What you will learn in
this class:
 Bioethics/Laws
 Advance Care Planning
 Completing an Advance Health Care Directive
 Choosing a health care agent
 Advance Directive vs. Physician Orders
for Life-Sustaining Treatment (POLST)
2
Common Questions
1) What is Advance Care Planning?
2) How do I complete an Advance Health
Care Directive?
3) How do I go about making such
important decisions?
3
Ethical Duties that Guide
Medical Decision Making:
 Respect for Persons
“autonomy”
 Do no harm
 Provide Benefit
 Fairness
4
Laws
Federal Law: Patient Self-Determination Act of
1991
 Patients right to accept/refuse treatment
 Upholds the right to create advance directives
California Rights: CA Health Care Decisions
Law: AB 891
 The law includes a form-Advance Health Care
Directive
5
Advance Health Care Directive
A form you complete that states your desires and
beliefs about treatment which includes:
 Who will make health care decisions for you
 Your beliefs about organ donation
 The name of your primary physician
 Person completing the advance directive must be:
a California resident
at least 18 years old
of sound mind
6
When Is Your Advance
Directive Activated?
When a patient loses “decisional capacity”
 Ability to understand
 Ability to organize information
 Ability to communicate a response
 Ability to deliberate according to
one’s belief system, values, and attitudes
7
Advance Care Planning
Continuum
Age 18
C
Complete an Advance
Directive
O
Update Advance Directive
N
Periodically
V
Diagnosed with Serious or
E
Chronic, Progressive Illness
R
(at any age)
S
Complete a Physician Orders
A
for Life-Sustaining Treatment
T
(POLST) Form
End-of-Life
I
O
Wishes Honored
N
8
What is POLST?
Physician Order for Life Sustaining Treatment
recognized throughout the medical system
 Brightly
colored, standardized
form for entire state of CA
 Portable
document that
transfers with the patient
 Provides
direction for a range
of end-of-life medical treatments
9
Advance Directive vs
POLST
Advance Directive
POLST
For every adult
For the seriously ill
Requires decisions about myriad
of future treatments
Decision among presented options
Clear statement of preferences
Checking of preferred boxes
Needs to be retrieved
Stays with the patient
Requires interpretation
Actionable medical order
10
5 “D’s” to Update an
Advance Directive
When you…
Divorce
reach a new Decade
receive a new Diagnosis
have a Decline in your condition
experience a Death of a close relative or friend
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Complete Advance Directive
 The doctor will provide
you with all the
information necessary
to make an informed
treatment decision
 You should know about
your disease process
and longevity
 What to expect with or
without treatment
12
Complete Advance Directive
“Advance Medical Directives” - Staywell Company
If I Had A…..
I Would Want…….
CPR
Pressors
Ventilator/
Respirator
Tube
Feeding
Kidney Pain
Dialysis Medication
No
Treatment
Sudden Complication
·With no other severe
problem
With other severe
problem
Chronic Illness
Controlled
Uncontrolled
Deadly Illness
·Treatment keeps me
comfortable
•Treatment cannot
comfort
Endless Coma
No other problems
Deadly illness
13
Who is the best Health Care
Agent for Me?
Someone who:




I trust to carry out my wishes
is emotionally stable
is an effective communicator
REALLY knows me and
can support my treatment choices
Your agent cannot be:
 your doctor or health care provider
 an employee of your doctor/hospital/
nursing home unless related
14
Health Care Agent
Duties/Obligations
To ensure that your medical treatment wishes are
followed using two standards:
1. “substituted judgment”
decided as YOU would decide
2. “best interests assessment”
if your wishes are unknown,
agent needs to consider your beliefs
and what is important to you
 quality of life
 extent of suffering
 prognosis
15
Health Care Agent
Duties/Obligations
Can:
 choose life-sustaining and other
treatment for you
 refuse life-sustaining and other
treatment for you
 agree that a treatment you are
having should be stopped
 access and release your medical
records
 request an autopsy
 donate your organs (unless stated
otherwise)
Cannot:
 commit you to a psychiatric
hospital
 agree to electric shock
treatment
 consent for psychosurgery
 consent for sterilization
 consent for abortion
16
Making Treatment Decisions
17
Potential Goals
of Treatment
 Cure of disease
 Avoidance of
premature death
 Maintenance or
improvement
in function
 Prolongation of life
 Relief of
suffering
 Quality of life
 Staying in
control
 A good death
18
Expectations / Quality of Life
 A treatment can produce an
effect, but, is it providing what I
believe to be a benefit?
