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Articles / 2010

Advance directives help families, and hospitals, in a medical crisis

Ventura County Star
Friday, 04/16/2010
By Emily Vizzo

Patient rights concerning end-of-life care have become more defined over the past two decades, with the Supreme Court ruling in 1990 that adult patients have the right to accept or refuse any treatment at any time.

That same year, Congress passed the Patient Self-Determination Act, which directed that patients over the age of 18 be notified of their rights to complete advance directives, describing treatment preferences.

Since then, between 25 percent and 28 percent of eligible patients have completed advance directives, said Dr. Jim Hornstein, of Community Memorial Hospital, who spoke Friday at a lunchtime seminar held in conjunction with National Health Care Decisions Day.

“The vast majority of these are respected by the hospital and are followed verbatim,” said Hornstein, who also chairs the CMH and Ventura County Medical Center Ethics Committee.

“All of us will one day face gut-wrenching decisions about medical care it’s so much worse when forced to make a decision in the middle of a crisis,” he said.

Far from the “death panels” that frightened some people during the national healthcare debate, Hornstein believes people can benefit from sharing their views on end-of-life care with medical professionals and family members — and putting those views in writing.

He cited a study published by The New England Journal of Medicine that said 70 percent of patients have, on some occasions, lost the ability to articulate treatment preferences.

Advance directives forms allow people to state preferences regarding organ donations, treatments that artificially prolong life and treatments for pain relief. The forms can also designate a power of attorney for healthcare. This is particularly helpful in California, which has no hierarchy laws that automatically confer decision-making status, Hornstein said.

Often, conversations with family members and medical professionals can unearth misconceptions about care, Hornstein said. The success rate for CPR on patients in television dramas is very high. But in real life, success rates are closer to 39 percent in best-case scenarios, and as low as 1.5 percent for some patients, including those with dementia, Hornstein said.

And real-life CPR rescue attempts can be extremely vigorous, resulting in cracked ribs, damaged internal organs or brain damage, Hornstein said.

But without a patient’s explicit refusal, it’s the standard for care in all hospitals — the only procedure automatically permitted without doctor’s orders during a medical crisis, Hornstein said.

Advance directives are helpful, but aren’t considered “doctor’s orders,” Hornstein said. People can fill out a one-page form — Physician Orders for Life-Sustaining Treatment — which is considered as such.

People check boxes expressing desires for or against resuscitation, comfort-only or potentially invasive treatment plans, and artificially administrated nutrition. They can also express wishes to permit treatments, but within limits.

Port Hueneme resident Kichi Iwamoto, 74, said that he and his wife, Caryn, had postponed completing advance directives, although both have survived major surgeries.

“It’s peace of mind for my spouse,” he said of their decision to create them. “And I would have hers.”

CMH medical social worker Sarah Johnston, 38, completed one 10 years ago upon starting work in the medical field and observing what can happen without one, she said.

“For me, it’s very comforting,” she said.