I don’t mean in the theoretical, warm-fuzzy, it-says-so-in-the-policy-manual-so-it-must-be-true, everyone-has-rights sort of way. I mean in hard practice: do the elderly really have autonomy to determine their own treatment? Illustrated in two recent cases I had, the short answer is No.
Case 1. Female patient, 94, previously competent, but in nursing home for other medical problems, arrives via EMS as an apparent CVA. A CT confirms a massive cerebral bleed and the patient later dies on an emergency stretcher in the Resus Room. Her advance directives, signed by the patient herself, clearly state “No transfer to hospital” and “Palliative measures only”. The nursing home, when questioned why this patient was transferred to hospital against her wishes — which in fact is the whole point of having an advance directive — can only say she was “unwell” and the nursing home physician “ordered her to be sent to hospital.”*
Case 2. 84 year-old female, who again has well-documented advance directives forbidding transfer to hospital previously written by the patient herself, but now has Alzheimer’s dementia, presents as a possible urosepsis. The nursing home says the patient was sent to the Emergency at the “request of the family.”
These aren’t hypothetical cases, and ones similar happen with dismal regularity. Physicial frailty means, in the minds of some, means mental incompetence. Advance directives are frequently subject to the capriciousness of nursing home staff or family members. In point of fact, the ability of anyone practically to direct their own care if incapacitated is limited. Even strictly delineated advance directives can and will be overridden by families and by health care professionals.
The nursing role in all of this is threefold: to educate patients and families on advance directives, to facilitate provision of services, including providers like home care, pain management and palliative care, and finally, to advocate for the patient. Whether we actually do it, of course is another question. Working in the Emerg, you frequently get the impression that expediency or convenience (or even laziness) trumps good patient care.
*The game, according to a colleague used to manage a nursing home, goes like this: The nurse in charge simply calls the nursing home physician, advises of patient’s condition, but “forgets” to tell the doc of the advance directive. The physician of course then orders the transfer.