What about the patient whose family lives too far away to see the patient on a regular basis? Look into hiring a local geriatric case manager, Dr. Epstein advises.
There is one person who should not serve as a patient’s surrogate: the attending physician, whether a hospitalist or the primary caregiver. Erin Egan, MD, JD, assistant professor of hospital medicine, University of Colorado Hospitals, warns that a hospitalist acting as a surrogate has a conflict of interest. “Most states prohibit hospitalists from acting as surrogates,” Dr. Egan warns. “In some cases a doctor can presume consent for a short time before a surrogate is appointed in order to make an immediate medical decision. As a general rule, however, a clinician should never assume the surrogate’s role.”
Look for advance directives: Ideally, every patient’s file would contain an advance directive indicating a surrogate or a note that there is no surrogate.2 In addition, there should be a healthcare advance directive, also known as a healthcare power of attorney, that appoints a surrogate. It is often accompanied by a living will, an instruction sheet stipulating what treatment the patient wants if he or she is unable to speak or communicate. Unfortunately, many hospitalists cannot find these documents when they admit a patient.
In this case, the hospitalist must search. Most hospitals, nursing homes, or home healthcare agencies are required by the federal Patient Self-Determination Act (PSDA) to offer information about advance directives at the time of admission. This information states the patient’s healthcare decision-making rights under state law and the institution’s policy about adhering to advance directives. Contacting these agencies is a starting point.
Make difficult decisions: While some advance directives carry legal power, they often are not helpful to hospitalists or surrogates making end-of-life decisions. Because a medical crisis cannot always be predicted and treatment options change rapidly, a specific directive may not be as helpful as a written description of a patient’s beliefs, religious convictions, and cultural values. Equally valuable are notes about conversations among patients, family members, friends, and caregivers.3 This creates a picture of the patient’s feelings about quality of life, treatment preferences, and end-of-life outcomes.
The hospitalist’s role in this situation is to facilitate such discussions among all family and friends involved. The goal is to develop an accurate picture of the patient to make appropriate decisions. The hospitalist should explore the cultural values and religious beliefs of the patient, surrogate, family, and friends. “Different ethnic groups view medical care differently,” says Richard L. Heinrich, MD, medical director of Hospice of the Lakes, Bloomington, Minn. “Some religions believe that suffering in this life is rewarded in the next life, which makes a difference when making treatment decisions,” he says. “We must honor and work with cultural values unless in our view the individual is suffering needlessly.”
The hospitalist should be alert to the need for an interpreter and anything else that will promote a meaningful discussion. And, the hospitalist and the medical staff should be prepared to share as much medical information as is possible, including individual staff opinions, the rationale behind recommendations, and the pros and cons of each suggestion. The surrogate and family cannot make any meaningful contribution without all the pertinent information.
The goal should be a consensus about the patient’s best interests, how certain medical decisions will provide benefit or burden to the patient, and if the decision is what the patient would want. It’s especially critical to call a family conference to allow everyone the opportunity to discuss the patient’s concept of his or her death.