Advance Care Planning. and advance directive forms MAKING AND COMMUNICATING YOUR HEALTHCARE DECISIONS IDAHO. Patient Education

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1 IDAHO Patient Education intermountainhealthcare.org Advance Care Planning and advance directive forms MAKING AND COMMUNICATING YOUR HEALTHCARE DECISIONS

2 DO YOUR LOVED ONES KNOW WHAT YOU WANT? I WANT my daughter to decide what s best for me if I can t do it myself. I WANT my doctors to do everything they can try every last measure to help me survive to see another day. I WANT to be allowed to die at home, if possible. I WANT you to let me go naturally, without feeding tubes or breathing machines or other things prolonging my passing. I WANT to talk about the medical care I ll get at the end of my life, and... I WANT YOU TO LISTEN.

3 What s Inside: ABOUT ADVANCE CARE PLANNING... 4 What does advance care planning include?...4 When do I make advance care plans?...4 Whom do I involve in planning?...5 CONVERSATION GUIDE... 6 How do I start the conversation?... 6 What do we talk about?... 7 Values... 7 Issues... 8 Scenarios... 9 IDAHO ADVANCE DIRECTIVE FORMS...10 What s an advance directive? What s the difference between the forms? Who can fill out an advance directive? What do I do with my advance directive form? What if I change my mind? How can I learn more? Details about the Idaho forms BLANK FORM: Living Will and Durable Power of Attorney for Health Care...13 YOU HAVE THE RIGHT TO MAKE YOUR OWN DECISIONS ABOUT YOUR HEALTHCARE. But there may come a time when illness or injury prevents you from making or communicating these decisions. What happens then? ADVANCE CARE PLANNING requires you to think carefully about your values and priorities about the meaning and quality of your life. More than that, it requires you to communicate the desires and decisions that come from that thinking. THIS BOOKLET provides you with information and tools to help you with advance care planning. Use it to help discover, clarify, and communicate your wishes for your medical care and treatment. SAMPLE ONLY: Physician Orders for Scope of Treatment (POST)...21 GLOSSARY...19 WHERE TO LEARN MORE...20 ADVANCE CARE PLANNING - IDAHO 3

4 About Advance Care Planning Advance care planning means thoughtfully considering a time when you may not be able to make healthcare decisions for yourself. This time may never come, but the thinking, sharing, and recording you have done will still be valuable. Advance care planning can help clarify your values and put your mind and your loved ones minds at ease. What does advance care planning include? There s no official checklist that tells you what you have to consider in your advance care planning. You can decide the scope of topics and level of detail for yourself. Still, it may help to know that advance care planning usually includes the following concerns: WHY SHOULD I MAKE ADVANCE CARE PLANS? Planning can be valuable and deeply comforting to you and your loved ones. According to one national study, patients who talked with their families or doctors about their preferences for end-of-life care: Had less fear and anxiety. Felt they had more ability to influence and direct their medical care. Believed that their doctors had a better understanding of their wishes. Expressed a greater understanding and comfort level than they had before the discussion. Are there situations in which you would refuse certain medical treatments or care? You may feel that some health states are worse than death. In advance care planning, you can articulate what it means to live and die on your own terms. There may come a day when your doctor must ask your spouse, siblings, or children for decisions about your care. Are they prepared for this responsibility? Do they want it? Would someone else be better able to carry out your wishes? Advance care planning can help clarify roles. You may choose to complete an advance directive form as part of your advance care planning. The section beginning on page 10 tells you more about this. When do I make advance care plans? Sometimes circumstances like a hospitalization will prompt a care-planning discussion. In other cases, you can choose your own time to bring up these topics. There s no perfect time to start your planning. Still, after looking through this booklet, you may feel that some of the issues raised in care planning are best considered before a medical emergency arises. You don t know what the future will bring. But you can make care plans today that help you face it with more confidence and clarity. 4 ADVANCE CARE PLANNING - IDAHO

