The University of
This handbook has been prepared
by the Hospital Ethics Committee to provide staff with easy access to
information about the Committee and its subcommittee, the Pediatric Ethics
Committee. It also provides information regarding guidelines and policies that
have been adopted by this institution for responding to ethical issues in the
care of patients.
The handbook will be revised and
expanded as needed. Suggestions for revisions or additions are welcome.
Requests for ethics case review
with the Hospital Ethics Committee can be made by contacting the hospital page
operator (ext. 85155) and asking them to page the Ethics Committee team member
on call, as further described in section A1, below.
For your convenience, the
Handbook has been divided into two sections. Part A includes guidelines and
policies adopted by the Hospital Ethics Committee and the Pediatric Ethics
Committee. Part B includes guidelines and policies adopted by other entities at
this medical center (such as the University of Kansas Hospital).
1.
Accessing the Ethics Committees
2. Ethics
Committee
3. Policies
and Procedures of Hospital Ethics Committee
4.
Policies and Procedures of Pediatric Ethics Committee
5.
Patient Rights and Organizational Ethics Committee
6.
Advance Directives
7.
Guidelines for Do Not Resuscitate (DNR) Orders
8.
Pre-Admission and Post-Discharge DNR Orders
9.
Honoring DNR Orders During Invasive Procedures
10.
Ethical Guidelines for Decision-Making: Withholding or Withdrawing Life
Sustaining Treatment (Adults)
11. Ethical Guidelines for Decision-Making: Withholding or
Withdrawing Life-Sustaining Treatment (Children)
12.
Guidelines for Withholding or Withdrawing Life-Sustaining Mechanical
Ventilation
13. Care
of Patients in a Persistent Vegetative State
14.
Recommended Procedures for Determining Brain Death
15.
Research Involving Human Subjects
1.
Patients’ Rights
2. Code
of Ethics and Professional Conduct
3.
Requests for Relief from Participation in Aspects of Care
4.
Privacy/Confidentiality
5.
Release of Information
6. Patient
Denial/No Information Status
7.
Resolution of Professional Disagreements
8.
Donation of Organs, Tissues and Eyes
9.
Informed Decision Making
10.
Refusal of Blood Transfusions
11.
Management of Patient/Family Complaints
12.
Support Services for Patients who are Deaf, Hard of Hearing, or Do Not Speak
English
13.
Patient Self-determination Act of 1990
___________________________________________________________________________
A1. Accessing
the Ethics Committees
The Hospital Ethics Committee
and its sub-committee, the Pediatric Ethics Committee, may be accessed 24 hours
a day by calling the Hospital’s page operator at 588-5155, and asking the page
operator to page the designated team leader (or alternate) of the on-call case
review team. Please be sure to specify which Committee you need (in general, if
you have an issue relating to someone who is under age 18, you probably want
the Pediatric Ethics Committee).
Every member of both committees
welcomes any questions or requests for informal discussion of clinical ethics
at any time. A number of members of these committees have formal training in
clinical ethics and most have served for several years on these committees. A
roster of current members can be obtained from the Chairs or Vice-Chairs of the
respective committee (in the case of the “adult” committee, from Jerry
Menikoff, jmenikof@kumc.edu,
588-7662, or Noreen Thompson, nthomps2@kumc.edu, 588-2038, and in the
case of the pediatric committee, Kathryn Veal, kveal@kumc.edu,
588-5908 or Martha Montello, mmontell@kumc.edu, 588-7432).
A2. Ethics
Committees Mission Statement
The Hospital Ethics Committee of
the University of Kansas Hospital and its subcommittee, the Pediatric Ethics
Committee, serve the entire medical center community by encouraging and
supporting: ethical reflection, mutually respectful dialogue, critical analysis
and, most importantly, standards of conduct which reflect this institution’s
commitment to patient-centered care.
A3. POLICIES AND PROCEDURES: HOSPITAL ETHICS
COMMITTEE
I. Function
The Hospital Ethics Committee (hereafter referred to as “the committee”) will have three functions or roles:
In cooperation with the hospital
administration, its various departments and divisions, and its medical/nursing
and allied health professional staff, the committee will undertake educational
efforts in clinical ethics. Depending on
the availability of resources, the committee will develop or assist others in
the development of lectures, seminars, workshops, courses, rounds, in-service
programs and the like in clinical ethics.
