The following article, by William J. Watts, M.D., the president of the King County Medical Society, originally appeared as his president's column in the January 2007 issue of the King County Medical Society Bulletin. The article is an excellent treatment of extraordinarily sensitive issues relating to end-of-life care decisions. The article is reprinted here with Dr. Watts' permission. In addition to being the president of the King County Medical Society, Dr. Watts is the head of the Respiratory Care Services at Overlake Hospital Medical Center in Bellevue. He is board certified in pulmonary disease, critical care medicine and internal medicine.
To the Staff at a Long Term Care Nursing Home
Olympia, WA
The undersigned are the five living sons of Kathryn Watts. We are in concordance with the statements listed below.
- Our mother is of advanced age and infirmity, and her death will likely occur within the year. During her life, our mother expressed opinions about medical treatment at life's end, and those opinions are reflected herein.
- Our mother should not undergo any diagnostic tests, such as blood tests or X-rays.
- Under no circumstances, should she be given any medication, except for the immediate relief of pain or shortness of breath.
- She experiences intermittent atrial fibrillation. She should not be given warfarin, the risk of stroke notwithstanding.
- Under no circumstances should she be transported to an acute care hospital.
- Although not formally a hospice patient, her care should be comparable. She is No Code Status.
These guidelines reflect our wish that our mother not suffer the misfortune of unwanted medical intervention at the end of her life. David Watts, DPOA, should be in receipt of any further correspondence.
Signed, Notarized,
The five living sons of Kathryn Watts
Elderly, frail, sometimes demented, patients are frequently transferred from nursing homes to acute care hospitals. Our family confronted this issue at the end of our parents' lives, and it gave me insight - from the perspective of a family member.
The transfer of an elderly patient to a hospital, usually via the emergency room (ER), is always associated with discomfort of medical care. Although studies show that hospitalization of medically ill nursing home patients is appropriate in the majority of cases, transfer to ER of some patients with grave illnesses near life's end aggravates suffering. We have all seen the tragedy of the bewildered elderly patient, pitiful and half naked, in the ER who suffers from unwanted and unwarranted medical intervention.
From a medical perspective, many patients don't need to be transferred to the ER. Reports have shown that treatment of patients with less severe pneumonia in the nursing home - rather than in the hospital - causes equal or better outcome. Patients can be effectively managed by a trained nurse using clinical pathway tools. Similar benefits for geriatric patients have been shown in patients with Alzheimer's, dementia and congestive heart failure. In a recent study, Advance Care Planning (ACP), which clarified patient treatment preferences, was performed on-site by a trained nurse. Ambulance calls were reduced by 20% and acute-care hospital bed utilization fell by 25%.
Although difficult to prove, it is likely nursing homes are sensitive to potential litigation as well as public opprobrium if there are perceived excess deaths. Care of the elderly between hospitals and nursing homes is inherently uneven, and there may not be a trusted physician helping guide end-of-life discussions. Thus, families may be unprepared and shocked when devastating illness occurs, leading to misunderstanding or antagonism.
The management of frail elderly nursing home patients who have medical illnesses presents ethical issues. No doubt, there is a sincere desire in all of us to limit unnecessary and harmful care to elderly patients and there has been earnest response from medical and nursing organizations. The development of the helpful POLST form (Physician Orders for Life-Sustaining Treatment) is a recent addition to safeguarding self-determination: patients or surrogates are specifically asked if an ill patient should be transferred to an acute care facility.
Washington and Oregon have been leaders in preventing unwanted care at life's end. The POLST form is now employed by the Washington State Department of Health as the preferred DNR order form. The Washington State Medical Association has workshops and online data for physician education (www.wsma.org). The presence of a statewide coalition (Washington End-Of-Life Consensus Coalition) indicates the widespread public support for avoidance of unwanted and futile medical treatment at end-of-life (Farber, S. Ann Intern Med 2006;145:788-789).
Many patients in nursing homes are seriously ill and will never get well again. Despite our agreement to limit treatment of the frail elderly, health care providers often don't foresee, or may not acknowledge or clearly spell out, the reality of a potential catastrophic illness. I believe physicians need to provide decisive guidance to patients and families regarding end-of-life options, particularly using the POLST form.
When presented with these treatment options for gravely ill patients, including avoiding transfer to an acute care facility, families may think it is "illegal," or that care is forced by "policy." Open discussion about end-of-life care can be deeply gratifying for physicians, especially since it is perhaps one area where oppressive regulations don't interfere with the tender privacy of the patient-family-physician relationship.
The future of care of the frail elderly in nursing homes is likely to change, with changing social values and economic realities. It is likely there will be more care of ill patients in the nursing home, wider use of the POLST form or similar directives, and increasing acknowledgement of the relative inefficacy of the standard living will. Since many chronically ill nursing home patients are subject to repetitive hospital admissions, hospitalists and other hospital-based physicians will play an increasing role advising patients and families of end-of-life options.
Mercifully, attention to these end-of-life preferences will reduce unnecessary and futile care of many of the very frail and elderly residents in nursing homes. n
John Ruhl serves as the KCBA president. He is a member in the Seattle office of Eisenhower & Carlson PLLC. His commercial trial practice includes employment, construction, transportation and banking matters. He can be reached at jruhl@eisenhowerlaw.com.
