Advance Care Planning/Advance
Health Care Directives
Willow Glen (San Jose)
Parkinson’s Support Group
Cheryl Bartholomew, BSN, RN
Volunteer Advance Health Care Directive Counselor
El Camino Hospital Health Library
[email protected]
4/1/2016
1
Advance Health Care Directive –
The Basics
• What is it, and what does it do for me?
• Is it a legal document?
• Does it need to be done by an attorney or a
Notary Public?
2
What does an AHCD do?
• Allows you to
– 1. Name agent(s) to make health care decisions
when you can no longer make them yourself
– 2. State what treatments you would like and
what treatments you would not like—and under
what circumstances—can spell these out in a
personalized statement
• May do both, but may do just one or the
other
– No named agent or No health care instructions
3
PART 1:
CHOOSING YOUR AGENT
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Agent must be:
Agent may be:
Eighteen or older
Have capacity
A family member or
friend
TO AVOID CONFLICTS
Agent should be: someone who knows
and will respect your values;
Can be expected to be available when needed;
Is willing to accept the privilege/responsibility;
Has the requisite personality to do the job __
TO AVOID CONFLICTS
Agent may not be:
• Someone you wish to “disqualify” in writing
• Possible reasons:
– Protection from someone arriving on the scene,
perhaps unexpectedly, demanding that he/she
be in charge or that the doctor “do everything”
– Fear of differing values interfering with proper
choices
– A personality that might prove difficult
6
Titles of decision-makers
• In California in 2012, there is no legal
hierarchy for naming the decision-maker
as in “spouse”, “adult child” etc.
•
•
•
•
Agent (written AD)
Surrogate decision-maker (verbal AD)
Conservator
Attorney-in-fact
7
When does the agent’s authority
become effective?
• When the primary physician determines that you have
lost capacity to make health care decisions…
• Unless you elect to have that authority in place even
while you have capacity:
–
–
–
–
–
Because of your lack of medical sophistication
Your cultural expectations
Aging, “slowing down” of thinking
Your wish to honor the person you’re choosing as ‘Agent’
Your wishing to avoid MD’s evaluation of your capacity
8
Competence v. Capacity
• Everybody presumed to be “competent”
• “Capacity” determined by “primary physician”
• No simple scheme to determine capacity… various tests,
subjective assessment by skilled practitioners
• Variability of capacity
– Fluctuates
– Can be affected by meds, time of day, pain level
9
PART 2:
END-OF-LIFE TREATMENT
OPTIONS
10
Typical Choices
• (a) Choice Not to Prolong Life . . . when
the likely risks and burdens of treatment
would outweigh the expected benefits, OR
• (b) Choice To Prolong Life. . as long as
possible within the limits of generally
accepted health care standards
• Burden/benefit ratio highly individual
11
Treatment is a benefit if…
• Prolongs life of acceptable quality to reach a
particular goal
• Restores or maintains desirable function
• Promotes your goals and values
• Is consistent with your cultural and
spiritual values
12
Treatment is a burden if …
•
•
•
•
•
Results in more or unacceptable pain
Damages body image or function
Does psychological harm
Creates unacceptable cost
Contradicts your spiritual and cultural
values
13
If you had irreversibly lost capacity,
what do you think you would prefer?
• A prolonged life, with visits from family and
friends?
• An illness or condition that could end your
life if not treated aggressively (such as
pneumonia or a severe heart attack)?
14
A few thoughts-• Most people would rather not die in a hospital
• About half of us are not able to make our own
decisions when we are close to death
• The “default position” in medicine these days
is to treat
• Conflicts are common when there are no clear
wishes
• Patients’ rights need to be protected
15
What do people, yourself or
others, fear at the end of life?
•
•
•
•
•
Pain & suffering, inadequate pain relief
Loss of control, loss of dignity
Being a burden
Relationship issues
Inappropriate prolongation/shortening of
life
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Current Standards of Care
• Physicians, PAs and NPs should talk with
all adult patients who have capacity about
future wishes if they lose capacity
• Treatment for patients lacking capacity
must respect their prior wishes
• Artificial nutrition and hydration are
medical treatments
• MD’s must comply with an AD “and a
reasonable interpretation thereof”
17
*
Standard AD form, with minimum
information/instructions
(CMA form, “standard” form available in several different languages)
vs.