The aims of these educational efforts will be to provide participants
with access to the language, concepts, principles and body of knowledge about
ethics that they need in order to address the complex ethical dimensions of contemporary
hospital practice.
The committee will assist the
hospital and its professional staff in the development of policies and
procedures regarding recurrent ethical issues, questions or problems that arise
in the care of patients. In this role
the committee may provide analysis of the ethical aspects of existing or
proposed policy or assist in the development of new institutional policy in
areas of need.
An important function of the
committee will be its role as a forum for analysis of ethical questions which
arise in the care of individual patients.
In most circumstances these questions concern appropriate care of
patients with diminished capacity to participate in decision making regarding
their care. In this role the committee
will attempt to provide support and counsel to those responsible for treatment
decisions including health care providers, patients, surrogates and members of
the patient’s family.
Case review is particularly
recommended in three specific categories of decision making:
1. decisions
involving significant ethical ambiguity and perplexity in which case review may
provide insight into complex ethical issues;
2. decisions
involving disagreement between care providers or between providers and
patients/families regarding the ethical aspects of a patient’s care; or
3. decisions
that involve withholding or withdrawal of life-sustaining treatment which are
not adequately addressed in policies and procedures included in this Handbook.
In this role the committee will
not act as a decision-making body, but will attempt to assist and to provide
support to those who do have this responsibility. Its role in all such cases shall be advisory.
II. Appointment
and Membership
The committee membership will be
multidisciplinary. A majority of the
membership will be non-physicians.
Additional membership will include as available at least the following
disciplines: nursing, social work, pastoral care, clinical ethics, law,
respiratory care, and dietetics and nutrition.
In view of the unique ethical problems involved in situations involving
pregnant women, one physician member shall be from the Department of Obstetrics
and Gynecology. The Chief Executive
Officer of the Hospital (or designee), the Chief of the Medical Staff (or
designee), and an attorney employed by the
Members will be approved
Committee and the Chief Operating Officer of the Hospital. The Medical Director of Hospital Ethics will
serve as the Chair. The Vice-Chair of
the committee will be chosen by the membership of the committee. It is recommended that the Vice-Chair be
identified from among those who have served on the committee at least one year.
III. Jurisdiction
In view of the establishment of
a Pediatric Ethics Committee as a standing sub-committee (see “Policies and
Procedures of the Pediatric Ethics Committee”), the mandate of the committee
will be to engage in its functions of education, policy development and case
review as these relate to the care of patients who are adults, i.e. 18 years of
age or older. The committee’s jurisdiction will also include the unique ethical
issues involved in decision making involving pregnant women when gestation is
felt to have progressed to the stage of fetal viability. Policies and procedures and all non-case
review activities of the Pediatric Ethics Committee are subject to the review
and approval of the Hospital Ethics Committee.
IV. Procedures
A primary educational emphasis
for the committee is its own education and mechanisms to ensure its continuing
education. The field of clinical ethics
is a new, broad and rapidly evolving one.
In order to maintain an appropriate level of expertise, the committee
will develop means of providing members information about clinical ethics and
access to the rapidly expanding body of literature in this field. Methods may include orientation of new
members, specific reading assignments, an annual retreat, seminars, mock
case/policy review exercises and the like.
In addition, the committee may participate in networking with other area/regional
ethics committees, such as the Greater Kansas City Ethics Committee Consortium
of the
Any educational efforts
undertaken by the committee for members of the hospital staff will be
coordinated with existing educational efforts as much as possible. Primary emphasis will be on assisting
departments and divisions to incorporate material about the committee and the
field of clinical ethics into their existing educational programs and
activities.
At the request of the Chief
Operating Officer of the Hospital, the Chief of Medical Staff, or the Executive
Committee of the Medical Staff, the committee will undertake review of any
existing policy, protocol or procedure; provide analysis of the ethical issues
involved; and, provide recommendations regarding appropriate modifications,
where needed. With the approval of the Chief Operating Officer of the Hospital,
the committee may also undertake such review at the request of any member of
the hospital staff.
In addition, when requested, the committee will assist the
hospital and/or its staff in the development of new policies in areas that
involve significant ethical questions or problems. If the committee feels that
there is a need for policy development in order to address a significant
ethical issue, it will submit a written recommendation to this effect to the
Chief Operating Officer of the Hospital and request permission to develop a
policy statement. Any recommendations for modification of existing policies or
development of new policy must be submitted in writing to the Chief Operating
Officer of the Hospital.
