Have YOU Had the Conversation?

Have YOU Had the Conversation?Lindsay Bergmann & Emily FraserNURS 810Families in Health and Illness

The University of New HampshireDepartment of NursingJuly 15, 2014

What ifWhat if something happened to you tomorrow?

What if that something left you unable to voice or make decisions about your own personal medical care?

What if that something happened today?

Would your loved ones know what your wishes were?

We know we should talk about what we would want at the end of life, but it can be hard.

Preparing helps.

Help ease your family's pain over questions like these when making difficult decisions for you and take comfort in knowing that your wishes are honored by talking about Advance Directives.

Advance Care PlanningThe 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. (4)DHMC 20086

Advance Care PlanningPlease click on the BLUE hyperlink below to learn more about Advance Care Planning.

https://www.youtube.com/watch?v=eMU8hS_Ia60

What is an Advance Directive?A legal document outlining your wishes for health care, so they will be known in the event you are not able to communicate those choices. An Advance Directive usually consists of two parts:Durable Power of Attorney for Health Care (DPOAHC)Living Will or Statement of Treatment Wishes

(4)

DHMC 20088

Durable Power of Attorney for Health Care(DPOAHC)Also referred to as your healthcare agent, proxy, or surrogate. Document where you name a person you trust and would want to make healthcare decisions for you if you become unable to make or communicate them yourself. (4)DHMC 20089

Living Will or Treatment WishesA document that helps you define your written wishes about life-sustaining treatments and comfort care, if you are permanently unconscious or near death and unable to speak for yourself.

(4)

DHMC 200810

Advance DirectiveA copy of your completed Advance Directive should be provided to:Healthcare providersLocal hospitalFamilyChosen DPOAHCAnd a copy for yourself (4)

DHMC 200811

Patient Self-Determination Act(PSDA)Started in 1990, encourages everyone to decide now about the types and extent of medical care they want to accept or refuse if they become unable to make those decisions due to illness.

Requires all health care agencies to recognize the living will and durable power of attorney for health care.

Under the PSDA, health care agencies must:Ask you whether you have an advance directiveGive you information about your rights under state law to make decisions about medical care and create an advance directive(1)American Cancer Society 201312

Physician Orders for Life-Sustaining Treatment (POLST)A set of specific medical orders that if you are seriously ill person you can complete and ask your doctor to sign.

It is kept with you, and can be used in different health care settings.

It is NOT an Advance Directive.

Emergency personnel - like paramedics, EMTs, and emergency room doctors - must follow these orders. Without a POLST form, emergency care staff are generally required to provide every possible treatment to keep you alive. (1)

American Cancer Society 201313

Im ConfusedAn Advance Directive sounds like the same thing as a POLST?

14

Advance Directive vs. POLSTADVANCE DIRECTIVEFor anyone 18 and olderProvides instructions for future treatmentAppoints a Health Care RepresentativeDoes not guide Emergency Medical PersonnelGuides inpatient treatment decisions when made available

POLSTFor persons with serious illness at any ageProvides medical orders for current treatmentGuides actions by Emergency Medical Personnel when made availableGuides inpatient treatment decisions when made available(10)

National POLST 2012

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Understanding the Importance of Advance Directives

Its Been Shown ThatIf you have an Advance Directive you are more likely to receive end-of-life care consistent with your preferences:83.2% of patients who requested limited care received it97.1% of patients who requested comfort care received it

Without an advance directive, 32% of the time your chosen DPOAHC will incorrectly choose the treatment you desire.This can be due to emotional closeness, stress, or religious beliefs. (12)

Tejwani 201317

92% of adults have heard of living wills, but only 36% have actually completed one.

(12)

Tejwani 201318

According to the American Medical Association (AMA):You have the right to participate in decisions about your own health care.

Discussing your goals and values will help you maintain a high quality of life as long as possible.

