EDITORIALS
Getting Medical Directives to the Public In this issue of Annals, Iserson addresses a dilemma that is a part of the daily practice of emergency medicine - determining appropriateness of emergency lifesaving care for patients. This concern changes principles of care when we evaluate a critically ill patient. If the patient appears chronically ill or elderly, our priorities change from "airway, breathing, and circulation" to "any d o c u m e n t s , family, old records?." M o s t p h y s i c i a n s and e m e r g e n c y medical services providers have endured the cruel experience of having resuscitated or stabilized a critically ill patient only to be castigated for providing u n w a n t e d care, thereby prolonging rather than alleviating suffering. Why? Few patients and families have initiated a dialogue regarding life-sustaining t r e a t m e n t . Those who have are often poorly informed regarding methods for communicating those choices. See related article, p 692. Dr Iserson calls us to take an active role in supporting this decisionmaking process and disseminating appropriate information. Our role should be one of leadership! We have many disparate friends on this issue. Primary care and specialty phygicians such as nephrologists and oncologists address these issues most often but are limited by family reluctance and the time required to adequately address them. Such health care providers as home health care and hospice workers, visiting nurses, and emergency medical services, and other public agencies have an intense interest in the provision of appropriate care to patients. Coordination between these groups would facilitate discussion of patient wishes and methods to communicate
20:6:June1991
these wishes to the emergency care system. Visiting nurses and hospice workers in particular are extremely helpful in discussing issues w i t h families and assisting with completion of appropriate documents. Nursing homes should address this issue aggressively, yet often do not discuss or document decisions. Because we must deal with these failures, emergency physicians must educate nursing home staffs of the importance of this issue. Medical societies and bar associations are excellent forums for development of policies and distribution of documents to their members. In Michigan, even the state trial lawyers' association has endorsed legislation to develop advance directives. Emergency physicians must support legislation for advance directives and work to assure that the format and use of these documents are appropriate. An advance directive, for instance, serves no purpose for the patient with agonal respirations if it is in a safety deposit box. Policies m u s t be i m p l e m e n t e d to assure transfer and acceptance of these docu m e n t s from i n i t i a t i o n of care at h o m e to a d m i s s i o n to i n p a t i e n t units. Sample directives and supporting educational materials must be identified. Medical societies in North Carolina and Hennepin County, Minnesota, have developed documents that are excellent examples.t, 2 Fortunately, the public has become more sophisticated regarding medical directives. The Supreme Court decision in the Nancy Cruzan case has created a deluge of media discussion regarding the need for clear and convincing evidence of one's wishes. Societies that should never have to exist, such as the Society for the Right to Die, report a tremendous increase in requests for sample living wills and other advance directives. Cases
Annals of Emergency Medicine
of physician-assisted suicide (Kervorkian, Quill) 3 have focused attention on the d e m a n d that patients place on controlling their destiny at the end of their lives. Patients and families are more willing than ever to address this complex issue. Clearly, we have an interest in facilitating these discussions and the use of these documents. The suggestion that we use emergency departments and their waiting rooms to disseminate this information is intriguing. While some might argue that it is inappropriate information for some families, it may be valuable for the families who need to broach the issue but have no baseline information. The potential to reach the families of 80 million patients annually cannot be ignored. Other forums for discussion recommended by the author, such as service organizations and clubs, often request emergency physicians' help in educating them regarding important issues. The use of audiovisual materials, though expensive, may be cost shared with inpatient oncology, home care, or pastoral care services. Decisions regarding withholding or limiting emergency care are extraordinarily difficult. We should make every effort to give patients the clear means to communicate their wishes tO US,
Robert A Swor DO, FACEP Department of Emergency Medicine William Beaumont Hospital Royal Oak, Michigan
1. Hennepin County Emergency Medical Services Council: Directives to Limit Emergency Medical Treat ment. Minneapolis, HCEMSC, 1984. 2. North Carolina Medical Society, North Carolina Hospital Association and the Duke Endowment: The Layman's Guide to Death with Dignity. Raleigh, NCMS, NCHA, DE, 1991. 3. Quill TE: Death and dignity A case of individualized decision making. N Eng] J Med 1991;324:691-694.
