What is an Advance Directive? (also known as a Durable Power of Attorney for health care, Living Will) An Advance Directive are forms that you complete to let your medical team know what kind of medical treatment you would want should you become very sick and are not able to speak for yourself. You also name a person, your Patient Advocate, to make decisions on your behalf. The Advance Directive serves as a guide in the event an illness makes you unable to communicate your decisions. Why should I have an Advance Directive? You have a legal and moral right to decide what kind of medical treatment you want and don t want when you are very sick and your death may be expected. It may be hard to think about medical treatment options when you are feeling well. But it may be a lot harder to think clearly during a time of crisis. Even worse, you may find yourself unable to communicate your choices because of severe illness or injury. If you take the time now to consider the kind of medical treatment you want, it may give you peace of mind. People often don t realize you also have the right to refuse medical treatment at any time. You have additional rights as patients described in Section 20201 of the Public Health Code, 1978 PA 368, and MCCl 333.20201 (9) Who should complete an Advance Directive? Anyone 18 years or older can complete an Advance Directive. As you get older, it is a good time to consider your future medical treatment options. If you have serious medical problems, it is especially important to do so. This allows you to be in control of your health care. When should I complete an Advance Directive? You can complete the forms at any time you are clear about the type of medical care you want. Typically, you should complete the Advance Directive forms when you are feeling well, able to think clearly, and not experiencing poor health. Your health care provider can answer your questions. These forms should be reviewed on a yearly basis with your health care provider. Advance Directives also can be reviewed at any time, especially if you are experiencing a change in your health. You also will be asked if you have an Advance Directive when you are admitted to the hospital. You can complete Advance Directive forms at that time if you have not already completed one. How do I complete an Advance Directive? The Decisions for Medical Treatment forms in this booklet allow you to record your decision regarding medical treatment options. When considering the following options, it may be helpful to review your personal beliefs and what makes your life worth living. People consider the positives and negatives of medical treatment in very personal ways. This explains why some people choose different types treatment. Questions to ask yourself are: How much would I be willing to live with if my chance of regaining my current health was low? What if the chances were high? What physical discomforts and limitations can I live with? To determine your beliefs and values, complete the questions on the following page, titled What makes your life worth living? The questions provide situations to consider if your health should change from how it is now. It also may help guide you in deciding what health situations are acceptable to you. It may help you to choose the type of medical treatments you may want or don t want in the future.
Your Beliefs and Values What makes your life worth living? Instructions This exercise will help you think about and express what really matters to you. For each row, check ( ) one answer to express how you would feel if this factor by itself described you. Initials & : Life like this would be: difficult, worth not can't but living, but worth answer acceptable just barely living now a. I can no longer walk but get around in a wheelchair. b. I can no longer get outside I spend all day at home. c. I can no longer contribute to my family's well being. d. I am in severe pain most of the time. e. I have severe discomfort most of the time (such as nausea, diarrhea, or shortness of breath). f. I rely on a feeding tube to keep me alive. g. I rely on a kidney dialysis machine to keep me alive. h. I rely on a breathing machine to keep me alive. i. I need someone to help take care of me all of time. j. I can no longer control my bladder. k. I can no longer control my bowels. l. I live in a nursing home. m. I can no longer think clearly-i am confused all the time. n. I can no longer recognize family/friends o. I can no longer talk and be understood by others. p. My situation causes severe emotional burden for my family (such as feeling worried or stressed all the time). q. I am a severe financial burden on my family. r. I cannot seem to shake the blues. s. Other (write in): Instructions To help others make sense out of your answers, think about the following questions and be sure to explain your answers to your loved ones and health care providers. If you checked "worth living, but just barely" for more than one factor, would a combination of these factors make your life "not worth living?" If so, which factors? If you checked "not worth living," does this mean that you would rather die than be kept alive? If you checked "can't answer now," what information or people do you need to help you decide? 21
