Advance Directives

Guest post by Darren Van Zyl 

I’ll make this really simple and start with the punch line: They’re called ADVANCE DIRECTIVES and they are all VALID. 

 The end.

But I better explain… So here goes: (Please keep reading this is IMPORTANT!). Pay attention (JZ, 2016) ….

(For the purposes of this paper we are referring to your garden variety patient who is legally and mentally competent to consent to (and therefore refuse) treatment. Making a bad decision / one that the practitioner disagrees with does not make the patient mentally incompetent. (For more information on informed consent and the requirements: (http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/ethical_rules/Booklet%204%20Informed%20Consent%20September%20%202016.pdf )

Four Principle approach to Medical Ethics

There are several models / approaches to medical ethics. The Four Principle Approach is very popular and useful to explain advance directives. The four principles are:

• Autonomy: Patients have a right to consent to / refuse treatment after they have been informed of the risks and benefits of either. Legally competent persons who can consent to treatment may also refuse treatment EVEN if this results in harm to self / death. Over-riding this principle is called Medical Paternalism and is not acceptable / legal in South Africa (Except in very specific situations, which for the purposes of this paper, are not going to be considered).
• Beneficence: This means that practitioners should act in the best interests of the patient.
• Non-maleficence: “Do no harm”: Always act to cause the least harm to the patient.
• Justice: Treating all patients equally regardless of religion, race, gender, etc. Being non-discriminatory.

Now, the problem comes in when the above principles conflict with each other. For example: Patient has refused treatment (autonomy) and this may result in harm / death (and might not even be in his / her best interests)…. Well, in Western society (including South Africa) the principle of autonomy over-rides the others and the patient’s wishes MUST be respected. It’s actually that simple.

You also can’t wait for the patient to deteriorate / get to the point where they can no longer communicate and then over-ride their previously communicated decision(s)!

And this is what makes advance directives valid: The principle of autonomy.

Types of advance directives and terminology

There are many terms for advance directives and the wording often causes confusion. BUT, essentially these can be issued / declared in three ways:

• By the patient him / herself. This is obviously the most ideal situation: communicate with the patient about his / her wishes, if possible, before the situation / condition deteriorates;
• By a surrogate for the patient (See below); and
• The medical team involved in the patient’s care (Specifically the physician in charge of the patient). This is specifically done when the principle of futility applies and further treatment would have no benefit and may even be unethical.

 

In all three cases documentation of the decision is essential and should be done as soon as possible. Verbal decisions on the part of the patient / surrogate are acceptable but should be recorded in the clinical notes (With names of witnesses to add extra vooma, although this is not strictly a requirement).

So let’s have a look at some popular terms that are used for advance directives and elucidate any differences:

• No not resuscitate (DNR) order: This is probably the most popular and common term. One of the challenges with this term is defining the word “resuscitation” because this could mean anything from rehydrating a dehydrated patient to CPR; and everything in between. The trend is to define the exact procedures that the patient is refusing and many now speak of “No CPR” orders. Some of the European literature is using the term “AND” (Allow natural death).
• Living will: This form of advance directive is usually issued by the patient and the wording is pretty standard (Google it) although modifications can be made and specifications stated. The standard wording starts with the implication that the document only comes into effect when “there is no hope” (continued treatment is FUTILE)… So this usually does not cover CPR / resuscitation or emergencies; although no CPR can be a condition.

Patient consent, surrogates, and emergencies

What do you do when you cannot communicate with the patient because they are incapacitated? Well, if he / she has already communicated their wishes verbally or in writing you respect any decisions made at that time. Otherwise, I can’t say it better than the current National Health Act: So I’m just going to copy and paste Chapter 2, Section 7 of the Act which tells you in which order to listen to the relatives:

A few things:

• In South Africa the definition of a “Partner” is simply “Living together as if married” (McQuoid-Mason & Dada, 2011);
• Item e above makes it very clear that if a patient has expressly denied consent (even if by conduct) then a practitioner may not over-ride this decision when they patient becomes further incapacitated and an emergency arises;
• We cannot go around questioning the motives of patient surrogates who refuse treatment (CPR or resuscitation) on behalf of their incapacitated relative. Unless there are obvious circumstances not to do so practitioners should take the wishes of the relatives / surrogates at face value and document such;
• Another copy and paste: The booklet on “Withdrawing and Withholding Treatment” published by the HPCSA states:

Conclusion

Please respect your patients’ decisions! Communicate! Document!

Read up on all of this BEFORE it happens.

Don’t call me at 2am because you didn’t: I’m sleeping.

And use the following useful links (Directly off the HPCSA website):

• National Health Act:

 http://www.hpcsa.co.za/uploads/editor/UserFiles/National%20Health%20Act.pdf

•  HPCSA Booklet 4: Informed Consent:

http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/ethical_rules/Booklet%204%20Informed%20Consent%20September%20%202016.pdf

•  HPCSA Booklet 7: Withholding and Withdrawing of Treatment (Read this one if you have limited time / concentration):

 http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/conduct_ethics/Booklet%207.pdf

 

[This is the self-promoting bit: Darren is an Advanced Life Support Paramedic who also completed a year long Certificate in Medicine and Law (UNISA). During this time he got to pick the brains of some of the Country’s medico-legal gurus and can therefore assure you that he wasn’t making up the information in this article]