Completion of Limitation of Medical Treatment Forms by Junior Doctors for Patients with Dementia: Clinical, Medicolegal and Education Perspectives

By Yoong, Jaclyn; MacPhail, Aleece et al. | Australian Health Review, October 2017 | Go to article overview

Completion of Limitation of Medical Treatment Forms by Junior Doctors for Patients with Dementia: Clinical, Medicolegal and Education Perspectives


Yoong, Jaclyn, MacPhail, Aleece, Trytel, Gael, Rajendram, Prashanti Yalini, Winbolt, Margaret, Ibrahim, Joseph E., Australian Health Review


Introduction

Limitation of Medical Treatment (LMT) forms, also known as Do Not Resuscitate (DNR) or Not For Resuscitation (NFR) forms, are universally recognised as an essential component of end-of-life care.1-4 These forms generally incorporate decisions about resuscitation orders and other therapeutic interventions. Appropriate use of the forms encourages open communication about end-of-life care, preserves a patient's autonomy and patient-centred care and reflects clear medical decision making about goals of care (GOC); it may also facilitate rational use of healthcare resources.

The use of an LMT form aims to prevent unnecessary suffering and inappropriate use of healthcare resources when life-prolonging treatments are likely to be futile, harmful or discordant with patient preferences.5 However, LMT orders are an ongoing source of concern and controversy for clinicians, patients, families and the general public, as illustrated by the recent high-profile legal proceedings in the UK.6 In that 2014 case, the failure of a hospital to consult a patient in their decision to insert a Do Not Attempt Cardiopulmonary Resuscitation Notice in the medical notes was ruled unlawful. This resulted in a change in the law that requires medical practitioners to consult all patients with regard to NFR orders, unless the clinician thinks the consultation may cause physical or psychological harm. This case underscores the ongoing controversial nature of LMT decisions and the growing move towards patient involvement and increasing awareness of LMT orders.

Medical practitioners often report low confidence in discussing LMT. Conflict and misunderstandings among patients, family members and medical staff are not uncommon, and discussions about LMT can, in fact, cause increased distress and may negatively affect quality of care.5,7-10 Medical practitioners also consider decision making around LMT as one of the most difficult skills in clinical medicine.11 Determining GOC for individual patients requires the complex tasks of prognostication, assessing possible risks and benefits of life-prolonging treatments, predicting quality of life, identifying patients' preferences and making clinical judgements about the appropriateness of any interventions. Effective communication between medical practitioners and patients and their families is critical in this process.3,5,12

An emerging and challenging area for LMT decision making is how it applies to patients with dementia. Specific attention to this patient cohort is required and justified because dementia was the second leading cause of death in Australia in 2013,13 is dementia is under-recognised as a terminal condition and dementia generally occurs with multiple comorbidities with pathological synergy.13,14 Furthermore, patients with dementia are more vulnerable and more likely to receive poorer care due to the associated stigma, discrimination and medical fatalism. Paradoxically, patients with dementia are frequently subject to aggressive and inappropriate treatments at the end of life.14-16

LMT decision making in patients with dementia is further complicated by the question of cognitive capacity and patients experiencing difficulty communicating their preferences.17 Unlike other neurological conditions that affect cognitive function (intellectual disability, cerebrovascular disease), dementia is rarely static and its course can be difficult to predict. Therefore, what constitutes 'appropriate care' and a patient's capacity to make or be involved in LMT decisions varies according to the trajectory of the illness.

Thus, we acknowledge the significant complexities associated with LMT decision making, and then more specifically inpatients with dementia, and acknowledge they exist for medical practitioners across all levels ofseniority. Nonetheless, we do note that junior doctors play a central role in completing LMT forms.1,18-22 Junior doctors have little training and experience in this area and therefore lack confidence in conducting discussions about LMT and find the process stressful. …

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