Completing the Decisions for Medical Treatment Form The Decision for Medical Treatment form contains 9 treatment options. For each one below, review the information and then complete the Decisions for Medical Treatment form found in this booklet. Check the appropriate boxes identified. Cardiopulmonary Resuscitation (CPR) This involves applying compressions to the chest, giving drugs through a vein, electrical shocks to the heart, and artificial breathing by machine. CPR is started if your heart or breathing stops. Advanced age and serious illness affect your body s ability to recover from CPR. Successful CPR may indicate that your heart has been restarted, but it does not guarantee that you will return to your previous level of functioning. Prolonged CPR may result in permanent unconsciousness or coma. Mechanical Breathing A tube is placed down your throat or through a hole in your neck into the lungs. A respirator machine breathes for you when your body can t breath for you. It may help you get better, but some people may not be able to live without a respirator and need to have it all the time. Surgery During a surgical procedure, you are given drugs to make you sleep and internal organs are removed or repaired, such as a gall bladder, etc. Surgery can carry the risk of infection or bleeding. Recovery from surgery can be painful. Dialysis Dialysis can do the kidneys usual tasks of removing the waste chemicals that build up in the body. A tube is surgically implanted into a blood vessel so that the dialysis machine can be connected. Dialysis usually takes several hours and is done on a regular basis, usually 3 times a week. Dialysis does the work of the kidneys but does not cure them. Nutrition/Hydration Fluid may be provided through an intravenous line (IV) placed in your arm, or chest. Nutrition may be given through a tube in your nose that enters the stomach or through a tube that is surgically placed in your stomach through the belly wall. There is the risk of bleeding and infection when this tube is placed. Transfusions You may receive blood or blood products such as platelets or plasma through an intravenous line (IV) in your arm or chest. Antibiotics These drugs are used to fight infections. Antibiotics can be given by mouth. They also can be given by injection into the muscle or given through an intravenous line (IV) into your vein. Invasive Tests Invasive testing includes procedures such as using a flexible tube to look in the stomach or lungs. Drugs may be given to help you sleep during these tests. There is isk of infection or bleeding. Noninvasive Tests These tests involve procedures such as x-rays or blood tests that are usually not painful or have complications.
How can I make my decisions known? Once you have decided what medical treatment options are best for you, discuss the options with your family and health care provider. You also should make sure that your Patient Advocate is aware of your decisions. Then, complete the Decisions for Medical Treatment forms found in this booklet. Completing all the forms in this booklet will ensure that your decisions are known. What is a Patient Advocate? ( also known as Surrogate Decision Maker, Health Care Proxy) A Patient Advocate is a person whom you choose to speak for you when you are unable to speak for yourself. This person will make health care decisions for you. Your Patient Advocate will continue your medical plan as you have chosen on your Decision for Medical Treatment form. The person you choose will make decisions for you only if your doctor and a licensed psychologist find that you have reached a point where you are unable to make your own health care decisions. Choose someone to be your Patient Advocate who is: At least 18 years of age Cares about you Will be available Knows you very well Can make difficult decisions Sometimes a spouse or family member is not the best choice because they are too emotionally involved. Sometimes they are the best choice. You know best. Make sure you choose someone who is able to stand up for you so that your wishes are followed. Make sure you talk about your wishes with this person and that he or she fully understands and agrees to respect and follow your decisions. (4) What will the Patient Advocate do for me? Your Patient Advocate may be asked to make health care decisions that are in your best interest (7), only in the event that you are unable to speak for yourself. These decisions may include: Understanding any instructions you may have given in writing or in discussion about the kind of medical care you want. Making choices about medical care services you could receive such as: tests, medicines, or surgery. These treatments could be ordered to find out what your health problem is, how to treat it, and can also include care to keep you alive. If the treatment or care has already started, your Patient Advocate can ensure it continues or have it stopped, allowing you to die peacefully. Continuing or stopping medical treatments, including artificially-provided food and water, and any other medical treatments to keep you alive. Obtaining, viewing, and approving release of your medical records and personal files. Arranging your admission to a hospital, hospice, or nursing home. Arranging for the hiring, and, if necessary, firing of health care workers who take care of you. Applying for Medicare, Medicaid, or insurance benefits and programs for you. Your Patient Advocate cannot make a medical decision which may result in your death if you are pregnant. (3) Your Patient Advocate may only be paid for necessary expenses during the course of making decisions for you. (5) Your Patient Advocate can choose to NOT be your Patient Advocate at any time. (8)
