Mardy Chizek, RN, FNP, BSN, MBA, AAS Charism Eldercare Services charism@charism.net www.charism.net 630.515.9223
Conflict of Interest Margaret Chizek has no: Financial relationship with companies who manufacture products used in the treatment of subjects under discussion. Financial relationships between the planner, content specialist or presenter and commercial supporter/s of the activity and Intent to discuss of-label uses of a commercial product or an investigational use of a product not yet approved for this purpose.
Purpose To increase understanding of advance directives for customer and family guidance and education
Goals Differentiate between competency and decision making capacity Be able to differentiate between the mandates of state and federal regulations and statutes Be able to articulate the elements of healthcare advance directives
Advance Directive A document in which the principal (patient/resident) instructs and specifies for the attorney-in fact (decision maker) the care the principal wishes to receive in anticipation of a time when the principle is unable to communicate their wishes. Does not mean do not resuscitate Does not mean do not treat
Power of Attorney Alternatives The Five Wishes Living Will that addresses medical, personal, emotional and spiritual wishes Valid in most States Physician Order for Life Sustaining Treatment (POLST) Mandated in some States Brightly colored paper copies Specifies measures that the patient wants
Case Study A resident sustained a fall and struck her head. She was a DNR. Neuro checks were done and over the following 24 hours she had a change in mental status. Recognizing the change, the nurse called the doctor and the resident coded during the phone call. Should the staff do CPR?
Competency All adults are presumed legally competent. Free to exercise all rights and responsibilities of an adult until determined and declared otherwise in a court of law.
Decision Making Capacity Elements of capacity 1. Posses set of values and goals necessary for evaluating different options 2. Ability to communicate and understand information 3. Ability to reason and to deliberate about the choices provided Capacity is not equal to Competence
Case Study A resident who had early stage dementia on admission, had been a long standing resident. There was no advance directive or living will, but the resident had always told the staff she did not want a feeding tube. A niece demanded a feeding tube for the resident when the resident had weight loss. Once the tube was placed the resident constantly pulled the tube out and would cry no, no, no. Should the PEG have been inserted and then reinserted?
Federal Statute Patient Self Determination Act (PSDA) All providers who participate in Medicare or Medicaid Mandatory information on advance directives to all patients Provider can not mandate advance directive as condition of providing care If unable to abide by advance directive, must transfer to a facility which will follow the advanced directive or DNR
Illinois Statute Comply with Federal Act Standardized Do Not Resuscitate (DNR) document Advance Directives in IL Health Care Power of Attorney Living Will Mental Health Treatment Declaration
Illinois Statute POAHC Unless a time limit is stipulated in the document it holds until your death May cancel POA HC at any time either in writing or verbally May name secondary and tertiary agent Primary agent must decline or be incapable of serving before secondary agent assumes role Changes must be in writing
Illinois Statute POAHC Executed when no longer able to make own decisions Created by patient or principal Chose agent for decision making Healthcare provider may not be your agent Witness should not be agent Document should be witnessed Agent required to abide by specific treatment be withheld of provided
lllinois Statute Terminal Condition Terminal condition incurable, irreversible such that death is imminent and application of death delaying treatment or procedures serve only to prolong the dying process. Food and water may not be withheld Requires two witness signatures Must alert healthcare provider to presence of living will May cancel at any time verbally or in writing
Case Study On admission, the family asked the admission coordinator if she had all of the necessary paper work. The admission person stated she did. The POAHC daughter signed the no advance directive document. After the third admission, the daughter was incensed because the mother s advance directives were not on the record and threatened and notified multiple agencies.
Do Not Resuscitate Medical treatment will not be attempted if your heart and breathing stops Physician order required Illinois Uniform DNR form is advance directive and also physician order on one document Must be signed by the physician to be valid
Case Study A co-morbid resident is a full code. The resident arrests while her two sons are visiting and a physician is making rounds. CPR is initiated. When the sons see what CPR entails they beg the physician to cease CPR and allow their mother to die. The physician ceases CPR and talks to the sons about their decision. When the long standing attending physician is notified, he is livid and reports the facility to the State. Should CPR have been discontinued?
Living Will/POLST Directives DNR do not resuscitate DNAR do not attempt resuscitation DNI no not intubate No artificial ventilation or ventilator No vasopressors No antibiotics No inotropic agents No enteral nutrition No parenteral nutrition Do not hospitalize Hydrate Organ donation Palliative care Hospice care
CPR Facts 2% to 30% success when administered outside the hospital 6% to 15% success for hospitalized patients Less than 5% success for elderly victim with medical problems 70% of time people stated they did not want life sustaining treatment if they had a poor prognosis and were incompetent
CPR Facts 75% successful rate of CPR short term and 67% long term on TV shows CPR on TV is on young patients and victims of trauma and near drowning which have highest success rates Most CPR is performed on sick, older individuals with cardiac disease 20% survival if V tach or V fib, but only 8% with other arrhythmias
Case Study A 97 year old man with Alzheimer s disease is a long standing resident at a nursing facility. His wife has been his decision maker until she died. Within days of his wife s death, one of his two daughters came to the facility with new POA for health care documentation designating her as his new POA. On the death of the wife/mother, the successor was the second daughter. The first daughter had the document signed and witnessed by a staff member from the facility. This daughter is an attorney and consistently threatens the staff at the facility with litigation. Because of their fear of her anger and threats, everyone attempts to comply with her wishes.
Health Care Surrogate Illinois Do not have an advanced directive Unable to make own healthcare decisions No designated agent Agent can act on your behalf if you have Qualifying condition Terminal condition Permanent unconsciousness Incurable, irreversible condition Order of priority Guardian Spouse Any adult child/ren Either parent Any adult brother or sister Any adult grandchild/ren A close friend Guardian of the estate
Glossary Artificial nutrition or hydration Delivery of nutrient and fluids when unable to eat or drink. May be delivered by tube in stomach, tube in nose or through IV tube. Decision making capacity Ability to make decisions that reflect understanding of the risks (nature) and benefits (consequences) of one s actions.
Glossary Hospice Delivery of palliative care at the end of life. Legal guardian Person appointed by the court who is responsible for managing property and rights of another person considered incapable of administering own affairs.
Glossary Life sustaining treatment Intervention which administered prolongs life and delays death. Palliative care Medical care or treatment to reduce severity of disease symptoms not striving to halt, delay or reverse progress of the disease or cure.
Glossary Persistent vegetative state American Academy of Neurology Form of eye opening permanent unconsciousness in which the patient has periods of wakefulness and physiologic/sleep wake cycles but at no time is aware of himself or his environment.
Glossary Terminal condition Status that is incurable or irreversible and which death will occur in a short time. No specific definition, but generally a short time is considered less than one year in many jurisdictions.