Advance Care Planning is shown to work best as it allows you to explore, discuss, and articulate preferences regarding future medical care, including life-sustaining treatments, in the event that you become unable to make your own decisions. (2)AMA 201419

Understanding Your Choices

Cardiopulmonary Resuscitation(CPR)Emergency medical procedure used to try and restart heartbeat and breathing. Involves:Vigorous compressions of the chestUse of electrical stimulationMedications to support or restore heart functionRescue breaths (forcing air into lungs)Insertion of a breathing tube into your windpipe(6, 13)

Foundation for Healthy Communities 2014 / Vermont Ethics Network 201421

Heres What You Should Really Know About CPRApproximately 15% of all adults who have CPR performed in the hospital survive and are discharged.

0-5% of elderly adults who have CPR performed in a nursing facility survive.

Other potential complications related to CPR include:Rib or breastbone fractureNeurological damageAbdominal injuriesDamage to the trachea, esophagus, lips, teeth, and lungs

(3)Cadogan 201022

Do Not Resuscitate (DNR)A medical order that in the event your heart or breathing stop, CPR is not be started. No attempt should be made to resuscitate you with chest compressions, insertion of a breathing tube, or by giving resuscitation drugs.(4)

DHMC 200823

Variations of DNRDNI: Do Not Intubate No breathing tube will be inserted, but chest compressions and medications may be used.

Partial DNRAllows you to specifically state what aspects of resuscitation you want and dont wantChest compressionsBreathing tube/Breathing machinesMedicationsElectric shock

Terminal Condition or IllnessAn irreversible illness that in the near future will result in death or a state of permanent unconsciousness from which the person is unlikely to recover. Examples of terminal conditions include:Advanced cancersHead injuriesMultiple organ failuresMassive heart attacks and strokes.

But in many states, a terminal illness is defined as one in which the patient will die shortly whether or not medical treatment is given.

These definitions can complicate or delay the use of a living will.

(1)

American Cancer Society 201325

Life-Sustaining Medical TreatmentIn most cases life-sustaining medical treatment is anything mechanical or artificial that sustains, restores, or substitutes for a vital body function and would prolong the dying process for a terminally ill patient.

It may include: Cardiopulmonary resuscitation (CPR) Artificial respiration (mouth-to-mouth breathing, manual ventilation, or a ventilator or respirator a machine that pushes air into your lungs) Medicine to help with blood pressure and heart function Artificial nutrition or hydration (liquid food or fluids given through a tube to the stomach or into a vein)Dialysis (a process that does the job the kidneys normally do) Certain surgical procedures (such as amputation, feeding tube placement, tumor removal, or organ transplant) (1)American Cancer Society 201326

Palliative CareTaking care of the whole person body, mind, and spirit. This approach views dying as natural and personal; its goal is to provide you with relief of symptoms. Can be given along with aggressive treatment or when aggressive treatment stops.(6)Foundation for Healthy Communities 201427

Hospice CareA team approach to provide comprehensive medical, nursing and social services, spiritual care and bereavement support for you and your family near the end of life. (6)

Foundation for Healthy Communities 2014

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Comfort Measures Only(CMO)Also referred to as Comfort CareKeeping you as comfortable and peaceful as possible, including pain medication, giving you ice chips and lip ointment, turning your body to prevent bed sores and bathing you. (6)

Foundation for Healthy Communities 2014

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Understanding Your ChoicesCPR: Emergency procedure to restart your heart and breathing.

DNR: A medical order if you wish for CPR to not be started.Variations of DNRDNI: States you do not want a breathing tube placed.Partial DNR: Specifies what aspects of resuscitation you would like.

Terminal Condition or Illness: Illness that will ultimately cause death.

Life-Sustaining Medical Treatment: Treatment at all means to keep you alive when you otherwise may not be.

Palliative Care: Care of the body, mind, and spirit.

Hospice Care: Team approach to care for you and your loved ones.

Comfort Measures Only: Keeps you comfortable and peaceful.