1. Access to
Committee. A case review
team will be available on-call to respond to requests for case review at all
times. A roster of team leaders and
members will be available through the Hospital Operator. A member of the committee will attempt to
have an initial discussion with the person making the request within
twenty-four hours of the request, whenever possible. The Team Leader will
undertake case review only in response to a reasonable and appropriate request
for review by either (1) any of the following persons who is involved in the
case: a member of the medical staff, house staff, hospital staff, or hospital
administration, or (2) the patient, patient’s guardian, surrogate or a member
of the patient’s family. Prior to
proceeding with the consult, the Team Leader will notify the patient’s
designated attending physician of the request for review, discuss the possible
basis for the review and request his/her support and involvement.
2. Informal
and Formal Case Review. Committee
members will be available to provide advice
regarding a case in both an informal and formal manner. The remaining
portions of this section (C) relate only to requests for formal case review. In
the case of a request for informal case review, no documentation of the
comments of any committee member will be placed in the patient’s medical
record. Informal requests for case review will, however, be reported by the
involved committee member to the full committee at the next regularly scheduled
meeting of the committee.
3. Determination
of Need for Review by Full Team. Following the receipt of a
request for case review, the Team Leader will determine whether or not there is
a need to present the case before the full team. In most situations, there is
likely to be no such need, and the Team Leader can, on his or her own, proceed
to review the case, and provide a recommendation, as is otherwise described in
the remainder of this section. Formal case review by the entire team will most
likely be advisable in cases that involve especially complex ethical issues.
4. Preparation
for Review Team Meeting. Following
a decision by the Team Leader that it is appropriate to have review by a team,
the team will consist of two to five members of the committee and will reflect
the multi-disciplinary composition of the committee. The team leader will review the request to
determine the nature of the case, the status of the patient, the ethical
question(s), concern(s) or problem(s) prompting the request and any other
information needed in order to determine if review is appropriate.
If in the judgment of the leader of the case review
team the request is appropriate, he/she will contact the patient’s physician to
discuss the request, to request his/her participation and to schedule the case
review meeting. In addition, absent special considerations, the patient or the
patient’s family or surrogate decision makers, as the case may be, should also
be notified that the case review will be taking place, and invited to
participate. Their decision not to participate, or their objection to the
consult, should not prevent a formal ethics consult from taking place, assuming
the consult is otherwise determined to be appropriate by the team leader. If
the patient’s attending physician believes that ethics case review is not
appropriate, this conflict should be referred immediately to the Chief of
Medical Staff for resolution. In the event of a persistent conflict, the Chief
of the Medical Staff will assist in the orderly transfer of responsibility to
another attending physician who is willing to permit the case review to go
forward.
The members of the team may
determine that it is appropriate to invite other participants to some or all of
the meetings in which the team discusses the case. Among those persons who
might be invited so such meetings are: members of the professional staff who
are directly involved in providing care to the patient; resource personnel with
special expertise; and the patient and/or members of the patient’s family.
If in the judgment of the case
review team, the request for ethics case review is inappropriate, the team
leader will so inform the party requesting review and/or the attending
physician. This action will also be
reported to and reviewed by the full committee at its next regularly scheduled
meeting.
5. Conduct
of Case Review Meeting. At the
meeting the leader of the team will instruct all non-members present regarding
the advisory role of the committee; the intent of the committee to serve as a
supportive forum for those who have the primary decision-making responsibility;
and the need for strict confidentiality of all material presented and
discussed.
If the patient’s attending physician and other
health care providers are present, it will likely be appropriate for them to
present information to the review team regarding the history of the patient,
the present condition of the patient, the prognosis and any other material
believed to be relevant to the case review.
The leader might then find it useful to ask those involved, including
patient/family members if present, to describe what specific ethical questions,
problems or issues prompted the request for case review.
Following appropriate discussion
of these and issues identified by members of the team, the team leader may, if
non-members were present during the earlier portions of the meeting, convene a
“closed” (members only) session in order to develop a specific recommendation
if appropriate.
Members of the case review team may also decide before or after the case review meeting that formal review of the case by the entire ethics committee is appropriate. In this case, the leader of the review team will notify the Chair (or designee) who will convene an emergency meeting of the entire committee as soon as possible.