Individualized health care instructions
(various organizations, disease-specific instructions, worksheets,
customized personal wishes)
18
Making an individual, specific,
“authentic” AD by
addressing issues of:
(pages may be added: must be signed and dated same time as AD)
•
•
•
•
Personal and cultural values, faith
tradition, family needs
Quality of life (“_______ ” is worse than
death for me)
Use of new treatment not previously known
Post-death wishes, arrangements
__
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Choices that might be addressed:
(additional sheets may be added as needed)
• Provision, withholding, or withdrawal of lifesustaining treatments: including but not limited to
–
–
–
–
cardio-pulmonary resuscitation (CPR)
artificial nutrition and hydration
antibiotics
transfusions
• Provision of pain relief—’palliative care’
• Organ or body donation
__
20
Stating goals of care
• “. . .minimum quality of life, meaning I must
be able to:
_________________________________
_________________________________”
21
Precedence statement: a choice
If there is a conflict between the health care
instructions I have given and what my agent
thinks best—in the moment, given new
information, for reasons of family needs (to
travel, for instance),
a) I give precedence to my agent, to make decisions
in his/her best judgment
OR
b) I want my written word to be followed as
precisely as possible
22
Only 3 requirements for legal AD:
(CA probate code 4673)
• Date of execution
• Signed by the principal (you!) (or in your
name by another adult in your presence
and at your direction)
• The AD is either acknowledged before a
notary public or signed by at least two
witnesses (certain requirements, e.g. not
the Agent)
23
Duration of an Advance Directive
• Lasts indefinitely unless
– A limited time has been specified in the AD
– You (the “Principal”) revokes it –this requires
capacity
• Prior to 1992, duration was limited to 7
years unless-– Already in effect (principal lost capacity while
AD was valid)
24
When to review Advance Directive?
• Regularly: at least every two years (Tax
time? Your birthday?)
• Change in circumstances
– New diagnosis or health status
– Death in family
– Divorce (if spouse was named as agent ,
automatic revocation only of agent designation)
– Different physician
– Different health plan
25
ADVANCE HEALTH CARE DIRECTIVES
DO NOT APPLY IN AN EMERGENCY
Paramedics will recognize only
1. The Pre-Hospital Do Not Resuscitate
form or
2. Physician Orders for Life Sustaining
Treatment (POLST) or
3. A Medic-Alert bracelet or medallion
engraved Do Not Resuscitate __
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DOCUMENT CLARIFICATION:
• AHCD (or AD): initiated by you and does not
require a physician’s signature;
• Pre-Hospital Do Not Resuscitate (DNR)
Form: can be initiated by you or your agent or
your physician and must be signed by a
physician;
27
• POLST (Physician Orders for LifeSustaining Treatment):
– must be signed by a physician, or as of
1/1/2016, a Nurse Practitioner or Physician
Assistant.
28
Pre-Hospital Do Not Resuscitate Order
• “Request to forgo resuscitative measures”
• Written document, signed by a) the principal
(you) or a legally recognized surrogate decisionmaker, and b) a physician
• Evidenced by Medic-Alert bracelet or medallion
engraved “do not resuscitate” or “DNR” (DNAR)
• Applies “within or outside a hospital or other
health care institution”
29
Physician Orders for Life
Sustaining Treatment:
POLST
• What is it?
– Physician order;
– AB 3000, effective Jan 1, 2009 (last revision
done 1/20/2016);
– Standardized bright pink form
– Addresses issues beyond resuscitation
• What is POLST not?
– Not an AD or a document limited to “Do
Not Resuscitate”
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Who SHOULD have a POLST?
• POLST particularly useful for
– Frail elders, especially those in any facility
– Anyone with one or more chronic, progressive
diseases
– Anyone with a terminal illness
– Anyone whose “death within the next 12
months would not surprise us”
– Others interested in defining their end-of-life
care
31
Thank you for the opportunity to visit
with you today and have this
conversation! Questions and/or
comments are welcomed!
• Cheryl Bartholomew, BSN, RN
• Volunteer Advance Health Care Directive Counselor
• El Camino Hospital, Health Library and Resource
Center
• For appointments: 650-940-7210
• [email protected]