30 Years of Experience in Caring for the Seriously Ill

By Mark O'Rourke, MD | Member to the SCMA Bioethics Committee

For an older person, admission to a hospital is frequently a time of difficult, major medical decisions and a time of diminished capacity to make decisions.  Frequently, frail elderly persons need help to make important medical decisions when they are hospitalized.  A study published online in January in JAMA Internal Medicine documented just how often older persons admitted to the hospital had to make major medical decisions and how often they needed help in doing so[1].  In the study of 1598 persons age 65 years and older who were admitted to two hospitals in a Midwestern city, the researchers defined a major medical decision as (1) life-sustaining care such as CPR, (2) a procedure or operation that required informed consent, or (3) hospital discharge to a nursing home.  They found that two thirds (1083) faced a major decision.  I am impressed by the high fraction.

Of those making major decisions, 47% depended in part or completely on a surrogate, such as a spouse, son or daughter.  Of those who were transferred to the ICU at some time during the hospital stay, 71% depended on a surrogate.  I take from this study that spouses, sons, daughters and other family members had to make a lot of important decisions for patients with diminished capacity.  Of the 1,083 patients, only 7.4% had a living will and only 25% had a health care representative document.  It appears that these spouses, sons and daughters usually had to figure out what the patient wanted and/or what was best for the patient without a living will or a healthcare power of attorney.

My experience over the past 30 years of taking care of seriously ill persons in the hospital is consistent with the statistics in this report.  I regularly see patients and families in distress in the hospital struggling with major medical decisions.  I can offer a few suggestions that may help and reduce the distress for all concerned.

First, every adult should designate a surrogate for medical decisions and fill out the paperwork for a healthcare power of attorney. Forms for South Carolina are available in hospitals, physician offices, attorney offices and online at www.scha.org/shared-decision-making.  The form is short and simple.

Second, when a person has a number of interested family members, designating a single surrogate as power of attorney makes it clear to the surrogate and to the others who the patient ultimately wanted to make the decisions.

Third, everyone should discuss their health, outlook and preferences with their surrogate and other family or friends.  This means discussing one’s health condition, considering one’s life expectancy, weighing the benefit of CPR (cardiopulmonary resuscitation) and describing how one feels about care at the end of life, when that time comes.

The seventh annual Health Care Decisions Day will be observed on April 16, 2014.  This day after income taxes are due is chosen to remind us of the two certainties in life, death and taxes.  As physicians, we can help educate our patients and the public about the need to plan ahead for healthcare decisions.  We can speak up in our practices and in our hospitals.  We can speak up in our places of worship and in our various clubs and associations.  We can write letters in newspapers and newsletters.  I encourage SCMA members to check out the website, www.hcdd.org, and to make a special effort this year to spread the word on Health Care Decisions Day.

1.         Torke, A.M., et al., Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults. JAMA Intern Med, 2014.