When a patient becomes critically ill, medical providers often turn to the patient or their surrogate decision maker to help guide medical treatments in accordance with the patient’s wishes and values. This can be incredibly difficult, as patients and their loved ones try to navigate an understanding of complex medical situations as well as their own emotions. As a critical care PA, this scenario comes up often in my work. Recognizing how scary and confusing the process can be, I want to take this opportunity to answer some of the most frequently asked questions.
Who Gets to Make Medical Decisions?
In the case that a patient is unable to make their own medical decisions, a surrogate decision maker steps in to represent the patient. Every state has a list of legally-authorized surrogate decision makers (sometimes also referred to a legal next of kin). In Georgia, where I practice, first priority is given to a legal spouse, followed by adult children, then parents, then siblings, then other family members and close friends. Keep in mind that a legal spouse includes a spouse from whom the patient is separated but not divorced, but does NOT include a long-term partner if they are not legally married. If a patient wants someone other than their legal next of kin to make decisions for them when they are unable to, they need to designate that person as a surrogate (sometimes also referred to as medical power of attorney) by completing an advanced directive. This is a legal document, available from every state, which takes effect only when the person is unable to make their own medical decisions. It can be completed while in the hospital, but ideally every individual would have their advanced directive completed (and have shared a copy with the person they’ve designated as their surrogate as well as their primary care provider) well before they experience any major illnesses. I have an advanced directive of my own.
What Does DNR Mean?
DNR means “do not resuscitate,” and it tells the providers that the patient would not want the providers to attempt to resuscitate them (via chest compressions, medications, or electric shocks) in the event that their heart were to stop. A DNR order is appropriate in situations where the patient and medical team feel that resuscitation measures would be futile. Despite what we see on TV, where the majority of CPR is successful in bringing a patient back to life, in reality, less than 20% of patients whose hearts stop while they are in the hospital survive to be discharged from the hospital, and a significant portion of those people will unfortunately suffer permanent disability even after recovery. Many patients or loved ones would prefer to allow a natural death in the event of a cardiac arrest. A DNR order only takes effect when a patient has already suffered a cardiac arrest. Until that point, a DNR order does NOT affect the type or level of medical care that the patient receives, and they will continue on their current treatment plan.
What is Hospice? What is Palliative Care?
Palliative care is a medical specialty focused on complex illnesses, management of pain and discomfort, and end-of-life care. They work alongside other specialists to support patients and their families through critical illness. If palliative care is consulted to assist with the care of your loved one, it may be because they are dying, but it also may be because they have a complex combination of diseases or an illness which require special attention to treating symptoms like pain, nausea, or anxiety. One of the many roles that palliative care plays is in hospice care. In hospice, a patient or their loved ones opt for a comfort-only focus, and opt out of invasive medical treatments and tests. Hospice care can take place inside a hospital, at a nursing facility, or in the patient’s home.
Making decisions for yourself or someone you love when they are critically ill can be scary. While it can seem sometimes like you are being asked to make big medical decisions, please remember you are being called upon simply to represent the patient’s values and wishes. Speak up for your own priorities, or stand in your loved one’s shoes and imagine what they would say, and we as your ICU medical team will do our very best to honor that.
Colleen Tope, MHS, PA-C
Colleen Tope is a Board Certified PA practicing in critical care.