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Reasons Advance Directives go Unaddressed

Research Has ProvenThree mainbarriersto completing and effectively using advancedirectives: Lack of education or knowledge about them.Difficulties with the paperwork while completing them.Disagreements among patients, family members or proxy, and providers.

Otherbarriersinclude:Socio-demographic factors.Patient and provider attitudes.Lack of knowledge about the potential financial benefits.(8)Glick 200432

FearIll get less than maximal medical care if my preferences are non-aggressive treatment.(12)

Tejwani 201333

DenialBut Im young and Im healthy!It can wait!

The growing consensus is that every adult, regardless of age, should consider preparing an advance directive because unforeseeable accidents can and do occur. Heat Attack, StrokeCar AccidentBombings, Shootings(12) Tejwani 201334

But I Have a DPOADesignating a person to serve as your DPOA is one part of the Advance Directive. This does not sufficiently express what your wishes are, unless you have previously discussed this with your DPOA (though it is best to have your wishes in writing through a legal document such as the Advance Directive). (12)Tejwani 201335

Conclusion

The best time to make healthcare decisions is before you are ill, when you can carefully consider your options.

The best time is now, because you never know when that something may happen.

For More InformationAmerican Hospital Associationwww.putitinwriting.org The Conversation Projecthttp://theconversationproject.org/ Five Wisheswww.agingwithdignity.org Foundation for Healthy Communitieshttp://www.healthynh.com/fhc-initiatives/advance-directives-healthcare-decision-coalition.html National Health Care Decisions Daywww.nhdd.org National Hospice and Palliative Care Organization www.nhpco.org POLST: Find out if your state utilizes POLST forms and learn more www.polst.org

ReferencesAmerican Cancer Society. (2013).Advance directives: Why do you need an advance directive?Retrieved July 18, 2014, fromhttp://www.cancer.org

American Medical Association. (2014). AMA policy on provision of life-sustaining medical treatment. Retrieved July 17, 2014, from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethics-group/ethics-resource-center/end-of-life-care/ama-policy-provision-life-sustaining-medical.page?

Cadogan, M.P. (2010). CPR decision making and older adults. Journal of Gerontological Nursing, 36(12), 10-15. doi:10.3928/00989134-20101109-01

Dartmouth-Hitchcock Medical Center. (2008). Advance care planning. Lebanon, NH: Dartmouth-Hitchcock Medical Center.

FHCMedia. (2012). Advance care planning. YouTube. Retrieved July 17, 2014, from https://www.youtube.com/watch?v=eMU8hS_Ia60

Foundation for Healthy Communities. (2014). Advance care planning guide. Concord, NH: Foundation for Healthy Communities.

Giovanni, L.A. (2012). End-of-life care in the United Sates: Current reality and future promise - a policy review. Nursing Economics, 30(3), 127-135.

ReferencesGlick, K.L., Mackay, K.M., Blasingam, S., Dolan, K.R. & Casper-Isaac, S. (2004). Advance directives: Barriers to completion.Journal of the New York State Nurses Association, 1,4-8.

Hammes, B. J., Rooney, B. L., Gundrum, J. D., Hickman, S. E., & Hager, N. (2012). The POLST program: A retrospective review of the demographics of use and outcomes in one community where advance directives are prevalent. Journal of Palliative Medicine, 15(1), 77-85. DOI: 10.1089/jpm.2011.0178

National POLST. (2012). POLST and advance directives. Retrieved July 17, 2014, from http://www.polst.org/advance-care-planning/polst-and-advance-directives/

Phillips, E. (2014). Helping clients initiate their personally chosen end-of-life strategies. Journal of Financial Service Professionals, 68(3), 63-71.

Tejwani, V., Wu, Y., Serrano, S., Segura, L., Bannon, M., & Qian, Q. (2013). Issues surrounding end-of-life decision-making. Patient Preference and Adherence 7, 771-775. doi: http://dx.doi.org/10.2147/PPA.S48135

Vermont Ethics Network. (2014). Taking steps: Planning for critical health care decisions. Montpelier, VT: Vermont Ethics Network.