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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 1: Advance Care Planning
    Five Steps for Successful Advance Care Planning

    Step 5. Apply when Need Arises Complementary Application of the Model for Advance Care Planning

    Step 5. Apply Prior Directives to Actual Circumstances

    When patients become incapacitated, the application of prior wishes to real circumstances can be challenging. The following guidelines may be helpful to ensure that a patient’s advance directives are followed as closely as possible

    Determine the Patient’s Capacity to Make Decisions

    • Most advance directives go into effect when the patient is no longer able to direct his or her own medical care
    • Learn to recognize when a patient becomes incapable of making decisions
    • While situations where the patient is unresponsive are obvious, if the patient has some ability to respond, the physician must first determine his or her capacity to make decisions (see Module 7: Goals of Care)


    Read the Advance Directive

    • NEVER assume an advance directive’s content without actually reading the document
    • Do not take for granted that patients who have living wills want treatment withheld
      • Some people indicate within their living will that they want all full measures taken to prolong their life


    Interpret the Advance Directive

    • Advance directives should be interpreted in view of the clinical facts of the case
    • Validated documents are likely to be more useful than short statements or statutory documents
    • No matter how thorough they are, advance directives cannot anticipate all possible circumstances
    • The proxy and the physician may need to extrapolate from the scenarios described in the advance directive to the current situation, and make an educated guess as to what the patient would want if he or she were able to speak for himself or herself


    Consult with the Proxy

    • Whenever significant interpretation is necessary, the physician should consult the patient’s proxy
    • Sometimes the physician and/or proxy may believe that a patient would have indeed wanted something other than what is reflected by a strict reading of the advance directive
      • In this case, they should work together to reach consensus


    Guidelines for Extrapolation

    • Certain patterns of decisions have high predictability and follow logically
    • For instance, a declination of less invasive interventions has been shown to predict for declinations of more invasive interventions
    • Acceptance of more invasive interventions predicts acceptance of less invasive interventions
    • If a patient has indicated that he or she would like intervention in a poor prognosis scenario, there is a high probability that the patient would also accept intervention in a better prognosis situation
    • Likewise, if the patient has indicated he or she would decline intervention in a better prognosis scenario, there is a high probability he or she would also decline if the prognosis were poor

    When Disagreements Arise

    • If disagreements cannot be resolved, assistance should be sought from an ethics consultant or committee
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