5 Whom do I involve in planning? Talk to the people close to you, those who might be called upon to make decisions for you. Talk with as many people as you feel comfortable with. But realize that if you re in the hospital at some point, it s best for the medical staff to have one person your healthcare agent they can go to for decisions. You can arrange for someone to be your healthcare agent by filling out an advance directive form (see page 10). Be sure to let your loved ones know whom you ve chosen. A good healthcare agent... Is at least 18 years old Lives close by, or could travel to be with you Knows you well and understands your desires, beliefs, and attitudes Can be a strong advocate in the face of conflicting opinions Will talk with you about sensitive issues Use the prompts on the following pages to share your wishes and preferences with your healthcare agent. WHO CAN HELP? It may help to talk with someone who is familiar with the concepts, forms, and terminology of advance care planning. In a hospital or other facility, you can ask to speak to someone about advance care planning. Many social workers, counselors, lawyers, and medical care providers have experience and training to help you and your loved ones make these plans. CAN YOU DO THIS FOR ME? As you begin to discuss your healthcare wishes with others, be sure to let them know what they may be called on to do. Say, As the person I choose to speak for me, you may need to do these things. Receive the medical information that I d receive if I could, talk to my doctors about it, and ask questions. Discuss treatment options or request consultations and second opinions. Agree to or refuse medical tests or treatments. This might include life-sustaining treatment. Authorize a transfer, if necessary, to another doctor, another hospital, or another type of facility (such as a nursing home). ADVANCE CARE PLANNING - IDAHO 5

6 Conversation Guide Experts say that a thoughtful conversation with those you trust is the most valuable part of advance care planning. This section offers questions and scenarios to help you discover and share what is most important to you in the face of serious illness. AN ONGOING CONVERSATION Advance care planning is a work in progress. That s because as circumstances change, your mind may change, too. Keep the conversation open. Revisit your decisions (and update any forms) as often as you need to. How do I start the conversation? Whether you re talking about your own wishes or trying to find out the wishes of someone close to you, getting started on a care-planning conversation can be difficult. But if your family knows you want to talk, they may be more willing than you think. To bring up the topic of advance care planning, consider the ways shown below. REFLECT ON THE EXPERIENCE OF SOMEONE IN YOUR FAMILY. When Uncle Martin died, he made it so easy on his children. They all knew what kind of care he wanted and didn t want. Everyone seemed so peaceful in his last days. I wonder if Grandma would have wanted her life to end like it did. I don t think she would want us to remember her the way she was those last few years. BRING IT UP WHEN YOU RE ATTENDING A FUNERAL OR READING THE OBITUARIES. I wonder what the last weeks of life were like for these people. When it s my turn, I want.... It says she died after a long battle with cancer. I m not sure I want a long battle, if it comes to that. I d rather have.... TAKE YOUR CUES FROM POPULAR CULTURE. Did you see that episode of Grey s Anatomy where the guy was on life support forever? I want to talk about how I d like it to be for me. I heard that my favorite actress didn t want any life support at all in her last days. But what I can t figure out is where you draw the line between normal medicine and unnatural intervention. TALK IN TERMS OF SOMEONE ELSE S NEEDS. My doctor says I have to tell him who s going to make medical decisions for me if I can t make them myself. My lawyer needs to know what kind of end-oflife care I m planning. I know you ll feel better if you really understand what I d like. 6 ADVANCE CARE PLANNING - IDAHO

7 What do we talk about? When you first sit down to discuss your future medical care, you may not have a very clear idea about what will be best for you. That s all right. Having this conversation can help you discover what you want. Try the approach below to help you and those close to you understand good ways to handle a variety of possible situations. 1 Talk about basic VALUES The way you feel about some things remains constant across many situations. Talk about your basic beliefs and fears about health, illness, and the end of life. This will help give your healthcare agent a better sense of how to make decisions for you in a variety of situations. Consider the following: Do you have fundamental beliefs about life and medicine? Do you believe that life should be preserved at all costs? Do you believe that life should not be prolonged through extensive intervention? Are some medical treatments against your beliefs? NOTES: Describe what you consider to be a good death. Where is a good place to be? Who is there? How long does it take? What happens in the time (days or weeks) before your death? NOTES: Which of these do you fear most? o Pain o Losing the ability to think o Losing the ability to communicate o Being a financial burden on your loved ones o Being removed from life support too soon ADVANCE CARE PLANNING - IDAHO 7

