December 14, 2001

VUH stressing documentation of patient wishes

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Dr. MacRae Linton

Advance directives are documents patients complete when they are healthy, in anticipation of a time when they will become sick. The purpose is to help ensure that when health care decisions need to be made, patients’ preferences will be better known and can help guide the decisions.

There are two types of advance directives: the living will and the durable power of attorney for health care. The living will allows patients to state what kind of care they want at the end of life, when they are terminally and irreversibly ill and are unable to participate in specific health care decision-making. The durable power of attorney for health care simply allows a patient to name another person to make all health care decisions on the patient’s behalf, including but not limited to end of life decisions, whenever the patient is incapable of doing so.

Today, Vanderbilt is doing more to ensure that patients’ advance directives, if they exist, are retrieved and inserted into patients’ medical records.

Since December 1991, federal law has mandated that hospitals and other health care organizations collect and document advance directive information for patients upon admission to the hospital. This requirement has also been adopted and enforced by JCAHO (Joint Commission for Accreditation of Healthcare Organizations) since 1992.

More recently, Vanderbilt physicians have been encouraged to discuss advance directives with all of their patients as part of the routine initial patient history gathered when patients are first seen in the hospital or the clinic. This way, there is a better chance that patients’ preferences will be well known before the time they are to be acted upon.

Unfortunately, successfully gathering and documenting patients’ advance directive information is a task that doesn’t always work as planned. In the summer 2000 inspection by JCAHO, VUH was found not to be following through when, upon admission, patients said they had advance directives but didn’t have copies with them and would have to retrieve them. A task force was established to study the problem and issue recommendations.

The solution involved revising the form used to keep track of patients’ advance directive information. Now, when a VUH patient replies that he or she has an advance directive, the form prompts the admitting clerk or nurse to take various measures to ensure that a copy of the directive makes its way into the patient’s chart. The measures include placing a follow-up reminder in WizOrder. While awaiting retrieval of an advance directive, as a stop-gap, patients’ preferences may be directly documented on the tracking form.

The learning center created a poster and information packets to inform admitting clerks and nurses about use of the new form. Use of the new form was checked by utilization management staff (who review medical records throughout the hospital in the course of gaining insurance company authorization for continued admission). Results of the audit were reported monthly to patient care units and the patient care services board. “The reports really helped awareness of this issue,” said Mary Reeves, director of medical information services and chairman of the task force.

In fact, the results were dramatic. In May only 64 percent of the checked charts had either an advance directive or the new form properly used, but by August compliance had risen to 94 percent.

Talk it out

“It’s important that patients and providers alike recognize that a living will won’t give patients complete control over their death,” said Stuart Finder, Ph.D., assistant professor of Medical Ethics and director of the Center for Clinical and Research Ethics. “Rather, it’s a way for patients to let others know how they see their death. It can help stimulate honest, direct conversations between doctors and patients. A living will can also help families come to grips with the dying of a loved one.”

Such open conversation is especially important in the highly charged settings of end of life care, when patients, families, physicians, and nurses are dealing with the impending death of the patient.

While the living will and the durable power of attorney for health care, as recognized legal documents, may be able to preempt legal conflict about what to do in end of life situations, they don’t necessarily remove or diminish the moral conflicts often associated with end of life care. Here, then, is where open dialogue between patients and their physicians about issues of dying and death, when patients are still healthy and able to express their preferences, is so vital.

“We need to continue to educate our medical staff, nursing staff and our community about the importance of dialogue about these important issues,” Finder said.

Vanderbilt’s clinical ethics consultation services is a program of the center for clinical and research ethics and is available to doctors, nurses, patients, family members and all others involved in patient care at VUMC. If called in, Finder said, “What we will do is to try in some sense to clarify what is going on: Is there a lack of communication? Is there a moral difficulty? Who has the most at stake and can we get the parties to speak to each other about what to do?” Contact the service by calling 6-2686, or by paging a clinical ethics consultant: Mark Bliton, pager 748-0258; Stuart Finder, pager 747-7324.