I'm not sure I can agree with you there. Primary care and palliative care 
have a long history of NOT resuscitating dying patients; emergency care I'm 
ashamed to say are the ones who've started this trend, i.e. resuscitation, 
originally applied in the early 1960s to patients with primary cardiac 
arrhythmias but now applied willy-nilly to anyone who's dying.

And I disagree with your suggestion that the poorly developed IT side of 
advance directives suggests that emergency care wasn't considered in their 
formulation. As you well know, advance directives have been around since the 
early 1990s, when IT really didn't exist in medicine. [In fact, the 
editorial you mentioned the other day was written in 1995, and not last year 
as you suggested.]

Anyway, emergency medicine has a lot to answer for when it comes to 
resuscitating dying people. As I've said, it's embarrassing sometimes; I 
can't believe some of the cases being dragged through our resus some days.

AF

----- Original Message ----- 
From: "Coats Tim - Professor of Emergency Medicine" 
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, May 09, 2007 12:21 PM
Subject: Advance directives

I don't think that the 'raison d'etre' for advanced directives was
emergency care. Emergency physicians were not greatly involved in the
discussions and the emergency aspects were a bit of an afterthought - as
we can see from this thread. They were designed by people with a ward /
hospice background so that the patient's wishes could be known and
influence the limits of care even if the patient was not in a position
to convey them. Emergency care is probably the most difficult place to
use an Advance Directive - if we were designing a system I bet that it
would be rather different to the current one and would involve some of
the communication and IT aspects that have been suggested by others in
this thread.

An Advance Directive is not (as has been assumed for some of this
thread) a 'do nothing' instruction, it may well set down in some detail
exactly what treatments are or are not wanted by the patient. All this
can be difficult to assimilate and verify in an emergency.

It comes down to clinical judgement - using all the information that you
have and making a decision about treatment which you believe is in your
patient's best interest, knowing that self-determination is one of the
pillars of ethical medical practice. As always, you may well have to
justify your decision to others.

Tim.

PS. I agree that nothing is 'cast iron' in medico-legal terms - but you
know what I meant, 'very strong' might have been better.

________________________________

From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Adrian Fogarty
Sent: 07 May 2007 14:37
To: [log in to unmask]
Subject: Re: SPAM_75:Re: Advance directives


Yes, I agree with the points you make about legal direction, Marina. I
don't think I'd go so far as Tim, however, to suggest that uncertainty
is a cast iron defence. I don't think there is any such thing as a cast
iron defence, and if I had that magic bullet (cast iron defence) I'd
patent it!

But while a law suit is just one end of the spectrum, I wouldn't be
surprised if a doctor were to receive a complaint, and probably via the
GMC, for ignoring, or failing to take sufficient heed of, or failing to
make reasonable enquiries as to the validity of, an advance directive.
Saying you were "uncertain" doesn't strike me as going far enough to
qualify as a defence to such a charge. You would then have to explain
what made you "uncertain" when you had the piece of paper in front of
you in resus.

Furthermore, if we are to remain "uncertain" even in such circumstances,
then it throws into doubt the whole raison d'etre of these directives in
the first place. They have been designed to guide doctors who don't know
the patient. The carers who already know the patient don't really need
them, and have acted without them for many years.

AF

"Shannon, Marina (WG) Critical Care PD Specialist"
<[log in to unmask]> wrote:


Intriguing thread which has tempted out a long-time lurker.

The comment below seems to encapsulate one of the main issues of
the debate. Quite aside from the ethical and professional arguments,
there is a paucity of legal direction around advance directives and
their implementation where the need arises.

Most decisions would be likely default to what was 'reasonable'
under what are often confusing or difficult communication scenarios.
Therefore, unless there was very clear intent on the part of the
practitioner to ignore a competent directive or statement then the
likelihood is they would be found to be legally, and most likely
professionally, acting in the patient's best interests.

Retaining this type of patient information would seem reasonable
and pragmatic, where systems allow, as many patients often only lodge
these statements with their GP or primary carers/family, which might
mean it is unavailable in an emergency.

I have one query tho'. Does anyone who accepts this information
set a time limit which requires patients to update or endorse a
directive as evidence of their continuing commitment to its contents?

Marina Shannon
PDS CC&T
Lanarkshire

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Adrian Fogarty
Sent: 07 May 2007 12:39
To: [log in to unmask]
Subject: SPAM_75:Re: Advance directives



I think your choice of words is illuminating: to err on
the side of treatment. My point would be that the correct way to manage
someone with an Advance Directive is to comply with that directive. To
do otherwise would certainly be to err.

Unfortunately we all too often opt for the "lazy" or
"safe" approach, which is to resuscitate. This disturbs me. What we
probably need is a few more law suits or complaints against doctors who
ignore Advance Directives, but they are hard to come by.

What I think we can do however and should do is to
support maximal conservative treatment (but short of interventional
resuscitation) the majority of which is palliative in any case, although
sometimes can be curative.

AF

Coats Tim - Professor of Emergency Medicine
<[log in to unmask]> wrote:

Yes. We use the same system as for the frequent
attenders who have specified care pathways and the special patients who
have rare conditions with a personal care plan. The receptionists print
out a copy of the additional information so that it comes with the notes
and can therefore be included in decision making.

However, even with a pre-specified management
plan (an Advanced Directive is only one type of pre-specified plan) a
thinking clinician needs to make a decision about how to proceed. To err
on the side of treatment whenever there is doubt will be supported.

Tim Coats.

Professor of Emergency Medicine
Leicester University.


________________________________

From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Brown, Ruth
Sent: 05 May 2007 15:42
To: [log in to unmask]
Subject: Advance directives

Does anyone on the list accept advance
directives from patients "in advance" - ie scan them onto the system and
flag them as a special case prior to their arrival? we have been asked
if we can do it, and I am concerned that to accept the advance directive
and undertake to scan it in suggests that we will be able to guarantee
we won't start resus and I am not sure that is possible
what do others think?
Ruth
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