701/149
Getting Medical Directives to the Public In this issue of Annals, Iserson addresses a dilemma that is a part of the daily practice of emergency medicine - determining appropriateness of emergency lifesaving care for patients. This concern changes principles of care when we evaluate a critically ill patient. If the patient appears chronically ill or elderly, our priorities change from "airway, breathing, and circulation" to "any d o c u m e n t s , family, old records?." M o s t p h y s i c i a n s and e m e r g e n c y medical services providers have endured the cruel experience of having resuscitated or stabilized a critically ill patient only to be castigated for providing u n w a n t e d care, thereby prolonging rather than alleviating suffering. Why? Few patients and families have initiated a dialogue regarding life-sustaining t r e a t m e n t . Those who have are often poorly informed regarding methods for communicating those choices. See related article, p 692. Dr Iserson calls us to take an active role in supporting this decisionmaking process and disseminating appropriate information. Our role should be one of leadership! We have many disparate friends on this issue. Primary care and specialty phygicians such as nephrologists and oncologists address these issues most often but are limited by family reluctance and the time required to adequately address them. Such health care providers as home health care and hospice workers, visiting nurses, and emergency medical services, and other public agencies have an intense interest in the provision of appropriate care to patients. Coordination between these groups would facilitate discussion of patient wishes and methods to communicate
20:6:June1991
these wishes to the emergency care system. Visiting nurses and hospice workers in particular are extremely helpful in discussing issues w i t h families and assisting with completion of appropriate documents. Nursing homes should address this issue aggressively, yet often do not discuss or document decisions. Because we must deal with these failures, emergency physicians must educate nursing home staffs of the importance of this issue. Medical societies and bar associations are excellent forums for development of policies and distribution of documents to their members. In Michigan, even the state trial lawyers' association has endorsed legislation to develop advance directives. Emergency physicians must support legislation for advance directives and work to assure that the format and use of these documents are appropriate. An advance directive, for instance, serves no purpose for the patient with agonal respirations if it is in a safety deposit box. Policies m u s t be i m p l e m e n t e d to assure transfer and acceptance of these docu m e n t s from i n i t i a t i o n of care at h o m e to a d m i s s i o n to i n p a t i e n t units. Sample directives and supporting educational materials must be identified. Medical societies in North Carolina and Hennepin County, Minnesota, have developed documents that are excellent examples.t, 2 Fortunately, the public has become more sophisticated regarding medical directives. The Supreme Court decision in the Nancy Cruzan case has created a deluge of media discussion regarding the need for clear and convincing evidence of one's wishes. Societies that should never have to exist, such as the Society for the Right to Die, report a tremendous increase in requests for sample living wills and other advance directives. Cases
Annals of Emergency Medicine
of physician-assisted suicide (Kervorkian, Quill) 3 have focused attention on the d e m a n d that patients place on controlling their destiny at the end of their lives. Patients and families are more willing than ever to address this complex issue. Clearly, we have an interest in facilitating these discussions and the use of these documents. The suggestion that we use emergency departments and their waiting rooms to disseminate this information is intriguing. While some might argue that it is inappropriate information for some families, it may be valuable for the families who need to broach the issue but have no baseline information. The potential to reach the families of 80 million patients annually cannot be ignored. Other forums for discussion recommended by the author, such as service organizations and clubs, often request emergency physicians' help in educating them regarding important issues. The use of audiovisual materials, though expensive, may be cost shared with inpatient oncology, home care, or pastoral care services. Decisions regarding withholding or limiting emergency care are extraordinarily difficult. We should make every effort to give patients the clear means to communicate their wishes tO US,
Robert A Swor DO, FACEP Department of Emergency Medicine William Beaumont Hospital Royal Oak, Michigan
1. Hennepin County Emergency Medical Services Council: Directives to Limit Emergency Medical Treat ment. Minneapolis, HCEMSC, 1984. 2. North Carolina Medical Society, North Carolina Hospital Association and the Duke Endowment: The Layman's Guide to Death with Dignity. Raleigh, NCMS, NCHA, DE, 1991. 3. Quill TE: Death and dignity A case of individualized decision making. N Eng] J Med 1991;324:691-694.
701/149