6. Recommendations. The results of the case review and any
recommendations will be communicated to the individual who requested case
review; to the attending physician; to other members of the staff; and, to the
patient/family as appropriate. Following
these discussions, and with the concurrence of the attending physician, the
team leader will record the results of the ethics case review in the patient’s
medical record. These results will also
be reported to, and reviewed by, the full committee at its next meeting.
V. Meetings
The committee shall meet monthly in addition to any
meetings called for specific case review.
An agenda will be developed by the Chair and distributed one week prior
to the meeting. Meetings which do not
involve discussion of specific case material will be open to any member of the
hospital community. Guests and other
interested parties will be allowed to attend at the discretion of the
chair. For purposes of conducting
business, seven members shall constitute a quorum. Actions of the committee shall be taken by
the vote of a majority of the members attending the meeting. Each member will
be required to attend at least five of the committee’s regularly scheduled
meetings each year. Failure to do so can
be considered to constitute a resignation and the vacancy shall be filled by
appointment of a new member.
VI. Record
Keeping
The committee will maintain
minutes of all of its meetings which will include summaries of all case reviews
and recommendations. Minutes will be
submitted by the chair for approval by the committee and forwarded to the Chief
Operating Officer of the Hospital. Records will not include identifying
information about specific patients, family members, individuals requesting
case review or professional staff participating in the case review process. These records will be maintained in
accordance with hospital policy and applicable law governing the
confidentiality of records of medical review committees.
VII. Liability
The Hospital will take whatever
steps are necessary in order to provide liability protection for committee
members who do not have such protection by virtue of their status as members of
the professional staff.
VIII. Adoption
and Approval of Policies and Procedures
Policies and procedures of this
committee will be reviewed as deemed appropriate by the membership of the
committee. Proposed modifications of
approved policies or procedures will be submitted to the committee in writing
at least four weeks in advance of a regularly scheduled meeting. Following approval by the committee, they
will be forwarded to the Chief Operating Officer of the Hospital for review and
approval.
A4. POLICIES AND PROCEDURES: PEDIATRIC ETHICS
COMMITTEE
I.
Introduction
The Pediatric Ethics Committee (PEC) is a standing
sub-committee of the Hospital Ethics Committee.
The development of such a committee was recommended in federal
legislation (Child Abuse Amendments of l984: P.S. 98-457) dealing with
so-called “Baby Doe” cases, i.e. treatment abatement decisions regarding the
care of imperiled and/or handicapped newborns.
Other than in its case review function, all actions by the PEC must be
submitted for review and approval by its parent committee.
II.
Jurisdiction
The jurisdiction of the Pediatric Ethics Committee includes
clinical situations involving: (a) infants: children from birth to less than
two years of age; (b) children or "minors:" of age at least two
years, and less than eighteen years, unless otherwise "emancipated." Emancipated minors include individuals who are
self-supporting and/or not living at home; any minor who is pregnant or a
parent; or any minor who has been declared emancipated by a court. Minors may also be treated as "mature
minors” in some situations (rarely applies to a hospitalized minor); or, can be
“medically emancipated” in situations involving selected legally designated
medical disorders, e.g., sexually transmitted diseases, drug or alcohol abuse,
and the like.
III. Purpose
A.
Educational
To assist the Department of Pediatrics and other
departments and divisions which provide services to children in development of
appropriate educational programs in clinical ethics for all providers of care
to pediatric patients. Such programs
would have as their goal the fostering of a sensitivity and an ability to
respond appropriately to the ethical aspects of the care of patients and
families.
B.
Policy Review and Development
To assist the medical center and it’s component
institutions in the review and development of institutional policies relating
to the care of patients under the jurisdiction of the PEC.
C.
Case Review
To serve as a forum for discussion and analysis of complex
individual cases, particularly those involving withholding or withdrawal of
life-sustaining treatment; and for discussion and resolution of conflicts regarding
the ethical aspects of a patient’s care among members of the staff providing
care to the patient; or conflict between staff and patient or family members.
The committee will also undertake retrospective review and analysis of selected
cases as further described herein.
D.
Responding to Reports of Medical Neglect of
Disabled Infants
To serve as a mechanism by which cases can be reviewed in
which a report of “medical neglect” has been received by the Kansas Department
of Social and Rehabilitative Services (SRS) regarding an infant patient
hospitalized at KUMC. (See Medical Neglect of Disabled Infants; Policies and
Procedures; Kansas Dept. SRS and Child Abuse and Neglect Amendments of l984;
P.L. 98-457; Fed Reg 50, No. 72)
IV. Committee Structure
A.
