• Advance directive → instructions given by an individual specifying what should be done for his or her health should he or she no longer be able to make decisions

• Living will → addresses specific directives regarding treatment course to be taken by caregivers (may forbid certain interventions—e.g., intubation, CPR) if pt unable to give informed consent

• Health-care power of attorney → appoints an individual (a proxy) to make health-care decisions should pt become incapacitated

• Mental competency → legal term; pt’s ability to make rational informed decisions

• Adults are presumed to be competent

• Only a court can declare a person incompetent

• Physician opinion of incompetency = opinion only

• Brain death

• Definition = permanent absence of brain & brainstem function

• Must rule out confounding factors (drug/toxins, hypothermia <32 degrees, metabolic derangements, Guillain–Barré syndrome, locked-in syndrome)

END-OF-LIFE ISSUES

• DNR/DNI is not automatically suspended during surgery

• In case of DNR/DNI, must clearly document that status & communicate with medical & nursing staff to avoid providing unwanted treatment

• Specific measures not to be performed should be clearly documented by a physician (e.g., intubation, chest compressions, defibrillation, invasive line placement, vasopressors)

• In cases of medical futility: Physician has duty to counsel medical decision maker (next of kin, legal guardian) & explain possibility of DNR/DNI status & potential for withdrawal of life-sustaining measures

• Medical decision maker should receive info about pt’s prognosis before making end-of-life decisions for the patient

PEDIATRIC/MINOR (<18 YRS) PATIENTS

• Physicians must obtain informed consent from a parent or surrogate before a child can undergo any medical intervention

• Consent for pregnancy termination procedure dependent on state laws

• Pediatric patients’ wishes should be included in decision-making process when appropriate

JEHOVAH’S WITNESSES (JW)

• JW patients usually will not accept blood or blood products (even under lifesaving circumstances)

• Obtain informed consent, discuss options, & document preoperative discussion with pt regarding products pt will/will not accept

• Special legal considerations may apply to minors, incompetent individuals, emergency procedures

• Physicians may opt out of providing care for a JW patient

• JW may agree to some blood conservation (special cell-saver) techniques

• Generally prohibited

• Allogenic transfusion of whole blood, red cells, white cells, platelets, plasma

• Autologous (preoperative donated) blood/blood products

• May be acceptable (discuss with JW)

• Cell-saver scavenging, cardiopulmonary bypass, dialysis, plasmapheresis

• If blood does not come out of a continuous circuit with pt

• Epidural blood patch

• Blood plasma fractions

• Albumin, globulins, clotting factors—factors VIII & IX

• Erythropoietin

• PolyHeme (blood substitute solution—chemically modified human Hgb)

• Hemopure (blood substitute solution—chemically stabilized bovine Hgb)

DISCLOSURE AND APOLOGY—COMMUNICATING ABOUT UNANTICIPATED EVENTS

Triggers for Disclosure

• Interception of a potential error (e.g., wrong site identified during time out)

• Error with no harm (e.g., drug dosing error)

• Adverse/unanticipated event (e.g., failed intubation)

• National Patient Safety Foundation guiding principle:

“When a health care injury occurs, the patient … is entitled to a prompt explanation of how the injury occurred and its short- and long-term effects. When an error contributed to the injury, the patient … should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors … will be investigated so that steps can be taken to reduce the likelihood of similar injury to other[s].” (11/14/00)

• The Joint Commission accreditation standards: require the disclosure of sentinel events and other unanticipated outcomes of care

Quick Guide to Breaking Bad News

• Use a quiet, private area free from distractions

• Provide a brief review of the event/unanticipated outcome; Don’t speculate, stick to facts

• Be frank, but kind in your delivery of news

• Pause after your disclosure; silence is OK; Give the patient time to react

• Gauge readiness for more information

• Invite questions

• Assure that physician follow-up is available

• Apologies:

• Avoid these ineffective phrases: “I’m sorry, but…” or “I’m sorry you feel …” → does not show apology for the error, shows sorrow/indifference toward the feelings of the patient/family

• Avoid placing blame

• Be an active listener and signal general agreement when appropriate “yes, good point”, or “I hear what you are saying”

• Practice the 3R’s: Restate, Respect, Respond “Let me repeat, your point is …”

Note: If an adverse event occurs, but was NOT the result of an error or omission, there is no need to apologize; review facts, explain findings and let the pt know it is OK to disagree.

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