3 Patient Documents You Should Keep on File

In the ER, I observe the making of many end of life decisions.  Often, the patient is unable to speak, think or make healthcare decisions for themselves so the providers do so for them.  Do we intubate this 95 year old patient to keep them alive artificially or not?  We don't know what they would have wanted.  Keeping certain patient documents in your EHR helps in making critical decisions for your patients.  Which documents should you keep on file?

1. Latest EKG

An EKG is like a map to the condition of a patient's heart.  Some people have perfectly normal EKG's while other patient's EKGs indicate signs of long term heart damage such as LVH or arrhythmia's like a fib.  Some EKG changes are easy to identify as benign or chronic while others are not.  When a patient presents to the ER with chest pain, if the provider knows which EKG changes are new versus old, it can significantly help in decision making regarding patient care.

Treating patients with old EKG's in the EHR system is much easier.  I am able to determine if a flipped T-wave is a significant new abnormality necessitating admission and possibly a cardiac cath or, if it is chronic and likely does not need urgent evaluation.  Treating patients for chest pain without old EKG's can be challenging.  Providers must assume that all abnormal changes are new resulting in hospital admissions and testing that may not be necessary.  If you are the primary care provider for a patient with an abnormal EKG, it is not a bad idea to give them a copy to keep in their wallet should they ever need emergent treatment for cardiac symptoms.

2. Power of Attorney

Making decisions regarding end of life care is a sticky situation.  It causes fights in families and uncertainty on the part of patients, providers and a patient's loved ones.  From my desk at work I have witnessed shouting matches and doors being ripped from their hinges as families attempt to decide exactly what medical treatment they should authorize for their loved one. 

If patients select a power of attorney, their families can often avoid the conflict associated with making medical decisions.  In a power of attorney document, a patient elects an individual to make decisions regarding their medical care should they be unable to do so themselves.  Primary healthcare providers should have conversations with patients encouraging them to select a power of attorney for their medical care long before it is necessary.  A copy of this document should be kept on file at the PCP's office for reference.  This will give medical providers a clear understanding as to who has the legal power to make medical decisions for the patient and preventing conflict within families.

3. Advanced Directive

Also referred to as a living will, this document specifies what treatment measures a patient would like should illness or incapacity render them unable to decide for themselves.  Studies indicate that 75 to 90 percent of individuals would like to refuse aggressive medical treatment rather than have their lives medically prolonged or live with a poor prognosis.  As healthcare providers we can easily observe that patients are not being treated with these most common end of life wishes in mind.  By creating an advanced directive, patients are able to outline exactly what treatment measures they want taken to keep them alive.

Primary care providers must encourage patients to create an advanced directive.  Patients should be encouraged to share their wishes with family members so their loved ones are more likely to accept these wishes in the event of end of life care.  Primary care providers should also keep a copy these documents on file for reference. 

Even with these documents, managing families of critically ill patients and making medical decisions based on a patient's wishes can be difficult.  But, these three documents can be very helpful in providing a starting point in patient care and guiding your decision making.  Keeping them handy for all your patients will help both you and other healthcare providers in making difficult medical decisions.

Comments

It is idealistic to think that in an emergency even if you do have these documents on file, they will be available to the provider who is actually treating you. Maybe in the future, but not with our current disjointed computer systems.

I do think it is a good idea to discuss power of atty. and end of life care with patients and encourage them to share their decisions with their families.

Susan

I agree it would be ideal to have these documents on file for all patients but I find there are 2 major barriers:

1. The EHR system used at my workplace doesn't have a feature that would allow me to store these type of documents
2. Even if I could keep them for patients at my clinic, there is no way for providers at other locations to see them

Chris