Membership
Membership shall be representational of the pediatric care
community and shall be multidisciplinary.
The PEC will have at least twelve members. Physician members will
include: one from the Division of Neonatology; one from the Division of
Oncology/Hematology; one from the Division of Cardiology or Intensive Care; one
from the Ambulatory Division; and a Pediatric Resident. Nurse members will include one from Nursing
Administration; and one each from neonatal and pediatric nursing staffs. In shall also include as available the
following disciplines: social work, pastoral care, and clinical ethics. The committee will also identify and nominate
for appointment at least one community representative who is not an employee of
the
B.
Meetings
The committee will meet monthly in addition to any meetings
called for specific case review. Written
notice of regularly scheduled meetings and an agenda will be distributed one
week prior to the meeting. For all
regularly scheduled meetings, a quorum shall be six members. Meetings which do
not include review and discussion of specific cases will be open to anyone
expressing an interest in the subject being discussed.
C.
Minutes/Records
The chair (or designee) shall keep minutes of all
meetings. Minutes of the meetings will
be maintained by the Chair of the committee. In order to maintain the privacy
of patients and their families, patients will be identified by initials only.
The Chair will maintain a master list of all reviewed cases should more
complete identification of cases be necessary.
Copies of minutes will be distributed to all members for review and
approval and sent to the Clinical Ethics Committee. Any other request for
access to committee minutes or materials shall be considered by the Chair in
consultation with the Office of Legal Counsel.
D.
Administration
Administrative support for the committee will be provided
by the office of the Chair of the Department of Pediatrics. In addition to its minutes, the committee will prepare an annual
report of its activities which will be submitted to the Department of
Pediatrics and to the Hospital Ethics Committee.
V. Procedures for Case Review
A.
Prospective Case Review
Prospective review—review prior to the undertaking of a
particular course of action in the treatment of a patient—will be conducted by
the committee when indicated.
1.
Mandatory Case Review
Mandatory review will be undertaken in response to a report
received by the Kansas Department of Social and Rehabilitative Services,
Division of Child Protection which alleges “medical neglect” of a hospitalized
infant. Following its review of the
case, the Chair will report the findings and recommendations of the committee
to the designated hospital liaison to the Department of SRS.
2.
Recommended Case Review
Case review may be appropriate in situations in which a
proposed course of treatment of a patient involves the withholding or
withdrawal of life-sustaining medical or surgical treatment. [See section A11,
“Ethical Guidelines for Decision Making: Withholding or Withdrawing Life
Sustaining Treatment in the Care of the Pediatric Patient.”] Case review is
recommended in cases in which there is unresolved disagreement regarding the
ethical aspects of a proposed course of treatment involving a pediatric
patient, the parent(s)/guardian and/or the professional staff providing care to
the patient.
3.
Discretionary Case Review
Since one of the essential responsibilities of the
Committee is that of assisting patients, families and staff facing difficult
ethical decisions regarding health care, it is anticipated that most requests
for case review will arise in a voluntary context. Requests for review may be made by the
patient, the parent(s)/guardian, or any member of the professional staff
providing care to the patient.
B.
Review Procedure
The primary role of the committee in case review is to
provide advice and support to those who have primary responsibility as decision
makers, i.e. the patient, the parent(s)/guardian and the professional staff
providing care. The committee should not
be viewed as a decision-making body.
Even in situations in which the committee plays a role in identifying
ethical problems in proposed courses of treatment, the committee will not
recommend specific alternative treatments to be undertaken.
1.
Case Review Team
Upon notification to the Chair or designee of a case
requiring mandatory review or following receipt of a request for review, the
chair will appoint an ad hoc Case Review Team.
The team will consist of three to five members of the committee,
including at least one physician, and will reflect the multidisciplinary
composition of the committee.
2.
Involvement of the Attending Physician
The individual appointed to lead the case review team will
review the request to determine the nature of the case, the status of the
patient, the ethical question, concern or problem prompting the request and any
other information needed in order to determine if review is appropriate. If in the judgment of the leader of the case
review team the request is appropriate, he/she will contact the patient’s
attending physician to discuss the request, to request his/her participation
and to schedule the case review meeting.
