Cynthia Ann LaSala, MS, RN Nursing Practice Specialist Phillips 20 Medicine Advisor, Patient Care Services Ethics in Clinical Practice Committee
What is Advance Care Planning (ACP)? Understanding/clarifying what your current state of health is and what your future health care needs may be Making decisions about the type of medical care and treatment preferences you may want based upon your personal goals, values, and beliefs Discussing your healthcare goals and decisions with loved ones before a situation happens where you are unable to speak for yourself
What are the Goals of ACP? To respect and promote your right to selfdetermination (autonomy) To improve your quality of life To reduce chances for unwanted admissions to a hospital or other healthcare facility (e.g. nursing home, rehabilitation center) To help prepare yourself and your family for your future health care needs To ensure that you will be able to die with dignity knowing that your values, beliefs, and health care choices will be respected and honored
What are some barriers to ACP? Misunderstandings regarding one s current health care needs and future choices/options Anxiety and fear Health literacy Confusing medical language or understanding advance directive forms Assuming that family members or significant others will know what decisions to make
What is an Advance Directive (AD)? A written legal document that describes a person s decisions regarding his or her medical care in the event should the person become unable to speak for his or herself (e.g. loses capacity to think clearly or becomes comatose) An advance directives may also be referred to as a durable power of attorney for health care.
What are some examples of AD documents? Health Care Proxy Form: a document in which a person appoints a health care agent to make health care decisions for him or herself if he or she loses capacity to do so Living Will: description of a person s values, beliefs, and treatment goals and preferences A Living Will is not legally recognized as an AD in all states (e.g. MA). Five Wishes http://www.agingwithdignity.org
Who should you choose as your agent? Someone you can trust Someone who knows you and respects your personal goals, values, and beliefs even though they may differ from his or her own Someone who will be able to speak on your behalf Someone who can be available both now and in the future Someone who can advocate for you if confronted by an unresponsive health care provider or institution Someone who can handle conflicting views between family members, friends, & health care providers
MA Health Care Proxy (MA General Laws, Chapter 201D) May be completed by any competent adult 18 years of age or older regardless of illness Agent may be any adult except an administrator, operator, or employee of a health care facility unless related to the patient by blood, marriage, or adoption Gives the health care agent full authority or authority with limitations to make health care decisions if the patient loses capacity
MA Health Care Proxy (MA General Laws, Chapter 201D) Signed and dated by the patient (principal) or designee appointed by the patient if physically unable to sign in the presence of two witnesses (Agent or Alternate Agent cannot serve as witnesses). Witnesses document the date, sign their names, and print their names and addresses. An Alternate Agent may also be named.
Keep in mind that The Health Care Proxy form and Agent go into effect only when the patient s physician determines that the patient is unable to make his or her own decisions. The patient may change or cancel his or her health care proxy at any time.
Keep in mind that A Health Care Proxy form is revoked or canceled when: The patient wishes to initiate a new form. The patient legally separates from or divorces his or her spouse who is named as health care agent. The patient notifies his or her agent, doctor, or other health care provider orally or in writing that he or she wishes to revoke a health care proxy. A health care proxy form is shredded, torn, or destroyed.
Consider re-evaluating your health care wishes when You start a new decade of your life. Your lose a loved one. You are diagnosed with a serious illness or your current health problems become chronic and progressive and begin to limit your ability to remain independent. Your current AD no longer reflects your wishes.
What should you do with your AD? Keep the original and place it in an easily accessible place. Give a copy to your health care agent, alternate agent, physician, and anyone else you want to have a copy (e.g. lawyer, clergy). Make sure to take a copy with you or contact someone who has a copy if you are admitted to the hospital or an extended care facility (e.g. nursing home or rehabilitation center) so that it can be placed in your medical record. Carry an AD wallet card with you.
Other things to consider What gives your life meaning? What could you learn to live with? What could you learn to live without? What fears or concerns do you have about the medical care or treatments you might need? Are there treatments you wish to have or would not want? What does no heroic measures or dying with dignity mean to you?
What are Life-Sustaining Treatments? CPR (Cardiopulmonary Resuscitation) DNR (Do Not Resuscitate) DNI (Do Not Intubate) Hemodialysis Food and Hydration (e.g. intravenous fluids, feeding tube) Non-Invasive Ventilation
MOLST (Medical Orders for Life-Sustaining Treatment (LST)) New MA Department of Public Health initiative as of 2014 Medical order versus legal document (AD) Reviewed if the patient becomes hospitalized based upon current care needs and goals Designed for patients of any age who have a lifethreatening illness or chronic progressive disease with limited life expectancy Guides EMTs, paramedics, police, fire department) in knowing what to do in an emergency
MOLST (Medical Orders for Life-Sustaining Treatment (LST)) Portable across all health care settings Signed by the patient or health care agent and physician, nurse practitioner, or physician assistant Can be changed or revoked at any time by the patient Describes the LSTs patients want, do not want, or are unsure about Identifies whether patients wish to be brought to the hospital
Palliative Care Focuses on preventing and relieving suffering to promote quality of life for patients and families by managing symptoms such as pain, difficulty sleeping, anxiety and fear, nausea and/or vomiting, constipation, or other symptoms that may cause the patient physical, emotional, or spiritual discomfort or distress Effective in helping to manage symptoms associated with chronic, progressive disease and may be a bridge to hospice care as a patient nears end of life
Hospice Care Utilizes a holistic approach to provide comprehensive care to patients at end of life, during the last few weeks or months of life, and supports both patients and families during the dying process Builds upon the palliative care model to minimize suffering through appropriate symptom management and includes bereavement support to loved ones after the patient has died