Medical emergencies require immediate action. At the same time, these must take the patient's presumed wishes into account. To ensure this, various forms exist. A national working group is analyzing in a sub-project the significance of these forms and their relationship to other documents relating to advance care planning (ACP). The aim is to create a standardised form for the whole of Switzerland.
Existing advance care planning (ACP) documents, such as advance directives and treatment plans often do not provide readily identifiable instructions for acute emergencies. They are therefore only partially helpful in these situations. Without time to derive the presumed wishes based on openly stated values.
The ACP concept for emergency situations or forms such as a «Medical order for life-sustaining treatment» fill this gap. However, at present there is no standardized definition or approach in Switzerland. For this reason, the national working group ACP has set up a sub-working group to clarify the significance of these forms and their relationship to other ACP documents. The aim is to introduce and use a standardized ACP form for emergency situations nationwide (see recommendation 11 of the ACP roadmap).
Example of an acute emergency
A patient living at home or in a retirement or nursing home suffers a sudden deterioration in her state of health with imminent circulatory failure and loss of capacity (or lack of capacity). Decisions must be made quickly: Should she be intubated or resuscitated? Would a transfer to a hospital be in line with the patient's presumed wishes?
Initial results of the sub-working group
Based on the responses obtained from the public consultation on the roadmap ACP, the sub-working group has addressed pending questions regarding ACP for emergency situations. The initial results on the clarification of formal, medical-ethical, and legal aspects are presented below.
Contents of an ACP form for emergency situations
The form
- contains only information for acute emergencies that require an immediate decision on the use of medical measures;
- contains instructions for healthcare professionals in the form of a yes-no scheme regarding resuscitation, invasive ventilation, hospitalization, transfer to the intensive care unit, and life-sustaining measures.
Purpose and function
The form
- increases the validity of advance care planning and ensures that the patient's presumed wishes are respected in an emergency;
- serves as a means of communication between institutions (emergency services, hospital, nursing home, etc.);
- is used at home, in the outpatient sector, and in institutions.
Development process
The ACP form for emergency situations is developed during an interview between a patient and a (medical) specialist, usually as part of an ACP process. If an advance directive or treatment plan is in place, the form summarizes the instructions for emergency situations. In the absence of an advance directive, a treatment plan for a person who lacks capacity, or a willingness to prepare these documents, the healthcare professional will at least clarify values and treatment goals in a discussion before the emergency form is discussed and completed.
The form contains instructions with far-reaching consequences. It is therefore crucial that the person concerned or their authorized representative is well informed and accepts or refuses a particular medical measure. The discussion ensures that only medical measures indicated by the person’s state of health are chosen.
Intended audience
The greater the likelihood of an emergency situation involving incapacity, the more advisable it is to complete the form. The completion of ACP documents is always voluntary. However, the experience of professionals consistently shows that those affected understand and appreciate the added value of ACP in emergency situations.
The form is recommended for anyone in a situation corresponding to module 3 of the roadmap: «Disease-specific ACP». This includes people with advanced incurable disease, chronic physical and/or mental (multiple) conditions, including those with severe cognitive disability and children/adolescents with life-limiting illnesses and/or people nearing the end of life. For people whose situation coincides with module 2 «Detailed ACP», completing the form may be considered.
Format
The form is on a single page and, ideally, uniformly designed throughout Switzerland. As a general rule, it is signed by two people: a) the person concerned or, if he or she is already lacking capacity, his or her authorized representative, and b) the doctor.
In exceptional cases, the form may be signed by the doctor alone, if it is necessary to document which medical measures are not medically indicated. This may be the case, for example, on admission to hospital if the patient's presumed wishes are not yet known and the medical situation has not yet been discussed with the person concerned or their authorized representative.
Where to store it
The ACP form for emergency situations is stored in electronic systems of the healthcare institutions and/or in PDF format. The person concerned, their authorised representative and other relatives have a printed copy of the form. A central storage location is crucial. Within the institution in the patient’s or resident’s dossier, or in a designated place at home such as the inside of the front door.
Legal aspects
The SAMS has commissioned Prof. Dr iur. Regina Aebi-Müller, University of Lucerne for an expert opinion on the legal issues. The main aim was to clarify the legal status of «Medical order for life-sustaining treatment» forms, which are used in many cantons and hospitals, in relation to the Swiss Civil Code (CC) which only refers to «advance directives» and «treatment plans» as ACP instruments.
The following findings can be derived from the legal opinion regarding the positioning of the ACP form for emergency situations and similar existing forms.
Although the form is not mentioned in the legislative framework, it is a valid ACP document that must be taken into account in treatment. For two reasons: Firstly, an advance directive can be limited to specific situations – including acute emergencies. Secondly, there is a connection to the treatment plan, which must not only cover the current medical situation, but also an expected emergency situation.
From a legal perspective, the existence of a separate legal form for emergency situations is an advantage. It is desirable for both the advance directive and the treatment plan to contain information on personal values and treatment goals or scenarios in the event of incapacity. However, in an emergency, it is often difficult to deduce the right course of action quickly enough. This form fills the gap and makes a vital contribution to ensuring that the patient's presumed wishes are respected.
Composition of the sub-working group
The broad-based sub-working group has been active since summer 2024.
Professor Miodrag Filipovic, St. Gallen, Intensive Care Medicine, President
lic. theol., dipl. biol. Sibylle Ackermann, Ethics, SAMS (ex officio)
Dr Gabriela Bieri-Brüning, Zürich, Geriatrics/Inpatient Long-term Care
Professor Monica Escher, Genève, Palliative Care
Monica Fliedner, Bern, Palliative Care (on behalf of Professor Steffen Eychmüller)
Dr Caroline Hartmann, Bern, Law
Isabelle Karzig-Roduner, RN, MAE, MScN, ACP-Swiss, Zürich, Advance Care Planning
Professor Dagmar Keller, St. Moritz, Emergency Medicine
Professor Tanja Krones, Zürich, Clinical ethics
Dr Barbara Loupatatzis, Wetzikon, Advance Care Planning
Dr Philippe Luchsinger, Affoltern, Family Medicine
Dr Marc Lüthy, Basel, Rescue Medicine
Dr Daniela Ritzenthaler, Lausanne, Ethics
lic. iur. Michelle Salathé MAE, Basel, Ethics and Law
Dr Andrea Trippini, Lausanne, Intensive Care Medicine
Silke Walter, MSc Palliative Care, APN, Liestal, Care
Further activities in the ACP sub-project for emergency situations
The aim of the sub-project is a single standardized ACP form for emergency situations for the whole of Switzerland and to implement its use widely. As a next step, the key points of this approach will be conceptualized in a document and submitted for a broad consultation process in early 2025. The consultation process will focus on open questions such as the name of the form in all national languages, the type of visualization of the yes/no scheme, or the question of a central storage location.