If the patient’s attending feels that ethics case review is not
appropriate, this conflict will be referred to the Chief of the Medical Staff
for resolution. In the event of
persistent conflict, the Chief of the Medical Staff will assist in the orderly
transfer of responsibility to another attending physician.
3.
The Case Review Meeting
The case review meeting will be held within twenty-four
hours of the request for case review whenever possible. Any member of the hospital staff who is
directly involved in providing care to the patient or family may be invited to
attend the meeting. In appropriate
circumstances, the patient, his/her parent(s)/guardian and other members of the
patient’s family may also be allowed to be present for at least part of the
meeting if they desire. At the meeting
the leader of the team will instruct all non-members present regarding the
advisory role of the ethics committee; the intent of the committee to serve as
a supportive forum for those who have the primary decision-making
responsibility; and the need for strict confidentiality of all material
presented and discussed. The patient’s
attending physician and other health care providers will be asked to present
information to the review team regarding the history of the patient, the
present condition of the patient, the prognosis and any other material felt to
be relevant to the case review. The leader
will ask those involved, including the patient/family members if present, to
describe what specific ethical questions, problems or issues prompted the
request for case review.
Following
appropriate discussion of these and issues identified by committee members, the
team leader may convene a “closed” (members only) session in order to develop a
specific recommendation if appropriate.
Members of the Case Review Team may also decide before or after the case
review meeting that formal review of the case by the entire ethics committee is
appropriate. In this case the leader of
the review team will notify the Chair (or designee) who will convene on
emergency meeting of the entire committee as soon as possible.
4.
Recommendations
The results of the case review and any recommendations will
be communicated to the individual who requested the case review; the attending
physician; the patient/patient’s family and to appropriate members of the
staff. Following these discussions, and
upon request of the attending physician, the team leader will record the
results of the ethics case review in the patient’s medical record.
C.
Retrospective Case Review
In order to evaluate its utilization and effectiveness, the
Committee may undertake periodic retrospective review and analysis of selected
cases or categories of cases. Examples
would include: cases in which a “Do Not Resuscitate” (“DNR”) decision had been
made; cases in which decisions were made to withhold or withdraw a medical or
surgical intervention; cases in which the Committee had provided prospective
case review; and others as appropriate.
The results of this review would be used to identify educational needs;
to evaluate existing policies or procedures; and, to determine areas in which
existing policy requires modification or in which policies need to be
developed.
VI.
Adoption and Approval of Policies and Procedures
Policies and Procedures of the PEC will be reviewed
annually. Suggested modifications of
approved policies or procedures will be submitted to the Committee in writing
at least four weeks in advance of a regularly scheduled meeting. Following
approval by the Committee, they would be forwarded to the Hospital Ethics
Committee for review and then forwarded to the Chief Operating Officer of the
Hospital for approval.
A5. Patient Rights and
Organizational Ethics Committee
The goal of this committee is to help improve patient outcomes by respecting each patient’s rights and conducting business relationships with the patient and the public in an ethical manner.
Patients have a fundamental right to considerate care that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values. These values often influence patients’ perceptions of care and illness. Understanding and respecting these values guide the provider in meeting the patient’s experience of and response to care. Thus, access, treatment, respect and conduct affect patient rights.
The standards address the following processes and activities:
1. Promoting consideration of patient values and preferences, include the decision to discontinue treatment;
2. Recognizing the hospital’s responsibilities under the law;
3. Informing patients of their responsibilities in the care process; and
4. Managing the hospital’s relationships with patients and the public in an ethical manner.
The multidisciplinary membership of this committee includes but is not limited to members from the following departments: Patient Relations, Medicine, Nursing, Social Work, Allied Health Sciences, Interpreter Services, Pastoral Care, Quality Improvement and Risk Management.
At least one member of the Hospital Ethics Committee and one member of the Pediatric Ethics Committee will serve on this committee.
I. Introduction
This statement seeks to provide
guidance to members of the hospital staff and to promote increased support and
recognition of the concept of the autonomy or right of self-determination of
the patients of this
An advance directive is a
document allowing a person to give directions about future health care, or to
designate who should make decisions regarding care if he/she should lose the
capacity to do so. There are at present two types of documents used for this
purpose. One type is used to provide health care providers and institutions
directives regarding treatments that a person wishes to receive or forego should
he/she lose decision-making capacity, such as a "living will". The
other type allows a person to designate a "proxy" or
"surrogate" who would be authorized to make treatment decisions on
behalf of the individual should he/she be unable to make such decisions. These
two types of directives may also be incorporated into a single form. Such a
form is available through Hospital Administration, Department of Social
Services, or the committee.