The Patient Advocate Form in this booklet has a place for the Patient Advocate to record their name and phone number. It is a good idea to list another person as a back up if your first choice for a Patient Advocate is not available when they are needed. Why should the Patient Advocate Form have witnesses signatures? The appointment of a Patient Advocate needs signatures of two witnesses. The two witnesses only confirm the signature is yours. The witnesses you select must be 18 years of age or older and cannot be: The person appointed as your Patient Advocate Your health care provider An employee of your health care provider Financially responsible for your health care An employee of your life or health insurance company Related to you by blood, marriage, or adoption Can I change my mind? You have the right to change your mind or take back your choice of a Patient Advocate at any time. You also have the right to change your mind about your decisions for medical treatment at any time. You must let your health care provider know you ve changed your mind. You need to complete a Revocation of Advance Care Documents Form. A form is included in this booklet. What do I do with the forms when they are all completed? Once you have completed the forms, make sure that you, your Patient Advocate, and witnesses sign in the correct spot on the forms. Give them to your primary care provider so that copies will be placed in your hospital medical record. This will make the forms available to all members of the medical team involved in your care. A copy should be taken home and kept in a safe place. Provide a copy to your Patient Advocate who will speak for you. You also can provide copies to other family members or friends whom you feel may require access to this information. Review the forms periodically. You may want to change information on the forms. Review the changes with your health care provider when necessary. Remember: Decide for yourself, before someone has to decide for you!
DATE MRN NAME Decisions for Medical Treatment I understand that there may come a time when I cannot express my wishes about medical treatment. If I have a condition where my doctors believe there is little chance I will recover from my illness and that my death is likely no matter what is done, then I request that this document be taken to indicate my decisions about the following medical treatments. I understand that these decisions are not all inclusive and that if I can no longer communicate, my physician along with my patient advocate will make the most appropriate treatment decisions based on what I have indicated in the following boxes. (Please mark appropriate boxes below) Cardiopulmonary Resuscitation (CPR)- The use of drugs, artificial breathing, and electric shock to start the heart after it has stopped Mechanical Breathing -Breathing by a machine through a tube placed in the throat Surgery - Such as removing the gallbladder or part of the intestine Dialysis- The use of a machine to remove waste from the blood when the kidneys can no longer do that job Invasive Tests -Such as using a flexible tube to look into the stomach or lungs Nutrition and Hydration Food and fluid given through a tube in the veins, nose, or stomach Transfusion- Of blood or blood products such as platelets & plasma Antibiotics Drugs to fight infection Non-invasive tests - Tests with little potential for complications or discomfort, such as blood tests or xrays WANT DON T WANT Other - Patient Signature Witness Signature Copies: Patient keeps a copy, give to doctor for medical record, give copy to patient advocate
DATE MRN NAME Patient Advocate Form If I am not longer able to make my own health care decision, this form names the person I choose to make these decisions for me. This person will be my Patient Advocate. I understand the requirements of being a Patient Advocate and accept those responsibilities. Patient Advocate Sign Name Print Name Home Telephone Work Telephone Successor Patient Advocate Sign Name Print Name Home Telephone Work Telephone Appointment of Patient Advocate This Advocacy shall take effect only in the event that I am unable to participate in decisions about my health care. My advocate shall have the authority to make all decisions to the same degree that I would have if able, regarding care, custody and medical treatment even if it may result in my death. I have discussed this document with my physician and understand the consequences of my decisions. Patient Signature Phone City/State/Zip Witness (2 witnesses required) Signature of Witness (1) Signature of Witness (2) Printed Name Printed Name City/State/Zip City/State/Zip Phone # Phone # Copies: Patient keeps a copy, give to doctor for medical record, give copy to patient advocate
DATE MRN NAME Revocation of Advance Care Documents I do hereby revoke any previous appointment of a Patient Advocate. I no longer wish to have as my Patient Advocate. Patient Signature Witness Signature I do hereby revoke my current Decisions for Medical treatment. Patient Signature Witness Signature Copies: Patient keeps a copy, give to doctor for medical record, give copy to patient advocate Form 4748 MR 8/00