8 12 Talk about ISSUES that may influence your care decisions The medical treatment you want may depend on your changing health and situation. As you think about what you want, remember that the issues listed below may be a factor and that your doctor s counsel would be important as you consider each one. Prognosis. Facing a serious health problem, you would be able to ask your doctor about different treatment options and the chances that you could regain your health or extend your life (your prognosis). Would this information affect your care decisions? In what way? NOTES: Length and possible impact of treatment. Your medical team could also tell you how long a treatment might last, whether it could be painful, and how much it might cost. In what ways if any might these factors affect your decisions about your care? NOTES: Setting. For a particular treatment or level of care, you might need to be moved to a nursing home or other care facility. You might need to be hospitalized. Your stay could be temporary or permanent. How do you feel about this does the setting matter in your care planning decisions? NOTES: Day-to-day caregiving. What are your feelings about being bathed or fed by a caregiver, if you couldn t do it yourself? Does it matter if your caregiver is a member of your family, a professional, or a volunteer? NOTES: 8 ADVANCE CARE PLANNING - IDAHO

9 3 Talk about different SCENARIOS Even if you ve thought about your basic beliefs and the factors that may influence care decisions, it can be difficult to predict the right plan for you. It may be easier to think about what you might want in a specific situation. So talk through these scenarios. What kind of treatment would you want? You ve suffered a stroke. You re alert, but can t communicate or care for yourself. You live in a fulltime care center. Your family comes to visit regularly. If spoon-feeding is no longer possible, do you want to be fed through a tube? NOTES: You have Alzheimer s disease. You live with your daughter but you don t recognize her anymore. She has hired someone to stay with you while she s at work, and the expense is hard on her family. You ve had pneumonia three times this year. The next time you get pneumonia, do you want antibiotics, or just comfort care until death comes? NOTES: You ve been in a chronic vegetative state for 16 months. Your doctors don t expect you to recover. Earlier in your life, you always said that you didn t want to be kept alive on life support. But your children don t agree with each other about withdrawing life support. Would you rather your children follow the wishes you ve expressed earlier, or would you rather they agree with each other on whatever decision is made? NOTES: ADVANCE CARE PLANNING - IDAHO 9

10 Idaho Advance Directive Forms This section gives instructions and a blank or sample form for two advance directive forms commonly used in Idaho: Living Will and Durable Power of Attorney for Health Care Physician Orders for Scope of Treatment (POST) What s an advance directive? An advance directive is a legal document that you can choose to complete as part of your advance care planning. If one day you aren t able to make or communicate your own decisions, an advance directive can help ensure that the care you receive is in line with your values and wishes. What s the difference between the forms? All advance directive forms express your wishes for healthcare. However, they vary in scope and level of detail. Also, they tend to be completed in different circumstances. See the table below for a quick comparison of two Idaho forms. Who can fill out an advance directive? Anyone who is at least 18 years old and who is able to make their own reasoned decisions can complete an advance directive. Page 12, Details about the Idaho forms, explains who needs to be involved when completing a form. Hospitals, home health services, and hospice organizations are required to offer their patients a chance to complete an advance directive. Intermountain Healthcare supports this practice and honors advance directives. In fact, Intermountain encourages all adult patients to have an advance directive and may offer one to you when you visit the hospital or clinic. It doesn t depend on your current health and it doesn t mean your doctors expect your health to get worse. FORMS at-a-glance... FORM WHAT it does WHEN it s usually completed Living Will and Durable Power of Attorney for Health Care Physician Orders for Scope of Treatment (POST) The Living Will part of the form gives your medical team the right to withhold, withdraw, or provide life-sustaining treatments in certain circumstances, which you can identify on the form. The Durable Power of Attorney for Health Care part of the form lets you identify your healthcare agent. This is the person you want to make healthcare decisions for you if you can t take part in decision-making. The POST form directs the medical team regarding the care and treatment you want provided or withheld. The POST is transferable, meaning that the instructions apply no matter where you re cared for hospital, home, skilled nursing facility, or hospice. The Living Will and Durable Power of Attorney for Health Care can be completed by an adult at any time and in any stage of life. Many people choose to complete this advance directive form before they re faced with a serious illness or injury. It can be a way of preparing for the unexpected like buying insurance or having a fire drill. The POST form is almost always completed in response to a specific health threat. To complete a POST, the medical team must be closely involved. For this reason, this booklet contains only a sample POST form, not a real blank form. If necessary, the medical team can help you obtain and complete a POST form. 10 ADVANCE CARE PLANNING - IDAHO