II. Treatment
Directives and Living Wills
Any individual with the capacity
to make decisions concerning health care can prepare a document providing
directions about treatments he/she might wish to receive or to forego in the
event of his/her future incapacity to make such decisions. Such a document
might indicate general treatment preferences, include a list of specific
treatments, contain statements about palliative care, appoint another person to
serve as "proxy" or surrogate (see following section: Proxy
Directives) and might include a variety of other provisions. Individuals
preparing such documents must inform appropriate health care professionals,
family members, friends, and health care institutions to which they are
admitted of the existence and contents of any such directive. Such a directive
should also be reviewed and revised regularly or as required. The individual is
also free to revoke the directive at any time.
The State of
Treatment directives or Living
Wills which are prepared by individuals who are not "qualified
patients" as defined by the Kansas Natural Death Act, or documents which
are not executed according to the provisions of this law, are not legally
binding on health care providers or institutions. However, such a document may
well provide important insight and helpful guidance to health care providers
and family members or surrogate decision-makers in the event that the patient
loses the capacity to participate in decision making. Knowledge of the patient's
values, preferences and wishes can be essential in evaluating the ethical
aspects of treatment decisions.
It is also important for health
care providers to understand that completion of a directive does not in itself
change the interests or status of a patient. For example, providers should not
make assumptions about treatment preferences based on the mere existence of a
Living Will, but rather see the directive as an instrument by which an
individual seeks to provide direction regarding certain specific treatment
options.
It should also be understood that a competent adult patient need not utilize this mechanism in order to have his/her present directives regarding utilization of life sustaining treatments respected. Competent adults clearly have the legal and ethical right to forego any or all life sustaining procedures.
III. Proxy Directives and Durable Power of Attorney
Alternative means for providing
advance directives are instruments that allow an individual to appoint another
person to make his/her health care decisions in the event of the loss of
capacity to do so. Any individual can prepare a written statement authorizing
another person to act as their proxy or surrogate. Such a designation can be
very helpful to health care providers since it identifies for them the
appropriate surrogate decision maker. This surrogate can then participate on
behalf of the patient in addressing the ethical aspects of decision making and
in making decisions regarding utilization of life-sustaining treatments in persons
who are no longer capable of participating in the decision making process.
In the State of
IV. Implementation
An essential aspect of
implementation of this policy will be the willingness of health care providers
and the institution to make information regarding advance directives available
to patients. In particular, physicians working with individuals facing
life-threatening, chronic, and/or terminal illness have the responsibility of
encouraging patients to make plans about treatment in advance of a crisis and
to engage in an on-going dialogue regarding mechanisms by which their values,
preferences, and directives might be respected in the event of their loss of
capacity to participate in decision making. It will also be essential that the
information about advance directives be incorporated into in-service and other
educational programs and into patient education programs and materials.
It will also be necessary for each department and division to develop procedures necessary to allow these advance directive mechanisms to be effective. Admission procedures will need to be developed for ascertaining if the patient has completed an advance directive document. Hospital and Foundation medical record personnel will need to develop mechanisms for incorporation of such documents into the records of both Hospital and Foundation patients.
The utilization of
cardiopulmonary resuscitation (CPR) has become routine in almost all hospitals
in the
These guidelines recommend the
procedures to be followed in making and implementing a decision to withhold
utilization of these emergency resuscitation techniques. If a patient has
included directives regarding such treatment as part of an "advance
directive" such as a Living Will, the provisions of that declaration and
related legislation will apply. (See section A6, “Advance Directives.”)
II. Definitions
"Competent Adult
Patient" - patient of at least eighteen years of age who is determined to
have the capacity to make his/her own treatment decisions, i.e. the capacity to
understand relevant information, reflect on it in accordance with his/her
values, and communicate with caregivers.
"Incompetent Adult
Patient" - patient who has been legally declared incompetent or a patient
who is determined to have an irreversible lack of decision making capacity.
"Pediatric Patient" -
patient of less that eighteen years who is not otherwise legally emancipated.
"Cardiopulmonary Resuscitation" - emergency treatment of acute failure of cardiac or respiratory systems (cardiac and/or respiratory "arrest") usually including at least one of the following procedures: chest compressions ("closed chest" cardiac massage), intubation/ventilation, and cardiac defibrillation.
