Surrogate Evaluation

00:02 And, you know, often when it's life-sustaining treatments, the patient may not be able to communicate with us.

00:09 They may have lost capacity and we're having to have these discussions with a surrogate decision maker. So, having a conversation about their evaluation, the surrogate's evaluation of the situation to know whether or not to withhold or withdraw the treatment.

00:26 So, the things you're going to want to ask the surrogate are number one, you know, what is the medical opinion? So, do we know what the consensus of the medical team is as to whether or not there's a recommendation about the treatment? Do we think the treatment can potentially provide some benefit? How certain are we that it can provide a benefit? What are we going to do if it's highly unlikely to work? You know, the calculus is more in favor of it not being beneficial than beneficial.

00:58 And what if the treatment has no benefit and actually may possibly cause more harm? What are we going to do in those situations? And then, lastly, in the evaluation when we're talking with surrogates, we're thinking about talking with surrogates is what if the treatment won't work at all? You know, we don't think it's going to achieve the physiologicals that we have in mind.

01:19 In those circumstances as we'll talk about when we have a lecture on futility, we're going to think about, that might be something that the clinicians do not offer to the family that it's not even offered as an option in terms of not even considering whether to withhold or withdraw it but not even providing it.

01:39 All right. So, let's think about different circumstances where the surrogates have to, you know, make a decision about a life-sustaining treatment.

01:47 So, we have a medical opinion that says this treatment seems like we should give it a try.

01:52 It's worth a try. Let's see what happens.

01:54 We think it might benefit the patient, so, therefore, you institute the treatment.

02:01 If you're uncertain about whether or not it's going to be beneficial, then, you can do a trial of therapy.

02:07 If you think it's highly unlikely to work, then, either you offer the trial of therapy, you let the surrogate make that decision in that circumstance, and then, you reevaluate.

02:20 Or if you say, "Really, I don't think it's worth pursuing at all.

02:23 I think it's highly unlikely to work. I don't want to offer it." Maybe the patient, you know, through their surrogate is going to say, "I would like to pursue it." In those circumstances, maybe there's an opportunity for them to transfer their care to another provider who would be willing to offer the treatment.

02:42 And lastly, the circumstance where you don't think there's going to be any benefit.

02:46 There's going to be possible harm, either you do a trial of therapy to see, you know, are you minimizing the harm as much as possible? Are you showing any benefits? But there's always going to be a reevaluation, a rereview to decide, where is that calculus between benefit and harm? If it's more harmful, maybe you think about withdrawing the treatment after a period of time.

03:10 When the medical opinion is uncertainty, I just don't know if this is going to work or not.

03:16 Well, if you think there's a chance that it could benefit, maybe you do institute the treatment with the surrogate's, you know, permission.

03:24 If you're uncertain of the benefit, maybe you consider a trial of therapy.

03:29 If the clinicians feel it's highly unlikely to work, well, maybe you don't offer the treatment at all.

03:36 It's permissive not to treat. And you then see how the patient does without the treatment.

03:42 And when you think there actually might be no benefit and possible harm, that is the prerogative of the clinician to say, "We're not going to offer this treatment." Now, the third circumstances might be, the medical opinion is this is not worth it.

03:55 The burdens clearly outweigh the benefits.

04:00 Something in another lecture I talk about is called potentially inappropriate treatment.

04:05 So, in this case, you know, you don't really see that there's going to be benefit where you think the burdens far outweigh the benefits.

04:13 You might start treatment but you're going to have an ongoing discussion with the surrogate of, you know, we really need to make sure that this is the right thing to do.

04:22 When you're uncertain whether there's going to be a benefit, you either don't offer the treatment or you offer a trial of therapy.

04:29 When you think it's highly unlikely to work, you, again, you may not offer the treatment at all or you might offer the trial of therapy.

04:38 And then, lastly, where you think there's actual possible harm, that might be a case where there's no benefit, more harm than good, you don't offer the treatment.

04:49 So, very challenging situations, especially when it's life or death decisions that either the patient or the family has to make.

04:57 So, you want to be clear, you know, to have these discussions, have family meetings, to go over these details, and then, document what the decisions have been and how you're going to move forward with the plan of care.

05:10 So, what you need to document when there is a decision about foregoing life-sustaining treatment, first of all, what the patient's medical condition was or is.

05:19 What you expect the natural history would be without treatment? What were the reasons given for either withholding or withdrawing the treatment? You know, both from the medical perspective as well as from the patient or surrogate perspective.

05:35 Who was involved in the decision-making process? So, was it the patient themselves? Was it their authorized decision-maker? How did they reach their decision? What are going to be the goals going forward for their ongoing care? So, even if the life-sustaining treatment might be foregone, what's going to be their treatment plan irrespective of that? How are we going to take care of them, make sure that their quality of life, their comfort is taken care of? And then, lastly, you know, what are the other ways we're going to manage any kind of distress either by the patient or their decision-maker as we move forward? And again, an opportunity for reevaluation, adjusting things to make sure we're serving everybody's interest in the process.