11 What do I do with my advance directive form? If you choose to complete an advance directive, keep the original form, following the specific instructions on the next page. But be sure to share a copy of your advance directive with others. Here s how: Bring a copy with you any time you are admitted to the hospital or another care facility, or any time you are transferred from one facility to another. Give a copy to your loved ones, your healthcare agent (if you have one), and to your doctor. Send a copy to Intermountain and to the Idaho Health Care Directive Registry. These registries can store your directives and may allow your healthcare providers to access them if they re needed. See the back page of this booklet for specific directions. FORMS at-a-glance... continued What if I change my mind? You can change or revoke (cancel) your advance directive form at any time. If you ve completed a new advance directive form, make sure to replace any copies you ve shared with others. If you ve stored a copy with Intermountain or the Idaho registry, send in the updated form. Only the most recent directive will be used. If you want to cancel your advance directive entirely, tear up the original and any copies you ve shared with others. If you ve stored a copy with Intermountain or the Idaho registry, either send in an updated form or send a signed letter stating that you want to cancel your directives. How can I learn more? Ask your nurse or doctor for more information about advance directives. They can answer your questions and help you identify the form that s best for you in your current stage of life. If you like, they can help you complete (or update) an advance directive form. Also see the resources on the back page of this booklet. WHEN it takes effect... WHO is involved in completing it... HOW to get one... Idaho s Living Will and Durable Power of Attorney for Health Care form takes effect only when you can t make communicate instructions AND: you have an incurable or irreversible injury or disease OR you are in a persistent vegetative state You complete and sign the Living Will and Durable Power of Attorney for Health Care form. Although a witness signature is not required, you can give your advance directive additional legal strength by having an unbiased witness sign the form. This booklet contains a blank Living Will and Durable Power of Attorney for Health Care form on pages 13 to 19. Additional blank forms are available from your healthcare provider and online at: intermountainhealthcare. org/advanceplanning The POST is an order for the medical team. It takes effect immediately as soon as it s completed and signed. To complete a POST, you (or someone speaking for you) must work closely with a doctor. See page 12 for details. This booklet contains a sample view of the POST form on page 21. Your medical team can help you obtain and complete an official POST form if necessary. ADVANCE CARE PLANNING - IDAHO 11