Evaluation and Discussion - A DNR order should be
considered in any clinical situation in which resuscitation would likely be
futile or in which the utilization of such treatment would be inappropriate in
view of the patient's diagnosis and/or prognosis. The patient's attending
physician has the primary responsibility to evaluate the patient and to
facilitate discussion with patient and/or family in situations in which such an
order is judged to be appropriate. Nursing staff can also play an important role
in this evaluation process and in supporting discussion with patient and/or
family.
Identification of Decision-maker - If the patient is a
competent adult, discussion and decision-making regarding a DNR order need only
involve the patient. A DNR order for such a patient should be written only with
his/her informed consent. If the patient has been adjudged to be mentally
incompetent by a court, the primary decision-maker is the patient's guardian.
If the patient is determined to lack the capacity to participate in the
decision-making process, the physician should determine if the patient had
previously indicated a choice of the appropriate individual to act as
decision-maker or seek to identify a member of the patient's family who will
act as a surrogate decision-maker.
Making the Decision - The decision about the DNR order
should be made in accordance with the expressed wishes of the patient or in
accordance with the explicit directives of the patient, i.e. "advance
directives" or in accordance with the known preferences and values of the
patient. Lacking any of the above, the decision should be based on a careful
and reasoned consideration of the patient's interests.
Pediatric Patient - Decision-making regarding utilization
of CPR for pediatric patients should be made according to the previously
approved guidelines. (See section A11, "Ethical Guidelines for
Decision-making: Foregoing Life Sustaining Treatment in the Care of the
Pediatric Patient.")
Conflict/Disagreement - Since decision-making regarding
DNR orders will frequently involve shared responsibility, there may be
situations in which there is disagreement among health care providers or
between providers and surrogate decision makers regarding the appropriateness
of a DNR order. Such disagreements should be discussed and examined thoroughly
and efforts made to achieve agreement. If they cannot be resolved, additional
consultation and/or referral to the Ethics Committee should be considered.
All orders not to resuscitate must be written or signed by
the patient's attending physician on the Physician's Order Sheet. It is
imperative that caregivers and patients/families realize that resuscitative
measures (calling a "Code Blue" and initiation of CPR) will be
performed routinely on all patients for whom there is not a written DNR order.
In addition to the order "Do Not Resuscitate
(DNR)", the physician may wish to modify the order by including
instructions regarding specific resuscitative interventions.
Verbal DNR orders can be received only by a licensed
physician and must be witnessed. Verbal or telephone orders must be
countersigned within 12 hours by the attending physician who gave the order.
In addition to the order itself, physicians must make
certain that the patient's medical record provides adequate documentation of
the evaluation, discussion and decision-making process. A specific entry
attendant to the order should be considered which includes: a short description
of the patient's condition and prognosis, reference to any consultations which
corroborate a DNR order, reference to discussions concerning the order with the
patient, guardian, and/or family.
DNR orders should be reviewed and renewed at regular
intervals. Since the condition of a critically ill, hospitalized patient may
change, this interval should not exceed one week. At each renewal, the medical
staff members should critically re-evaluate the basis for the DNR order,
consult again with the patient or surrogate decision-maker, and rewrite the
order if appropriate. Caregivers and patients/surrogates should also be
informed that a decision to forego resuscitative treatment can be revoked at
any time by the patient.
A. Level of Care.
Although a DNR order may be part of an overall treatment
plan which involves reduction of the level or intensity of care the patient is
receiving, caregivers, patients and families must understand that the order not
to resuscitate has no implications for any other treatment decisions. Patients
with DNR orders on their charts may remain candidates for all vigorous care,
including intensive levels of care.
B. Terminal Illness.
It should also be understood that a candidate for a DNR
order need not be suffering from a terminal illness. Many chronically ill,
debilitated or elderly patients may wish to forego this particular form of
life-sustaining treatment.
C. Surgery, Anesthesia, and Invasive Procedures.
When a patient with a DNR order is to undergo surgery,
receive an anesthetic agent and/or be subject to an invasive procedure that may
be associated with risk to cardio-pulmonary function, it is the obligation of
the physician performing such procedures to discuss the DNR status with the
patient or surrogate decision-maker as part of the consent process. (See
section A9, "Honoring DNR Orders During Invasive Procedures.")