A Word About Documentation

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Max Diamond, M.D.

November 9, 2021

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Meeting a patient’s needs and expectations for an ‘optimal’ end-of-life experience generally requires careful planning.

Convey Expectations

Truly compassionate care requires health care professionals to help patients and their families understand the risks and benefits of available interventions near the end of life, which are typically unlikely to prolong life or a meaningful existence in a significant manner, and may actually cause pain and suffering during the final moments.

When death arrives unexpectedly, without the opportunity for the patient and family to organize their thoughts and their estates, anxiety and often anger ensue. Sometimes this anger is misdirected toward the physician and the facility in the form of legal action. 

Certainly, some claims are based purely on greed, and only a few have real merit. The burden, capable of consuming great amounts of time and money, falls on the physician and the facility to prove that they served the patient in a manner consistent with the standards of care. Although a caregiver’s personal testimony may prove helpful, the only solid evidence, however, is the medical record.

Many health care professionals document only the episodic care that they provide on a given visit and fail to discuss the patient’s overall condition. Due to their personal beliefs, lack of comfort, or inexperience, some clinicians do not recognize (or choose to ignore) that the end of life is near. This is especially true when the patient does not have a preexisting, documented terminal disease, such as Stage IV lung or other cancers. 

Take, for example, an actual recent lawsuit from the daughter of a 92-year-old nursing facility resident, which states that her mother died “unexpectedly and prematurely.” Despite a one-and-a-half-year downward clinical course, including end-stage Alzheimer’s, seven episodes of urosepsis, two episodes of aspiration pneumonia, two pressure ulcers, and functional decline due to a non-ambulatory status, the patient’s daughter believes she was given some hope for meaningful recovery of her mother through multiple hospitalizations and intravenous antibiotics. Upon review, no documentation of the patient’s limited life expectancy was found in the nursing facility or hospital record. The case was subsequently settled in favor of the complainant through arbitration.

Clearly, it is imperative that health care professionals document both the determination that the end of life is near and all conversations with the patient and family in that regard. Examples of such documentation could include statements such as: 

“The inevitable effects of aging are in place;” 

“The patient’s life expectancy is limited;” 

“Multiple organ system failures are occurring;” and 

“The patient’s quality of life will continue to deteriorate.” 

Statements such as these should appear frequently in a long medical record; preferably, shortly after admission and then at least monthly as applicable.

Timing And Hope

A word on timing: The meeting about a compassionate care plan (at which the family is present) may be the most appropriate time to thoughtfully discuss and document the patient’s long-term prognosis, set expectations, determine end-of-life wishes, and offer clinical options to enhance patient comfort.

When discussing a poor prognosis and setting expectations with patients and families, health care professionals should focus on shifting a family’s hope from recovery to a comfortable, pain-free end-of-life experience.

All individuals desire an ‘optimal’ end-of-life experience. Through the provision of compassionate care, setting of expectations, and planning, physicians and other health care professionals working in concert can make this a reality for many patients.

In addition, careful and consistent clinical documentation of these issues may also help provide protection against frivolous lawsuits. 

For additional information please contact Dr. Max Diamond at 714-221-5182 or mdiamond@regalmed.com.

REFERENCES AND RECOMMENDED READINGS

1 . “20 Common Problems: End-of-Life Care” by Barry M. Kinzbrunner, MD; Neal Weinreb, MD; Joel Policzer, MD; 2002.

2 . “The Karnofsky. Performance Status Scale: An Examination of its Reliability and Validity in a Research Setting.” Cancer. May 1984; 53 2002-7. Mor, Vincent (Brown University).

3 . “Outcomes of Cardiopulmonary Resuscitation in Nursing Homes: Can We Predict Who Benefits?” Am J Medicine. August 1993; 95: 123-30. Tresch, Donald D.

4 . “Informing the Patient about Cardiopulmonary Resuscitation: When the Risks Outweigh the Benefits.” J General IM. September 1989; 4: 349·55. Moss, Alvin H.

5 . “Outcomes of Cardiopulmonary Resuscitation Initiated in Nursing Homes.” J Am Geriatrics Society. March 1990; 38:197-200. Applebaum, Gary E.

6 . “Tube Feeding Preferences among Nursing Home Residents.” J General IM. June 1997; 12:364-71. O'Brien, Linda A.