If you suspect that your patient lacks sound decision-making capabilities, consult with the healthcare team to ensure a comprehensive exam is performed. Healthcare team members that should be included in this exam are psychiatrists, nurses, social workers, chaplain services, and primary care and consulting physicians. They’ll evaluate each patient’s case individually to explore the patient’s reasons for refusing life-sustaining treatment and to ensure that the patient fully understands that refusal of life-sustaining treatment will result in death.
If your patient is found to be not competent to make medical decisions, the healthcare team will assess him or her for potential reversible causes, such as profound dehydration, depression, pain, drug combination interactions, and adverse reactions to new medications. Treating these causes may restore competence.
Many healthcare facilities offer the assistance of an ethics committee to direct the healthcare team in situations where the critical or terminally ill patient is deemed incompetent and there are no available family members or surrogates to make decisions when prolonging treatment is futile.
WHO CAN MAKE DECISIONS?
Although patients usually choose family members to make healthcare decisions for them when they become incapacitated, they can delegate this responsibility to anyone. Many patients may have a living will or a durable power of attorney for healthcare document.
A living will is a legal document that an individual uses to make known his or her wishes regarding life-prolonging medical treatments. It can also be referred to as an advance directive, healthcare directive, or a physician's directive.
A durable power of attorney for healthcare is a legal document that identifies a specific person or persons to make medical decisions for an individual in the event he or she becomes incapacitated.
In the absence of a living will or durable power of attorney for healthcare, a surrogate medical decision maker is needed. Both the living will and durable power of attorney for healthcare can be revoked at any time by a competent patient.
TALKING ABOUT SURROGATES
Ask your patients upon admission and as needed if they have a designated surrogate assigned to make healthcare decisions in the event they become incapacitated or are unable to make their own healthcare decisions. In some situations, families may quarrel over who should be granted this decision-making power. You can often help by respectfully and gently reminding the family to concentrate on what the patient wants in the event of his or her incapacitation. This may prevent the family from displacing their anxiety, sadness, or unresolved emotional feelings onto each other or the healthcare team. If family, friends, or loved ones have unresolved emotions involving the patient, it can pose a significant problem when the competent patient elects to refuse life-sustaining treatment.
The primary focus should remain centered on honoring patients’ wishes regarding their health. However, you can offer the assistance of ancillary staff, such as chaplain services, to the patient’s loved ones to help them during this emotional time. With the support of ancillary staff and the healthcare team, the patient’s loved ones often realize that the last “gift” they can give the patient is the difficult and selfless gift of letting him or her go.
If the patient is an adult, surrogates are listed in the following order: spouse, majority decision of adult children, parents, majority decision of adult siblings, or the nearest adult relative.
If the patient is a child, the surrogate is the legal guardian of the child. When the decision to withhold life-sustaining treatment for a child is made by the parents, the healthcare team has the responsibility to seek guidance from their ethics committee and legal team if they feel the decision isn’t in the best interest of the child. This conveys the healthcare facility’s commitment to ensuring the right decision is being made for the patient who’s a minor. In the extremely rare circumstance that the parents’ or guardians’ medical decisions aren't legally deemed to be in the best interest of the child, courts may appoint an independent, impartial healthcare decision maker.
EMBRACING QUALITY OF LIFE
After your competent patient has made the decision to refuse life-sustaining treatment, you should assume a supportive role for the patient and his or her loved ones. The care plan focus should shift from acute care treatment to palliative care maintenance of the patient’s healthcare needs. Palliative care is a holistic specialty area of healthcare that focuses on optimizing the patient’s quality of life by alleviating the symptoms, pain, and stress commonly associated with serious illnesses.
With supportive care from the healthcare team, patients can continue leading an active life filled with activities that bring them joy, such as traveling, hobbies, attending social outings with friends, or spending quality time with their loved ones. Refusal of life-sustaining treatment isn’t about death; rather, it’s about how a patient chooses to embrace his or her life.
By Charlotte Davis, BSN, RN, CCRN
CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.
Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.
Andrea M. Stone, BSN, RN
MICU Direct Care Nurse • VA Medical Center • Nashville, Tenn.