GeriPal Podcast: Surrogate Decision Making

In 1983, a 25 year old Nancy Cruzan was thrown from her car while driving home in Missouri, landing in a water filled ditch. She was resuscitated by EMS, but did not regain higher brain function, and was eventually diagnosed as being in a persistent vegetative state. In 1988, Cruzan s parents requested that her feeding tube be removed, arguing that she would not want to continue in this state. The hospital refused without a court order, and the case eventually made its way to the Supreme Court. Arguing for the state of Missouri against the Cruzan s was Ken Starr, who would later be assigned the role of special prosecutor in the investigation of the Clintons (Whitewater, Lewensky, etc). In 1990 the Supreme Court ruled for the state of Missouri. On the one hand, this was unfortunate, as it meant Nancy Cruzan could not be disconnected from the feeding tube immediately. On the other hand, the ruling allowed states to set their own evidentiary standards to refuse or withdraw life sustaining interventions. Missouri set a very high bar, explicit written documentation that applies to this specific circumstance, which the Cruzan s eventually cleared. Other states set lower bars, including oral assignment of surrogate decision-makers. The Cruzan ruling led to a flood of interest in Advance Directives, and eventually to the Patient Self Determination Act, which mandates provision of information about advanced directives to all hospitalized patients. Today, we talk with Bernie Lo, prominent bioethicist and practicing primary care internist, and Laurie Dornbrand, geriatrician at the IOA On Lok PACE, about the legacy of Nancy Curzan. We use Bernie s NEJM Perspective as a springboard for discussion. We discuss, among other things: How and why in the 30 years since the Cruzan ruling the emphasis has shifted from advance directive forms to in-the-moment discussions And validating the importance of the advance directive forms in some circumstances, and in starting conversations The role of the clinician in engaging patients in advance care planning and in-the-moment serious illness conversation: what questions are important? What words to use? Is the POLST useful? How? Under what circumstances? Should we abandon the term, comfort measures?

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