In this second part, a more in-depth examination of the legal framework underlying the decision-making process in the management of a patient at the end of life was therefore presented. Building on the issues of consent and mental performance explored in Part 1, it provides readers with a range of opportunities to further explore legal considerations related to end-of-life care and to address issues such as advance planning, ADRTs and DNACPR decisions. Paramedics may also be called to patients for whom the prospect of death is the unexpected result of a traumatic injury or medical emergency and for whom there was no reason to participate in advance planning or consider ADRTs. In these cases, while paramedics should ideally be able to actively involve the patient in the decision-making process (see Taylor and Brogan (2020) for a more in-depth discussion of the informed consent imperative), they rely on information from other sources and must ensure that their decision-making is consistent with best interest principles. These principles are set out in the Mental Capacity Act, 2005 (Taylor, 2016) and reflected in the section “What happens if the patient is incapable of giving consent in an emergency situation?” in the first part of this article (Taylor & Brogan, 2020). (2) Advisory documents should be based on validated worksheets to ensure reasonable confidence that end-of-life treatment preferences can be identified and recorded fairly and effectively and are applicable to medical decisions. Physicians should recognize the steps patients can take to ensure that their end-of-life wishes are respected during medical treatment. The suggestion that patients request legal documents about their wishes for care and treatment eliminates the doubts or burdens of spouses and family members in certain situations. The responsibility for this decision rests with the most senior attending physician, but to the extent possible, it should allow for consensus with the other clinicians present. There is also a “presumption” (BMA et al, 2016: 10) to discuss with the patient or their representatives and justify the decision to the patient if they are unable to do so. Although paramedics decide not to attempt (or eventually abort) CPR, decisions about other treatments (e.g., pain relief and other symptom management) continue to be made based on clinical necessity (BMA et al., 2016). Physicians must develop the necessary skills to manage end-of-life decision-making If there is a valid and documented decision that CPR should not be attempted in the event of cardiac and/or respiratory arrest (DNACPR decision), it must be respected.
However, unlike a valid TRA, where the patient has explicitly rejected CPR trials, a DNACPR form is “non-binding [and] should be considered a prior clinical assessment and a recorded decision to guide immediate clinical decision-making in the event of a patient`s death or cardiorespiratory arrest” (BMA et al., 2016: 17). Stronger advance care planning efforts are needed to tailor end-of-life care to patients` preferences so that they can live a satisfying final chapter of their lives. There is a need to improve the availability and tracking of living wills and to more systematically adopt document forms that can be considered in all U.S. states. The discouraging evidence of inadequate decision-making at the end of life highlights the need for several improvement strategies: a person may orally appoint a health representative. In the absence of such a declaration, a representative may be designated by law in order of priority as follows: the patient`s spouse (and adult children if they are not children of the spouse), adult children, parents, adult siblings, adult grandchildren, and all adults who know the patient`s preferences. However, a health care provider can only act as a representative if they are related to the person with a blood or step-disability. Progressive health care decision-making is an integral part of estate and disability planning to ensure that health care decisions align with the patient`s philosophy, values and desires. The foundation of health care decision-making is the patient`s right to informed consent; Everyone has the right to make their own medical decisions, including the right to refuse medical treatment or withdraw consent to treatment once started. This right to self-determination does not end with the patient`s incapacity for work.
A living will outlining a power of attorney for health, a living will, or a written combination of both can ensure that a patient`s wishes for incapacity for work are respected. Paramedics are required by law and profession to respect their patients` right to dignity, respect and autonomy – and this includes the general requirement to obtain their consent before proceeding with any procedure. The first part of this two-part article focused on the challenges this could pose to the paramedic. This second article expands on this topic and explores the legal framework underlying the decision-making process when caring for a patient at the end of life. It also examines issues of consent and mental performance in more detail, addressing issues such as preliminary decisions on attempts to refuse treatment (ADRT) and cardiopulmonary resuscitation (DNACPR). If a permanent unconscious patient has never been competent or has left no evidence of past preferences or values, since there is no objective means of determining the best interests of the patient, the surrogate`s decision should not be challenged as long as the decision is based on the decision-maker`s genuine concern about what would be best for the patient. Physicians have a duty to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This also includes effective palliative treatment, although it can predictably hasten death. Medical Orders Living wills in health care go hand in hand with medical orders. The policy provides evidence of a patient`s wishes for care, which can then be converted into a doctor`s prescription to ensure the patient`s wishes are respected. If a patient or other party indicates that a valid ADRT exists, paramedics are required by law to comply with it if it is applicable and valid. After initially determining that the patient is unable to consent to treatment, physicians must ask several additional questions to determine validity (Department for Constitutional Affairs (DCA), 2007): Living will A living will expresses a client`s wishes regarding life-sustaining treatments and instructions for their health care.
The law defines life-sustaining treatment as any medical procedure or intervention that, when administered to a patient with a terminal or permanently unconscious illness, serves only to prolong the process of death or to keep the person in a permanent state of unconsciousness, even if the living will specifically provides for artificial feeding and hydration. This is the second part of a two-part article on caring for patients who are dying or at risk of dying. In the previous episode, it was recognized that caring for these patients is a fundamental part of the professional role of front-line paramedics (Taylor & Brogan, 2020). Paramedics are called upon to care for patients and their families at one of the most difficult times in their lives and must fulfill their duty of care to the patient by making decisions that have a sound clinical, professional and legal basis (Cassidy v. Department of Health, 1951; Health and Care Professions Council (HCPC), 2016). Health worker A health representative serves as a substitute decision-maker for a person who cannot make medical decisions and has not executed a living will in the health care sector. The representative may make decisions on behalf of such a person if an attending physician has determined that the person is incompetent, has no health authority or that the officer is not available and no guardian has been appointed for the person. Providing hydration and nutrition is an essential part of human flourishing.
Families and professionals struggle with every thought from stopping clinically assisted hydration and nutrition to the last hours or days of life. When nutrition and hydration are clinically supported, they are classified as treatment rather than primary care. Therefore, if they no longer provide overall benefits, they may be withdrawn.6,7 (3) Physicians should discuss the patient`s preferences directly with the patient and their representative. If possible, these discussions should be conducted in advance. The key steps to structure a basic discussion and sign and record the document in the medical record should not be delegated to a junior member of the health care team. In addition, paramedics can be challenged by the environment in which care is provided. Factors such as the risk of personal harm (when caring for a victim of abuse), desperate parents and other witnesses, adverse weather conditions, or the sounds and activities of other emergency services can all serve as potential distractions in the decision-making process.