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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)

What you will learn in What you will learn in this class:this class:

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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?

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Ethical Duties that Guide Medical Decision Making:

Respect for Persons “autonomy”

Do no harm Provide Benefit Fairness

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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

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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

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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

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Advance Care Planning Continuum

Complete an Advance Directive

Complete a Physician Orders for Life-Sustaining Treatment (POLST) Form

Age 18

End-of-Life

Wishes Honored

Diagnosed with Serious or Chronic, Progressive Illness (at any age)

Update Advance Directive Periodically

CC OO NN VV EE RR SS AA TT II OO NN

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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

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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

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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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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

Complete Advance Directive

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Complete Advance Directive “Advance Medical Directives” - Staywell Company

If I Had A….. I Would Want…….

CPR Pressors Ventilator/ Respirator

Tube Feeding

Kidney Dialysis

Pain Medication

No Treatment

Sudden Complication·With no other severe problemWith other severe problem

             

Chronic IllnessControlledUncontrolled

             

Deadly Illness·Treatment keeps me comfortable•Treatment cannot comfort

             

Endless ComaNo other problems Deadly illness

             

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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

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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

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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

17Making Treatment Decisions

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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

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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?

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(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

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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

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Palliative Care/ Hospice

Pain/ symptom control Spiritual Care Psychosocial Care

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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

Cardiopulmonary Resuscitation

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Mechanical Lung Ventilation

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Nasal Gastric Tube Feeding

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Percutaneous Gastric Tube Feeding

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Kidney Dialysis

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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?

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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?

Quality of Life/ Values

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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?

Beliefs

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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)

What you learned in class:What you learned in class:

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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

Now What do I Do?

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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 RoadSan Diego, CA 92120

Now What do I Do?

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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

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Paula Goodman-Crews, M.S.W., L.C.S.W.

Medical Bioethics Director

Kaiser Permanente, San Diego

voice-mail: 619-528-5213

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Michael Markman MD

Division of Pulmonary/Critical Care Medicine

Kaiser Permanente, San Diego