12 Details About the Idaho Forms Pages 13 to 19 contain a blank Living Will and Durable Power of Attorney for Health Care directive form for your use. If you choose to complete the form: Keep the original in a safe place that is easy to get to. (You probably should NOT lock it away in a safety deposit box.) Share copies of your directive in the ways described on the back of this booklet. Page 21 offers a sample view of the POST form. If you have a POST: Keep the original POST form at home, in a visible or expected place. Consider posting it on the refrigerator or on the wall over your bed. Share copies of your directive in the ways described on the back of this booklet. Living Will and Durable Power of Attorney for Health Care PURSUANT TO IDAHO CODE This legal document allows you to identify a healthcare agent, the person you want to make healthcare decisions for you if you can t make or express them yourself. The form can also give your healthcare agent or medical team the right to withhold or withdraw life-sustaining treatments in certain circumstances, which you can identify on the form. Idaho s Living Will and Durable Power of Attorney for Health Care form is a very flexible document. You can fill out some or all parts of the form. For example, you may choose not to name a healthcare agent, but use the form only to record your wishes for life-sustaining treatment. Or you may choose to only name an agent. Who is involved in filling it out? You fill in the form according to your wishes, then sign and date the form. And although it s not required, you can give additional legal force to your advance directive by having it signed and dated by a witness. (Have the person write the word witness on the last page of the form, provide their signature there, and then print their name and contact information next to the signature.) The witness should be someone impartial so, NOT a family member, a person providing medical care to you (your doctor or nurse, for example), or your healthcare agent. Instead, have your form witnessed by a neighbor, friend, coworker, or hospital volunteer. Physician Orders for Scope of Treatment (POST) The POST is a set of instructions (orders) for your doctors and other medical caregivers. The POST specifies your wishes for life-sustaining treatment and other types of care. It is a transferable form, meaning that the instructions apply no matter where you re cared for hospital, home, skilled nursing facility, or hospice. Who is involved in filling it out? You (or someone speaking for you) must work closely with a doctor, who will consult with you to prepare the POST. Both you and your doctor must sign and date the form. 12 ADVANCE CARE PLANNING - IDAHO

13 page 1 of 7 Living Will and Durable Power of Attorney for Health Care Date of Directive: Name of person executing Directive: Address of person executing Directive: A Living Will A Directive to Withhold or to Provide Treatment 1. I willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below. This Directive shall be effective only if I am unable to communicate my instructions and: a. I have an incurable or irreversible injury, disease, illness or condition, and a medical doctor who has examined me has certified: OR 1. That such injury, disease, illness or condition is terminal; and 2. That the application of artificial life-sustaining procedures would serve only to prolong artificially my life; and 3. That my death is imminent, whether or not artificial life-sustaining procedures are utilized. b. I have been diagnosed as being in a persistent vegetative state. In such event, I direct that the following marked expression of my intent be followed and that I receive any medical treatment or care that may be required to keep me free of pain or distress. Check one box and initial the line after such box: I direct that all medical treatment, care, and procedures necessary to restore my health and sustain my life be provided to me. Nutrition and hydration, whether artificial or non-artificial, shall not be withheld or withdrawn from me if I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition.

14 page 2 of 7 Living Will and Durable Power of Attorney for Health Care OR I direct that all medical treatment, care and procedures, including artificial life-sustaining procedures, be withheld or withdrawn, except that nutrition and hydration, whether artificial or non-artificial shall not be withheld or withdrawn from me if, as a result, I would likely die primarily from malnutrition or dehydration rather than from my injury, disease, illness or condition, as follows: (If none of the following boxes are checked and initialed, then both nutrition and hydration, of any nature, whether artificial or non-artificial, shall be administered.) Check one box and initial the line after such box: A. Only hydration of any nature, whether artificial or nonartificial, shall be administered. B. Only nutrition, of any nature, whether artificial or nonartificial, shall be administered. C. Both nutrition and hydration, of any nature, whether artificial or non-artificial shall be administered. OR I direct that all medical treatment, care and procedures be withheld or withdrawn, including withdrawal of the administration of artificial nutrition and hydration. 2. If I have been diagnosed as pregnant, this Directive shall have no force during the course of my pregnancy. 3. I understand the full importance of this Directive and am mentally competent to make this Directive. No participant in the making of this Directive or in its being carried into effect shall be held responsible in any way for complying with my directions.

