Published December 2013 Overview of End of Life Care LOSS PREVENTION SELF STUDY COURSE
Educational Objectives and Credits Educational Objectives Completion of this self study course will allow healthcare professionals to: Be aware of the services and documents required at the end of a patient s life. Understand core aspects of Advanced Medical Directives. Understand the dierence between a Healthcare Representative, a Healthcare Agent and a Conservator. Understand the considerations necessary to prepare a written plan for end of life care. CME Credits Connecticut Medical Insurance Company (CMIC) is accredited by the Connecticut State Medical Society to provide continuing medical education for physicians. CMIC designates this enduring material for a maximum of one AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This self study material is designed to provide doctors with background information on end of life care. To receive one CME credit, you must read this article, achieve a minimum of 80% on the online post-test and complete the online evaluation form. (Which in total should be approximately one hour of time.) Your CME certificate will be automatically generated. Internet access is needed to complete this process and a printer is needed to print the CME certificate. (You have the ability to access the certificate at a later time.) Instructions can be found at the end of this article. Original release date: December 20, 2013; expires: December 19, 2016 Reviewed by: William S. Potter, MD The information in this course is obtained from sources generally considered to be reliable; however, accuracy and completeness are not guaranteed. The information is intended as risk management advice. It does not constitute a legal opinion, nor is it a substitute for legal advice. Legal inquiries about topics covered in this course should be directed to your attorney. 2013 CMIC. All rights reserved. 2
Introduction A person s dying may not be easy, but what of value in life is? Similarly, caring for our loved ones as they die is simply part of full and healthy living. It is rarely fun, indeed is often hard - but it is as important and valuable as any experience in life. Ira Byock, MD End of life care focuses on providing patients with the specialized care they require towards the end of a serious illness or unexpected event. It is important for doctors to understand the special services that are required at the end of life to help educate their patients and reduce stress when it is time to make decisions regarding palliative care, pain management and medical therapy. The following information is designed to give you a brief overview of the end of life documents. For further information, links to specific state laws are included at the end of this article. Advanced Medical Directives Advanced Medical Directives are documents that describe a person s wishes about medical care, particularly those that relate to decisions about end of life care. The two main types are Living Wills and a document that names an individual to make medical decisions for the patient when the patient cannot. This document is known by multiple names, depending on the state or even the time period at which the document was originally executed. Examples include a Health Care Agent Form, Health Care Proxy, Power of Attorney for Health Care Decisions and Health Care Representative document. Living Wills A Living Will is a statement of the individual s beliefs and wishes about medical care, including termination of life support, use of artificial hydration and nutrition, do not resuscitate orders and the like. It may be a formal witnessed document or a personal letter from the individual identifying it as a statement of his or her wishes. It may include the appointment of a Health Care Representative who can make medical decisions in the event the individual can no longer communicate his or her wishes as a result of incapacity (whether as a result of dementia, coma, persistent vegetative state, locked in syndrome, severe psychiatric illness or other event that prevents any meaningful communication with and/or comprehension and decision-making by the individual). When it does include such an appointment, it is referred to as a combined form. A combined form is useful because it allows the individual to appoint a decision-maker and communicate his or her wishes in one document. If the patient has capacity and able to communicate his/her medical decisions, there is no reason to consult a Living Will. If the patient is not competent or able to communicate his/ her decisions, the Living Will is a guide to what the patient intended for his/her care. However, if there is a Health Care Representative available, and the Living Will does not clearly apply to the current circumstances, the Health Care Representative s decision may take precedence over the Living Will. If the Health Care Representative instructions are 3
contrary to the clearly stated wishes in the Living Will, the doctor should seek a decision from the Probate Court. Health Care Representative The Health Care Representative is a person who has the authority to make any and all health care decisions for a person who is incapable of expressing those wishes for him/herself. A Health Care Representative makes decisions on the patient s behalf based on the patient s wishes, as stated in the patient s Living Will or as otherwise known to the Health Care Representative. The Health Care Representative stands in the shoes of the incapacitated patient. If the Health Care Representative knows the patient s wishes, he is bound by them. But if the Health Care Representative does not specifically know the patient s wishes in a particular situation, he may make a decision in the best interest of the patient based on what is known. The Health Care Representative s role is wider than the former Health Care Agent who was limited to making any decisions about life support or comfort care, and former power of attorney for health care decisions who was limited to making medical decisions not involving life support. There are still older types of Health Care Representatives out there. A doctor may continue to rely on the decisions of a power of attorney for health care decisions or a health care agent where such individuals were appointed prior to the new law and where a newer Health Care Representative has not been appointed. However, it is important to note that the old roles were and remain slightly dierent from the role of the new Health Care Representative. Importantly, the more recent appointment of a Health Care Representative would trump the appointment of an earlier health care agent or power of attorney for health care decisions. The appointment of a Health Care Representative is made through a legal document. Role of Conservator A conservator of the person is someone appointed by the Probate Court when the Court finds that a person is incapable of caring for himself/herself, including the inability to make decisions about his/her medical care. A person who is conserved by a court is known as a ward. A conservator appointed by the Court of Probate must comply with a patient s previously executed advanced directives, including a Living Will, DNR order and appointment of Health Care Representative. The Conservator must allow the patient s Health Care Representative to continue to make health care decisions for the patient. DNR A Do Not Resuscitate Order (DNR) is a physician order, whether entered in a hospital record or for a patient living in the community, which directs that in the event the individual suers a cardiopulmonary arrest, he or she is not to be resuscitated. This order directs hospital sta and/or first responders that the individual or authorized representative has requested that no resuscitation be attempted in the event he or she suers a cardiopulmonary arrest. A DNR may be revoked by the patient or the patient s authorized representative by removing the bracelet and by telling a licensed health care provider or certified emergency medical technician who will document the statement in the patient s permanent medical record and notify the attending physician and the physician who entered into the DNR order. An authorized representative in this context means a person who is authorized by law to provide consent to the issuance or revocation of a DNR order for an incapable person or incapacitated person. Additional Considerations to be Included in End of Life Documents Each individual has unique needs for information and support. By preparing a written plan in advance, confusion can be avoided and/or eliminated when decisions need to be made. 4
Considerations should be made regarding: CPR Antibiotics Artificial nutrition and hydration Dialysis Surgery Blood Transfusions Deactivation of automatic implantable cardioverter-defibrillators Intubation Discussions regarding medical treatment at the end of life should be considered early and discussed with patients. If a patient does not wish to receive artificial nutrition and/or hydration, through the use of an advance direction, a patient may refuse treatment. In some states the refusal of artificial nutrition and hydration must be clearly stated. When there is confusion over the desire of the patient to receive or not to receive treatment, the treatment will usually continue. Understanding the types of documents will aid in the ability of family members and friends to make decisions if and when a patient is unable to make those choices for themselves. Risk Management Reminders Consider including a question on your intake form to identify if a patient has a Living Will or has identified a Health Care Representative. Be sure that both oice sta and other providers can readily identify the presence of these documents in the medical record. Be sure to discuss and document the discussions regarding advanced directives with patients that will be undergoing any surgical procedures. Make available patient educational materials including brochures, forms and/or articles regarding Living Wills and Health Care Representatives for distribution to patients and their family members. Periodically update information regarding Living Wills or Health Care Representatives in your medical record. Document all conversations with patients and their families regarding advanced directives in the progress note of the medical record. Be sure to indicate exactly who was present for the conversation, the issues discussed and the resolution. Utilize the resources of the hospital ethics committee and your local Probate Court for any issues regarding lack of consensus. Laws of Interest Connecticut Eective October 1, 2006, Connecticut law created the role of a Health Care Representative, a person who can make any and all medical decisions, including the withholding and withdrawal of life supports. The Health Care Representative can act only when the patient cannot appreciate or understand the consequences of certain medical decisions or is incapable of making his or her wishes known. The Health Care Representative combines Connecticut s two formal roles power of attorney for health care decisions and health care agent into one. The terms incapacitated, permanently unconscious and terminal condition are now defined in Connecticut General Statutes 19a-570. Incapacitated means being unable to understand and appreciate the nature and consequences of healthcare decisions, including the benefits and disadvantages of such treatment, and to reach and communicate an informed decision regarding the treatment. 5
Permanently unconscious means an irreversible condition in which the individual is at no time aware of him or herself or the environment and shows no behavioral response to the environment and includes permanent coma and persistent vegetative state. Terminal condition means the final stage of an incurable or irreversible medical condition which, without the administration of a life support system, will result in death within a relatively short period of time, in the opinion of the attending physician. For more information, go to: http://www.jud.ct.gov/lawlib/law/livingwills.htm Massachusetts http://www.malegislature.gov/laws/generallaws/partii/titleii/chapter201d New Hampshire http://www.gencourt.state.nh.us/rsa/html/x/137-j/137-j-mrg.htm Rhode Island http://www.health.ri.gov/lifestages/death/about/livingwill Vermont http://healthvermont.gov/vadr Loss Prevention Resources CMIC Loss Prevention Department 800.228.0287 www.cmic.biz CT Department of Public Health 860.509.8000 www.dph.state.ct.us MA Department of Public Health 800.414.0168 www.mass.gov/dph NH Department of Public Health 603.271.4496 www.dhhs.nh.gov RI Department of Public Health 401.222.5960 www.health.ri.gov VT Department of Public Health 802.863.7200 www.healthvermont.gov 6
This is the end of the self study material. To receive your CME certificate: 1. Close/Minimize this PDF Browser. 2. If a blank internet explorer window appears, close it. 3. Click the Continue to Post Test button. (Example shown below)