on in the hospitalization, the patient was refusing many aspects of her care, raising the issue of paternalism in the burn center. Results The patient was later deemed to have capacity for assigning a surrogate decision maker, but not for complex medical decision making. She assigned her fiancée as the surrogate decision maker, although he initially refused. Medical treatments that would significantly decrease morbidly and mortality were instituted even though some were “contraindicated” in pregnancy. A gastrostomy tube was placed through burnt tissue for direct enteral access even though the patient was alert, oriented, and could tolerate oral intake in order to enhance her nutritional status. The burn center adopted a practice of “benevolent parentalism” as a means to overcome the patient’s resistance of medical care and treatments. Conclusions Pregnancy in the burn patient represents a deeply ethically challenging situation which have not been discussed in previous case reports. Ethical guidelines for the management of the pregnant burn patient should be established. Guidelines for surrogate decision making must be followed. In addition, the concept of “benevolent parentalism” must be elucidated and should replace the notion that burn centers are paternalistic.

POLST Signature Requirements: Responding With Compassion While Ensuring Informed Consent

The majority of states require the signature of a surrogate decision maker on a POLST form for a patient who lacks decisional capacity. While commendable in its intention to ensure informed consent, in some cases this may lead the surrogate to feel that they are signing their loved one’s “death warrant,” adding to their emotional and spiritual distress. In this paper we argue that such a signature should be recommended rather than required, as it is neither a sufficient nor necessary condition of informed consent. Additional steps—such as requiring the attestation and documentation of the signing health care professional that verbal consent was fully informed and voluntary—can achieve the ultimate goal of respecting patient autonomy without adding to the surrogate’s burden.