15 page 3 of 7 Living Will and Durable Power of Attorney for Health Care 4. Check one box and initial the line after such box: 4. Check one box and initial the line after such box: I have discussed these decisions with my physician and have also completed a Physician Orders for Scope of Treatment (POST) form that contains directions that may be more specific than, but are compatible with, this Directive. I hereby approve of those orders and incorporate them herein as if fully set forth. OR I have not completed a Physician Orders for Scope of Treatment (POST) form. If a POST form is later signed by my physician, then this living will shall be deemed modified to be compatible with the terms of the POST form. A Durable Power of Attorney for Health Care 1. DESIGNATION OF HEALTH CARE AGENT None of the following may be designated as your agent: (1) your treating health care provider; (2) a non-relative employee of your treating health care provider; (3) an operator of a community care facility; or (4) a non-relative employee of an operator of a community care facility. If the agent or an alternate agent designated in this Directive is my spouse, and our marriage is thereafter dissolved, such designation shall be thereupon revoked. I do hereby designate and appoint the following individual as my attorney in fact (agent) to make health care decisions for me as authorized in this Directive. (Insert name, address and telephone number of one individual only as your agent to make health care decisions for you.) Name of Health Care Agent: Address of Health Care Agent: Telephone Number of Health Care Agent: For the purposes of this Directive, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose or treat an individual's physical condition.

16 page 4 of 7 Living Will and Durable Power of Attorney for Health Care 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE By this portion of this Directive, I create a durable power of attorney for health care. This power of attorney shall not be affected by my subsequent incapacity. This power shall be effective only when I am unable to communicate rationally. 3. GENERAL STATEMENT OF AUTHORITY GRANTED I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this Directive or otherwise made known to my agent including, but not limited to, my desires concerning obtaining or refusing or withdrawing artificial life-sustaining care, treatment, services and procedures, including such desires set forth in a living will, Physician Orders for Scope of Treatment (POST) form, or similar document executed by me, if any. (If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4, "Statement of Desires, Special Provisions, and Limitations", below. You can indicate your desires by including a statement of your desires in the same paragraph.) 4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS (Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning artificial life-sustaining care, treatment, services and procedures. You can also include a statement of your desires concerning other matters relating to your health care, including a list of one or more persons whom you designate to be able to receive medical information about you and/or to be allowed to visit you in a medical institution. You can also make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by this Directive, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated in my Physician Orders for Scope of Treatment (POST) form, a living will, or similar document executed by me, if any. Additional statement of desires, special provisions, and limitations:

17 page 5 of 7 Living Will and Durable Power of Attorney for Health Care (You may attach additional pages or documents if you need more space to complete your statement.) 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH A. General Grant of Power and Authority Subject to any limitations in this Directive, my agent has the power and authority to do all of the following: (1) Request, review and receive any information, verbal or written, regarding my physical or mental health including, but not limited to, medical and hospital records; (2) Execute on my behalf any releases or other documents that may be required in order to obtain this information; (3) Consent to the disclosure of this information; and (4) Consent to the donation of any of my organs for medical purposes. (If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4, "Statement of Desires, Special Provisions, and Limitations", above.) B. HIPAA Release Authority

18 page 6 of 7 Living Will and Durable Power of Attorney for Health Care My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. 6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES Where necessary to implement the health care decisions that my agent is authorized by this Directive to make, my agent has the power and authority to execute on my behalf all of the following: (a) (b) Documents titled, or purporting to be, a "Refusal to Permit Treatment" and/or a "Leaving Hospital Against Medical Advice"; and Any necessary waiver or release from liability required by a hospital or physician. 7. DESIGNATION OF ALTERNATE AGENTS (You are not required to designate any alternate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent you designated in paragraph 1 above, in the event that agent is unable or ineligible to act as your agent. If an alternate agent you designate is your spouse, he or she becomes ineligible to act as your agent if your marriage is thereafter dissolved.) If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this Directive, such persons to serve in the order listed below:

19 page 7 of 7 Living Will and Durable Power of Attorney for Health Care A. First Alternate Agent Name: Address: Telephone Number: B. Second Alternate Agent Name: Address: Telephone Number: C. Third Alternate Agent Name: Address: Telephone Number: 8. PRIOR DESIGNATIONS REVOKED I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (You must date and sign this Living Will and Durable Power of Attorney for Health Care.) I sign my name to this Statutory Form Living Will and Durable Power of Attorney for Health Care on the date set forth at the beginning of this Form at: (Signature) (City, State)

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21 Michelle: please replace this with the Idaho POST form ---but treat it visually just like the POLST (keep it on blue paper, keep the sample only thing on top) Print Form page 1 of 2 IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST Physician Idaho Order Physician for Life Orders Sustaining For Scope Treatment of Treatment (POLST) (POST) THIS FORM MUST BE SIGNED BY A PHYSICIAN IN SECTION E TO BE VALID If any section is NOT COMPLETE, provide the most treatment included in that section Patient's Last Name: Patient's First Name: Jonathon Date of Birth: 1/11/1911 EMS: If questions arise, contact on-line Medical Control Male Female Section Cardiopulmonary Resuscitation: Patient does not have a pulse A and/or is not breathing: Select only one box Section B Section C Section D Section E Resuscitate (Full Code) Do Not Resuscitate (No Code): Allow Natural Death; Patient does not want any heroic or life-saving measures. If patient is not in cardiopulmonary arrest, please follow the orders found in B, and C. Medical Interventions: Patient has a pulse and/or is breathing: Comfort Measures: Please treat patient with dignity and respect. Reasonable measures are to be made to offer food and fluids by mouth and attention must be paid to hygiene. Medication, positioning, wound care, and other measures shall be used to relieve pain and discomfort. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. These measures are to be used where patient lives, do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Limited Additional Interventions: In addition to the care described above, you may include cardiac monitoring and oral/iv medications. Transfer to hospital if indicated but do not use intubation or advanced airway interventions. Do not admit to Intensive Care. Aggressive Interventions: In addition to the care described above, you may include endotracheal intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated. Recieving hospital may admit to Intensive Care if indicated. Other Instructions: Artificial Fluids and Nutrition: Feeding tube No Feeding tube IV fluid Other Instructions: No IV fluid Antibiotics and Blood Products: Antibiotics Blood Products Other Instructions: No Antibiotics No Blood Products Advance Directives: The following documents also exist: Living Will DPA DPAHC Patient/Surrogate Signature: Jonathon Smith SAMPLE ONLY. Self Print Patient/Surrogate Name Relationship Date Physician Signature: Ronald Brown, MD M12345 Jul 2, 2007 Print Physician's Name Idaho License Number Date Discussed with: Patient Spouse DPA DPAHC Other The basis for these orders is: Patient's request Patient's known preference FORM SHALL ACCOMPANY PATIENT WHENEVER TRANSFERRED OR DISCHARGED IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST Smith Your healthcare provider can work with you to complete an official form if necessary. Jul 2, IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST IDAHO POST