 Contributing to a life that I
deem acceptable?
19
(DNR)
Do Not Resuscitate Orders
A medical order to refrain from CPR if your
heart stops beating -- it does not mean
that other treatments will be stopped
CPR will be attempted unless there is a
DNR order in your medical chart
20
Why Choose DNR?
 When CPR won’t restore function of heart or
lungs
 When death is expected due to irreversible
medical condition
 terminal illness
 permanent unconsciousness
 irreversible organ failure with
survival not likely
21
Palliative Care/ Hospice
 Pain/
symptom control
 Spiritual Care
 Psychosocial Care
22
Cardiopulmonary
Resuscitation
Procedures to restart the
heart and breathing, like
mouth-to-mouth
resuscitation, external chest
compressions, electric
shock, insertion of tube to
open airway, injection of
medication into the heart,
open chest heart massage
23
Mechanical Lung Ventilation
24
Nasal Gastric Tube Feeding
25
Percutaneous Gastric Tube
Feeding
26
Kidney Dialysis
27
Pressors
 Medicines that control one’s blood pressure
 Use of pressors in the ICU is generally for
making blood pressure go up
 What are the benefits of pressors?
 What are the burdens of pressors?
28
Quality of Life/ Values
 What do you fear most about illness?
 How would you feel if you lost your
independence? Mental alertness? Physical
abilities? Financial independence?
 How would you feel if you could not engage in the
activities you enjoy?
 How would you feel if you could not interact with
the people you love?
 How do you feel about being cared for in a
nursing home?
29
Beliefs
 What are your beliefs about life
and death?
 Does your religion, culture,
spiritual beliefs strongly guide you
in decisions about life and death?
 What role do pain and suffering
occupy in your life?
 What is the role of medical
technology in prolonging life?
30
What you learned in class:
 Bioethics/Laws
 Advance Care Planning
 Completing an Advance Health Care Directive
 Choosing a health care agent
 Advance Directive vs. Physician Orders
for Life-Sustaining Treatment (POLST)
31
Now What do I Do?
 Discuss with your primary doctor and/or specialist
any questions, worries, issues about your health
before you fill out your advance directive
 Discuss your wishes and advance directives with
your surrogate(s) and close family members,
ensuring that they can and will follow your wishes
in the event you cannot speak for yourself
 Fill out the directive
32
Now What do I Do?
 Sign and date it before 2 witnesses or a
notary public
 Make copies for yourself, your surrogate
(s), your doctor, your family, your lawyer keep original in an accessible place (not a
safe-deposit box)
 Mail your form to:
Kaiser Medical Office Records
7385 Mission Gorge Road
San Diego, CA 92120
33
Kaiser Permanente Resources
 KP Web Site www.kp.org
 http://www.permanente.net/homepage/kaiser/pdf/44666.pdf
 www.kp.org/healthylifestyles (personalized
programs for weight loss, smoking cessation,
stress reduction, nutrition)
 Healthier Living Class 619-641-4194
 Positive Choice -Weight Mgmt. 858-573-0090
 Health Education - Quit Smoking Program & many
other programs for health and well-being
619-641-4194
34
Paula Goodman-Crews, M.S.W., L.C.S.W.
Medical Bioethics Director
Kaiser Permanente, San Diego
voice-mail: 619-528-5213
35
Michael Markman MD
Division of Pulmonary/Critical Care Medicine
Kaiser Permanente, San Diego
36