Advance Care
Planning
Care Coordination Collaborative
April 5, 2017
What is Advance Care Planning?
It’s the process of planning ahead for medical care in the event
that you are unable to communicate your wishes to your family
and your healthcare providers.
It involves having conversations about your values and wishes
for care with your family and healthcare providers before you
become ill.
Why do we need to talk about
advance care planning?
Dying has changed…
1900
2016
Age at Death
46 years
81 years
Leading Causes
Infection
Accident
Childbirth
Cancer
Heart Disease
Stroke/Dementia
Disability before Death
Unusual & Brief
On Average, > 4 years
Costs
Low & Affordable
Very High & Long
Periods
Where do we die today?
88% say they want to die at home
20% actually die at home
“A Soul Doctor and a Jazz Singer”
90% of people say that talking with their loved
ones about end-of-life care is important.
One
27% have actually done so.
conversation
80% of people say that if seriously ill, they
would want to talk to their doctor about wishes
for medical treatment toward the end of their
life.
can make all
the difference.
Source: The Conversation Project National Survey (2013).
7% report having had this conversation with
their doctor.
Source: Survey of Californians by the California HealthCare Foundation (2012).
82% of people say it’s important to put their
wishes in writing.
23% have actually done it.
Source: Survey of Californians by the California HealthCare Foundation (2012).
Types of Advanced Directives
Health Care
Proxy
Living Will
Do Not
Resuscitate
Orders
(DNR)
MOLST
Power of
Attorney
Health Care Proxy
The New York Health Care Proxy Law allows you to appoint someone
you trust (a family member or close friend) to make health care
decisions for you if you lose the ability to make decisions for yourself.
• Encourage all of your patients to complete a health care proxy! Appointing a
health care agent is a good idea even if you are not elderly or terminally ill
• Anyone 18 years of age or older can be a health care agent
• A Health Care Proxy is different than a living will. A Health Care Proxy does not
require that you know in advance all the decisions that may arise- instead, the
health care agent can interpret your wishes as medical circumstances change and
can make decisions you could not have known would have to be made
• All competent adults, 18 years of age or older, can appoint a health care agent by
signing a form called a Health Care Proxy
• Does not require a lawyer or notary; just two adult witnesses
Living Will
• A Living Will is a written declaration of your health care wishes
• Serves as evidence of your wishes about medical treatments you may
or may not want, when you are no longer able to decide for yourself
• New York does not have a statute governing Living Wills, the Court of
Appeals states that Living Wills are valid as long as they provide “clear
and convincing” evidence of your wishes
• There is no standard Living Will form
How do I help my patient decide what advance
directive is best for them?
If you are in a coma or vegetative state or otherwise incapacitated, would you
want someone you trust to make medical decisions for you?
If the answer is YES, consider a Health Care Proxy that is appointing someone you
trust as your Health Care Agent to speak and decide for you when you are unable
to do so.
If the answer is NO because you have no one you trust to act as your Health Care
Agent, consider a Living Will so that your medical instructions are clear and can be
read by your care givers when you are unable to communicate your wishes.
How do I help my patient decide what advance
directive is best for them?
Even though you want someone you trust to make medical decisions, do you still
have strongly held views about specific situations?
If YES, you may consider being more specific on the Health Care Proxy form, so
that the person you appoint to act on your behalf can also rely on your written
instructions to make decisions for you.
If NO, then maybe just a Health Care Proxy will meet your needs.
Medical Orders for Life-Sustaining
Treatment (MOLST) Form
• Allows doctors to record your preferences regarding life sustaining
treatments on to one form as a physician order
• MOLST must be completed by a health care professional and signed
by a New York State licensed physician to be valid
• Intended for patients with chronic, serious, advanced illnesses
• Not intended to replace a Health Care Proxy and/or Living Will
• MOLST translates your current medical treatment preferences into
physician orders whereas a Health Care Proxy and/or Living will
guides future medical care
Do Not Resuscitate Orders (DNR)
• A DNR Order instructs medical professionals not to perform emergency treatment to restart your
heart or lungs when your heartbeat or breathing stops
• Doctors, nurses, paramedics will not initiate emergency procedures such as mouth-to-mouth
resuscitation, external chest compression, electric shock, insertion of tube to open your airway, or
injection of medication into your heart or open chest
• In New York, any adult 18 years or older can get a Hospital or Non-Hospital DNR Order
Hospital DNR
Non-Hospital DNR
• Issued if you are in a health care
facility such as a hospital or nursing
home
• If you are outside of a hospital or
nursing home, consider a NonHospital DNR
• EMS must honor your Hospital DNR
Order during transfer
• Must be recorded on a state specific
form (DOH-3474)
• Must make Hospital DNR wishes
known in your health care proxy,
living will or a MOLST form
Power of Attorney
Under New York State law, you can designate a person to make property,
financial, and other legal non-healthcare decisions on your behalf through a
Power of Attorney.
• Durable Power of Attorney: allows you to appoint an Agent to act for you immediately upon its
execution or the occurrence of some future event identified b you and lasts until cancellation by
you or upon your heath; this power continues when you are mentally or physically incapacitated.
• Power of Attorney: can be used to grant any and all of the following legal powers: buy/sell your
real estate, manage your property, banking transactions, invest/not invest your money, make
legal claims
Power of Attorney is often used to plan for one’s future incapacity or disability of competence
resulting, for example, from Alzheimer’s disease or a catastrophic accident.
Power of Attorney cannot be used to make medical decisions on your behalf.
You play a very important role!
The people you serve may feel more comfortable with you
given your personal relationship and YOU can encourage them
to start these difficult conversations.
You can act as an advocate! You do not need a clinical
background to initiate Advance Care Planning.
Call to Action: You are encouraged to identify and assist 3
patients with completing a Health Care Proxy.