22 Notes: 22 ADVANCE CARE PLANNING - IDAHO

23 Glossary of Terms Used in Advance Care Planning Knowing the medical and legal terms below will help you make your advance care plans. Advance directives: legal documents that express your wishes for healthcare in the event that you can t make or share medical decisions for yourself. There are several different advance directive forms. A blank Utah Advance Health Care Directive form is included in this booklet. Artificial nutrition and hydration (also called tube feeding): adds to or replaces ordinary eating and drinking by giving nutrients and fluids through a tube placed into the stomach, the upper intestine, or a vein. Chronic (or persistent) vegetative state: ongoing unconsciousness or lack of awareness caused by serious brain damage. People in a vegetative state may breathe on their own and make noises and movements, but they can t communicate, recognize loved ones, or respond to talk or touch. With artificial nutrition and hydration and other care, a person may live for many years in a vegetative state. Dialysis: a treatment to clean the blood when the kidneys aren t working well. Dialysis is done in different ways, but always requires several hours. Patients with chronic (long-lasting) kidney failure must have dialysis frequently from 3 to 7 times weekly usually for the rest of their lives. Do-Not-Resuscitate (DNR) order: a written order stating that healthcare providers should not try to restart a patient s breathing or heartbeat. A DNR order is written at the request of the patient (or the patient s family or healthcare agent), but must be signed by a doctor. Healthcare agent: the person you designate to make medical decisions for you if, at some time in the future, you can t make them yourself. Your agent can make decisions any time you lose the ability to make a medical decision. Rather, it aims to provide the highest quality of life for whatever time remains. Hospice strives to keep patients comfortable and free of pain and to meet their unique spiritual, emotional, and social needs. You, your family, and your doctor decide together if and when hospice care should begin and where you should receive it (at home or in a facility). Intubation: putting a tube through the mouth or nose into the trachea (windpipe). This treatment helps breathing by keeping the airway open. Life-sustaining treatments (also called life support treatments): treatments that replace or support basic bodily functions. Examples include CPR (cardiopulmonary resuscitation), mechanical ventilation, artificial nutrition and hydration, and dialysis. Mechanical ventilation: using a machine called a ventilator (or respirator) to force air into the lungs of a person who can t breathe on his or her own. Palliative care: team-based treatment that focuses on improving a patient s quality of life and controlling pain and other symptoms of illness. Palliative care can be used alone or given in support of medical care that aims to treat disease. Prognosis: the prospect of a person s survival and recovery, based on the usual course of the disease and the specific circumstances of the person. Resuscitation: restarting a person s heart or breathing. This can sometimes be accomplished by an attempt at CPR (cardiopulmonary resuscitation), and may involve a machine that shocks the heart, or a tube that helps breathing (intubation). Terminal illness: an illness or condition that can t be cured and is expected to end the person s life. Hospice care: supportive care offered to patients who are expected to live 6 months or less. Hospice care does not aim to treat disease or prolong life. ADVANCE CARE PLANNING - IDAHO 23

24 Where to learn more about advance care planning and advance directives... Intermountain Healthcare Talk to your doctor, nurse, or other healthcare provider Toll-free call at any time to be referred to someone who can help with advance care planning Visit this website: intermountainhealthcare.org/ advanceplanning Idaho Secretary of State Website: Caring Connections From the National Hospice and Palliative Care Organization, NHPCO Website: caringinfo.org Toll-free phone number: (HelpLine) (en español: Cuidando con Cariño) Physician Orders for Life-Sustaining Treatment From the Center for Ethics in Healthcare Website: How to share an advance directive form... If you ve completed an advance directive, keep the original form. But be sure to share a copy of your advance directive with others. Here s how: Bring a copy with you any time you are admitted to the hospital or another care facility, or any time you are transferred from one facility to another. Give a copy to your loved ones, your healthcare agent (if you have one), and to your doctor. Send a copy to the Idaho Health Care Directive Registry. Registering will allow any healthcare provider with Internet access a chance to view your directive through a secure database in an emergency. Follow the directions provided by the Idaho Secretary of State s Office: Send a copy to Intermountain so that it can be stored in your electronic medical record. If it s ever needed, your form can be accessed by your Intermountain medical team. If your wishes change, complete a new form and provide a new copy to Intermountain. Use the contacts below. Mail a copy to: Advance Directive at Intermountain Healthcare PO Box #70539 Salt Lake City, UT FAX a copy to: attn: Advance Directive at Intermountain a copy (as an attached document) to: advance.directive@imail.org Intermountain Healthcare complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Se proveen servicios de interpretación gratis. Hable con un empleado para solicitarlo. 我們將根據您的需求提供免費的口譯服務 請找尋工作人員協助 Intermountain Healthcare. All rights reserved. The content presented here is for your information only. It is not a substitute for professional medical advice, and it should not be used to diagnose or treat a health problem or disease. Please consult your healthcare provider if you have any questions or concerns. More health information is available at intermountainhealthcare.org. Patient and Provider Publications ACP00ID - 07/16 (Last reviewed - 07/16)