Mrs. C. & Advance Directives

In reviewing this case, I didn't come across any advance directives in the medical records. The Centers for Medicare & Medicaid Services requires all health care professionals or organizations that participate in those programs to address advanced directives with the patient. This requirement is related to the Patient Self Determination Act discussed in the previous post. What does this mean if you are a physician or home care agency? The intent and spirit of the law is that the health care provider ask the patient if they have advance directives. If they do, it is requested that a copy be provided for the file. If they do not, the health care provider will provide counseling to recommend and assistance to complete if needed. Anecdotally in my clinical experience, I do not see the "push" to provide the assistance to get the paperwork completed. There is a tremendous amount of literature that discusses the lack of advance directives for the elderly. There is no consensus in the literature that I reviewed for a reason that advance directives are not routinely signed. Some articles cite a need for more education of nurses and doctors of the importance of "pushing" the issue with their patients. Other literature discusses the need for assistance and education for elderly and low income populations. "End of Life" planning is not a topic that is easily discussed and many people want an choose to "put if off".



In the case of Mrs. C., there were no written advance directives. The testimony by family and friends was that Mrs. C wanted to die in the home that she spent her whole life in. Her son intended to honor that wish. Substituted Judgment was in place at this time.There was no documentation in either the physician's or home care agency's records that this was in place. The physician and the home care agency followed the plan to keep her at home until a week before her death when the nurse practitioner from the physician office discussed nursing home placement. This discussion was precipitated by communication from the home care agency about her poor physical condition. Neither health care professional documented any support or education for the family about palliative care or the need for hospice care. Adult Protective Services was called by the physician's office in the spirit that the son was not taking proper care of his mother. The son was not told of the referral nor counseled on the care issues for his mother.



On the day that Mrs. C died, the sheriff made a visit to the house as is customary in that community when 911 is called and hospice was not involved. He was shocked by her emaciated condition and bed sores. Four years later the son and granddaughter in-law were indited for manslaughter in her death.



Would an advance directive have made a difference? I am not sure. There is no documentation to reflect a disagreement between health care providers and the family. The discussion about nursing home placement does reflect some concerns by the physician, but Mrs. C did not go to a nursing home.The son stood by his beliefs.



The ethical issues that I see in this case are: