MAKING YOUR WISHES KNOWN: Advance Care Planning Guide

MAKING YOUR WISHES KNOWN: Advance Care Planning Guide

ADVANCE CARE PLANNING The process of learning about the type of medical decisions that may need to be made, considering those decisions ahead of time and then letting others know your preferences, often through an Advance Directive. ADVANCE DIRECTIVE Legal document that explains to others the type of care that you do or do not want in cases when you are unable to make your wishes known. DURABLE POWER OF ATTORNEY FOR HEALTH CARE This is not the same as a financial Power of Attorney. It is an Advance Directive that designates a person to make medical decisions if you are incapable of making them yourself. Sometimes the words agent and proxy are substituted for Power of Attorney. Even after naming a Durable Power of Attorney for Health Care, you still have power to make your own decisions as long as you are able to do so. LIVING WILL A type of Advance Directive that lists the kinds of treatments you do or do not wish to have administered if you cannot make your wishes known. Some areas that may be addressed in this document include the use of artificial nutrition, hydration and breathing machines. TERMINAL ILLNESS An illness that has no cure, even with medical treatment. Generally, a person who has a terminal illness is someone who is not expected to live longer than six months. In a terminal illness, life-sustaining treatments prolong the dying process, not stop it. CPR (CARDIOPULMONARY RESUSCITATION) Aggressive treatments such as pushing on your chest, inserting a breathing tube or administering electric shocks to restart breathing and/or a heartbeat. TERMS YOU NEED TO KNOW DNR (DO NOT RESUSCITATE) A medical order stipulating that CPR will not be used if your heartbeat or breathing stops. A DNR does not mean that other treatments stop or change. A separate order is needed for that. Comfort care and pain medications continue. DDNR- (DURABLE DO NOT RESUSCITATE) A medical order that travels with you stipulating that CPR will not be used if your heart beat or breathing stops. This order must be on a STATE or POST (Physician Orders for Scope of Treatment) form to be recognized by emergency medical services. ARTIFICIAL NUTRITION/HYDRATION Food and water that is given through a tube if you cannot eat or drink enough to sustain yourself. COMFORT CARE Care that keeps you comfortable but does not treat the illness. This could be pain control, bathing, bed turning and lip moistening. VENTILATOR A machine that helps you breathe. A tube connected to the ventilation is put though the throat into the trachea (wind pipe) so the machine can force air into the lungs. POST (PHYSICIAN ORDERS FOR SCOPE OF TREATMENT) A set of orders written by a physician that is based on your medical condition and expressed wishes.

No one knows what the future holds. Sometimes, you can become so ill so quickly that it is not possible to communicate your health care and treatment choices. That s why a special Advance Directive document is so important. Before getting ill, you can create an Advance Directive so your medical choices are clear. Preparing an Advance Directive or other legal document like a Living Will or Power of Attorney can be confusing. This booklet will explain what you need to know. WHEN MAKING DECISIONS, ASK THESE QUESTIONS: DO I KNOW ENOUGH ABOUT THESE LIFE-PROLONGING TREATMENTS TO MAKE AN INFORMED DECISION? Every person s situation is unique. Talk to your doctor about your particular situation and medical options you may face, such as mechanical ventilation (a machine that assists patients who cannot breath on their own), CPR, artificial nutrition and hydration. HOW DO I FEEL ABOUT LIFE-PROLONGING TREATMENTS IF I AM TERMINALLY ILL, IN AN IRREVERSIBLE COMA OR DEALING WITH SUCH CHRONIC ILLNESSES AS ALZHEIMER S? Would you want antibiotics administered to cure an infection that might lead to your death? Would you want food and water administered artificially through a tube? If you were in pain, would you want aggressive pain management, even if it might shorten your life? WHAT AM I MOST AFRAID OF HAPPENING? You may be most concerned about pain, loss of independence, being kept on life-support machines or being a burden to your family. IF I HAD A TERMINAL ILLNESS, HOW WOULD I WANT TO SPEND MY LAST DAYS? Would you want to go to the hospital for aggressive treatments, or is it more important to stay in your home? What measures could help you spend the rest of your life the way you most want? WHAT DO I SEE AS AN ACCEPTABLE QUALITY OF LIFE? If you are confined to a bed or a machine breathes for you, would you consider that living? WHO SHOULD I CHOOSE AS MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE? This very important person should be someone whose values are similar to your own and whom you trust to know and carry out your wishes. This person must be at least 18 years old and be willing to accept the responsibility of making difficult decisions even though others may disagree. Make sure this person understands your wishes clearly and has the opportunity to ask questions. Other family members and loved ones should also be told of your wishes. HOW CAN I ENSURE MY ORGANS OR BODY ARE DONATED AFTER I DIE? IS HAVING IT NOTED ON MY DRIVER S LICENSE ENOUGH? Even with the notification on your driver s license, it is best to state your specific wishes on your Advance Directive and discuss them with your Durable Power of Attorney for Health Care and family members. Advance approval is needed to donate your body to a medical school. Your doctor should be able to assist you with this request. HOW DO I GO ABOUT MAKING AN ADVANCE DIRECTIVE? Once you have had a chance to talk with your doctor and family and have considered the above questions, you are ready to put your wishes in writing. You can use many types of forms to create a document. Versions are available on the Internet, from Chesapeake Regional Medical Center, or from your attorney. You do not, however, need an attorney s assistance to complete an Advance Directive. If you create a new form, make sure the old one is destroyed to avoid confusion.

VIRGINIA HEALTH CARE DECISIONS ACT By law you have the right to make decisions regarding your health care. Advance Directives are documents that explain to others the type of care you do or do not want in cases where you are unable to make your wishes known. Advance Directives should be talked about with loved ones and those you trust. Take the time to carefully prepare your Advance Directive based on your beliefs and values - the things that are important to you. In completing your Advance Directive, it may be helpful to consider your responses to the following questions from the Extended Values History Form: OVERALL ATTITUDE TOWARD LIFE AND HEALTH What would you like to say to someone reading this document about your overall attitude toward life? What goals do you have for the future? How satisfied are you with what you have achieved in your life? What, for you, makes life worth living? What do you fear most? What frightens or upsets you? What activities do you enjoy (e.g. hobbies, watching TV)? How would you describe your current state of health? If you currently have any health problems or disabilities, how do they affect you? Your family? Your work? Your ability to function? If you have any health problems or disabilities, how do you feel about them? What would you like others (family, friends, doctors) to know about this? Do you have difficulty managing daily activities such as eating, preparing food, sleeping, dressing and bathing, etc? What would you like to say to someone reading this document about your general health? PERSONAL RELATIONSHIPS What role do family and friends play in your life? How do you expect friends, family and others to support your decisions regarding medical treatment you may need now or in the future?

Have you made any arrangements for family or friends to assist in making medical treatment decisions on your behalf? If so, who has agreed to assist in making decisions for you and in what circumstances? What general comments would you like to make about the personal relationships in your life? THOUGHTS ABOUT INDEPENDENCE AND SELF-SUFFICIENCY How does independence or dependence affect your life? If you were to experience decreased physical and mental abilities, how would that affect your attitude toward independence and self-sufficiency? If your current physical or mental health gets worse, how would you feel? LIVING ENVIRONMENT Have you lived alone or with others over the last 10 years? How comfortable have you been in your surroundings? How might illness, disability or age affect this? What general comments would you like to make about your surroundings? RELIGIOUS BACKGROUND AND BELIEFS What is your spiritual/religious background? How do your beliefs affect your feelings toward serious, chronic or terminal illness? How does your faith community, church or synagogue support you? What general comments would you like to make about your beliefs? RELATIONSHIPS WITH DOCTORS AND OTHER HEALTH CAREGIVERS How do you relate to your doctors? Please comment on: trust; decision making; time for satisfactory communication and respectful treatment. How do you feel about other caregivers, including nurses, therapists, chaplains, social worker, etc.? What else would you like to say about doctors and other caregivers?

THOUGHTS ABOUT ILLNESS, DYING AND DEATH What general comments would you like to make about illness, dying and death? What will be important to you when you are dying (physical comfort, no pain, family members present, etc.)? Where would you prefer to die? How do you feel about the use of life-sustaining measures if you were: suffering from irreversible chronic illness (e.g. Alzheimer s disease)? terminally ill? in a permanent coma? What general comments would you like to make about medical treatment? FINANCES What general comments would you like to make about your finances and any costs connected with your health care? What are your feelings about having enough money to provide for your care? FUNERAL PLANS What general comments would you like to make about your funeral and burial or cremation? Have you made your funeral arrangements? If so, with whom? WRITTEN LEGAL DOCUMENTS Do you have a Living Will or an Advance Medical Directive? List date and location: Do you have a Durable Power of Attorney? List date and location: Do you have an organ donation document? List date and location: Do you have a family attorney? List date and location: Would you choose to use experimental treatments if you have a life threatening illness in which normally accepted medical procedures have been unsuccessful?

WISHES CONCERNING MONEY AND HEALTH CARE COSTS: Do you want to spend your assets on life-sustaining medical care? Given the choice between home care and institutional care, on which would you prefer to spend your assets? Is it important to you to preserve your assets for your family or beneficiaries? THE FOREGOING DOCUMENT EXPRESSES MY WISHES AND DESIRES SHOULD I BECOME DECISIONALLY INCAPACITATED. THIS INFORMATION MAY BE RELIED UPON BY MY SURROGATE DECISION-MAKER OR DURABLE POWER OF ATTORNEY. SIGNED: DATE: WITNESS: WITNESS: (When prepared by the individual as an advance planning tool, it is useful to have two non-family members witness and sign the Values History.)

ADVANCE MEDICAL DIRECTIVE I,, am capable of making an informed decision and make this Advance Directive as an expression of my wishes for medical treatment. This will only be used if I ever become incapable of making an informed decision. If there are any sections of this form that you do not want to complete, cross through it and sign the center of the X. SECTION I APPOINTMENT OF HEALTH CARE AGENT If you do not appoint a health care agent, your nearest relative, as defined by the Code of Virginia, will be relied upon to provide informed consent for providing, withholding or withdrawing medical treatments if you become incapable of making an informed decision. I hereby appoint the person below to be my primary agent. Name Telephone Address Cell Phone If my primary agent is not available or is unable or unwilling to act as my agent, then I appoint the person below to serve in that capacity: Name Telephone Address Cell Phone I grant my agent full authority to make health care decisions on my behalf as described below, my agent shall have this authority whenever and for as long as I have been determined incapable of making an informed decision. Powers of My Health Care Agent (Cross through any language you do not want and add any language that you do want.) The Powers of my agent shall include the following: A. To consent to or refuse or withdraw consent to any type of health care including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if such medication carries risk of addiction or of inadvertently hastening my death B. To request, receive, and review any information regarding my physical or mental health, and to consent to the disclosure of this information C. To employ and discharge my health care providers D. To authorize my admission to or discharge from any medical care facility E. To continue to serve as my agent even if I become incapable of making an informed decision and then protest his or her authority F. To authorize my participation in health care research that might benefit me

G. To authorize my participation in health care research to promote human well-being, even if it would not benefit me H. To restrict the following people from visiting me while I am in a health care facility: (If you do not want to restrict visitors, write, None. ) I. To take any lawful action necessary to carry out these decisions, including the granting of releases of liability to medical providers. SECTION II MY HEALTH CARE INSTRUCTIONS In sections A and B below, put your initials next to the statement that communicates your wishes. If you do not want to make specific instructions, but instead allow your health care agent to make choices that are consistent with your values, you may cross though this section and write no instructions in the margin. A. Terminal condition: If my attending physician determines that my death is imminent (very close) and medical treatment will not help me recover: (choose one of the following by placing your initials in the blank beside the item) I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis and antibiotics. I direct that I be allowed to die naturally. Medication or procedures that provide comfort or alleviate pain shall continue to be provided. I want all medically appropriate treatments to prolong my life as long as possible. Other instructions: B. Permanent and severe illness or brain injury: If my condition makes me unaware of myself or my surroundings or unable to interact with others, and it is reasonably certain that I will never recover: (choose one of the following by placing your initials in the blank beside the item) I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis and antibiotics. I direct that I be allowed to die naturally. Medication or procedures that provide comfort or alleviate pain shall continue to be provided. I want all medically appropriate treatments to prolong my life as long as possible. I want to try treatments for a period of time in the hope of some improvement of my condition. I suggest as the period of time after which such treatment should be stopped if my condition has not improved. My health care agent should decide on this time period together with my physician. Other instructions:

SECTION III - ORGAN OR TISSUE DONATION I donate my organs, eyes and tissues for use in transplantation. I donate my organs, eyes and tissues for use in therapy, research and education. I do not wish to donate organs or tissues. I donate my whole body for research and education. Other instructions: SECTION IV - SIGNATURE AND RIGHT TO REVOKE By signing below, I indicate that I am emotionally and mentally capable of making this Advance Directive and that I understand the purpose and effect of this document. I understand that I may revoke all or any part of this document as long as I am capable of making an informed decision. This Advance Directive shall not stop in the event of my physical or mental disability. My Signature: Date: Witnesses: This document was signed in my presence. Witness #1 Date: Witness Name (print) Witness #2 Date: Witness Name (print) Important Notes: A Notary is not required in Virginia. All three pages of this document should be kept together, even if you crossed out some sections.

Make certain to provide copies of your Advance Directive to your doctor, key family members, a lawyer and clergy. Always have a copy with you when you receive medical treatment. Should you have questions or need assistance with completing an Advance Directive, your doctor or nurse can answer questions or contact trained personnel for help. Additional copies of this booklet may be downloaded on your computer by visiting www.chesapeakeregional.com. 667 KINGSBOROUGH SQUARE, SUITE 202 CHESAPEAKE, VA 23320 757-312-3085