Surrogate decision making

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Surrogate decision making

  1. 1. SURROGATE Shaden Eldakar
  2. 2. • Basic Definitions • Advance Directives and use • Surrogate statutes • Vermont’s take • History in law OUTLINE
  3. 3. • Autonomy – Ability to act with intention and understanding, separate from another person or controlling force – Underlying concept of informed consent • Substituted Judgment – Choosing what the patient would have chosen • Best Interests – Unknown patient preferences or patient has never had capacity – Decision is made in evaluating what may be in the best interest of the patient DEFINITIONS
  4. 4. • Guardians – Appointed by the court • Agents – Appointed by the patient • Surrogates – Appointed by the clinician DEFINITIONS
  5. 5. • Sanctioned in 1976 – Uphold patient autonomy • Patient Self Determination Act in 1990 – Medicare institutions – Provide information to patients HISTORY OF ADVANCE DIRECTIVES
  6. 6. • 5-25% of patient have completed Advance Directives • 25-45% of hospitalized patients lose capacity WHY IS THIS IMPORTANT?
  7. 7. • Primary purpose is to make clear that the typical method of utilizing family members as decision makers is legally ok • Avoid costly guardianship hearings SURROGATE STATUTES
  8. 8. • Implemented with an executed advance directive • Operative when patient loses capacity • Priority of persons who may serve as a surrogate SURROGATE STATUTES
  9. 9. • We don’t have a statute!?! • Why fix something that isn’t broke? WHAT DOES VERMONT DO?
  10. 10. • Property law • “interested individual” • COLST, hospice VERMONT
  11. 11. • More than one decision maker • Physicians are involved • Focus on the core values of the patient – “tell me about your loved one” • “This is what we would recommend… does that seem right to him/her?” SUBSTITUTED INTEREST MODEL
  12. 12. • Predicting who will need decision making is difficult – Cognitive impairment, cva and NH residents • Completed ADs more likely to receive care of preference – Increase in AD completion – ADs for typical course, DPHOA for unforeseen AD AND DECISION MAKING
  13. 13. • Hypothesis: Surrogates “are not better than chance” at substituted judgment. • Asked patient/surrogates what they would do in certain scenerios – Assessed the accuracy of patient designated vs legally assigned surrogates – Impact of prior discussions of patient’s preferences ACCURACY OF SURROGATE DECISION MAKERS
  14. 14. • Surrogates failed to predict patient preference 1/3 of the time • There was no difference in patient designated vs legally designated surrogate • Previous discussions did not improve accuracy of the decision RESULTS
  15. 15. • State do not have to accept substituted judgment of family members if they feel there is insufficient proof that this represents the patient’s desires DUE PROCESS CLAIM
  16. 16. • Nancy Cruzan • Cruzan vs Director, Missouri Dept of Health WHY IS THIS IMPORTANT?
  17. 17. • Karen Ann Quinlan • Devote Catholics • Extraordinary means WHY IS THIS IMPORTANT?
  18. 18. • Mary O’Connor • Multiple CVAs, NH resident WHY IS THIS IMPORTANT?
  19. 19. • Terry Schiavo • 1990 cardiac arrest, PVS • 1998 feeding tube removal requested • 2001 feeding tube was removed for the first time • 2005 FT removed • 14 appeals and numerous motions, petitions, and hearings in the Florida courts; five suits in federal district court WHY IS THIS IMPORTANT?
  20. 20. • Patient Autonomy- Advance Directives • State statutes hope to avoid guardianship CONCLUSIONS
  21. 21. • There’s more work to be done.AND…
  22. 22. • 1 Bliss, Sally. Personal interview. 2/2014 • 2 Brody, H et al. Withdrawing Intensive Life-Sustaining Treatment- Recommendations for Compassionate Clinical Management. New England Journal of Medicine. 2007. 336;9: 652-657 • 3 Cruzan by Cruzan v. Director, Missouri Department of Health. 1990. • 4 Health Care Decisions Act Summary. http://www.uniformlaws.org/ActSummary.aspx?title=Health-Care %20Decisions%20Act. Accessed 2/2014 • 5 Making Medical Decisions for Someone Else, A Vermont Handbook. Vermont Ethics Network. 2009. • 6 Matter of O’Connor. New York Court of Appeals. 1988. • 7 Matter of Storar. New York Court of Appeals. 1981. • 8 Pope, T. Making Medical Decisions for Patients without Surrogates. New England Journal of Medicine. 2013. 369; 21: 1976-8. • 9 Silveira, M, et al. Advance Directives and Outcomes of Surrogate Decision Making before Death. New England Journal of Medicine. 2010. 362; 13: 1211-18. • 10 Sulmasy, D., et al. Substituted Interests and Best Judgements. Journal of American Medical Association. 2010. 304; 17: 1946-7. • 11 Torke, A., et al. Scope and Outcome of Surrogate Decision Making Among Hospitalized Adults. Journal of American Medical Association. 2014. Published electronically January 20, 2014 • 12 Vermont Statutes Online. http://www.leg.state.vt.us/statutesmain.cfm. 2/2014 REFERENCES

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