Advance Care Planning/End of Life Care

Advance Care Planning/End of Life Care

Disclosure Declaration 0I have no actual or potential conflict of interest in relation to this program or presentation. 7/22/2015 2

OBJECTIVES To understand an Advance Directive & its usefulness in transitions of care. To understand the Health Care Proxy & his/her role in end-of-life care decisions. To understand the physician s role in advance care planning. To become familiar with resources for advance care planning. 7/22/2015 3

ADVANCE CARE DIRECTIVES: a legal document, consistent with state law, that helps to ensure that one s health care wishes will be carried out; may be an oral communication, verbally expressed to family members or to a health care agent. 7/22/2015 4

Two main types of Advance Directives: Medical POA/Health Care Proxy Living Will/Treatment Directive 7/22/2015 5

MEDICAL POA: A written document in which a person (Agent) is named to act as health care proxy in the event: one is no longer able to speak for him/herself; or there is cognitive/physical decline that results in lack of capacity as determined by a physician. 7/22/2015 6

LIVING WILL: Documents personal directives for EOL care in the event that decision-making or communication abilities are lost. Includes directives for: IVF hydration, parenteral/enteral nutrition, CPR, mechanical ventilation, hemodialysis, stopping life-prolonging treatment. 7/22/2015 7

Qualifications for a Health Care Proxy/Agent: Meets legal criteria of the state Willing to speak on the patient s behalf Able to act on the Principal s wishes Readily available Understands what is important to the Principal 7/22/2015 8

Qualifications (cont.): Trustworthy Able to discuss sensitive issues Able to handle conflicting opinions b/t family members/friends/health care providers Can be a strong advocate in the face of an unresponsive physician or institution Will be available as long as the Principal is alive 7/22/2015 9

Surrogate decision making: A surrogate may make health care decisions for an adult who doesn t have a designated Proxy/Agent or Guardian. Order of choice: Spouse Adult child Sibling Grandchild Other 7/22/2015 10

Rules disqualifying for health care proxy: Less than 18 years of age Proxy is the patient s health care provider or is an employee of the health care provider. Proxy is the owner of the health care facility where the patient resides. 7/22/2015 11

When to create or change an Advance Directive: Any major change in status Five D s : odecade odeath odivorce odiagnosis odecline 7/22/2015 12

Obtain an Advance Directive form: Local hospital s social service, patient education, admissions, or chaplaincy departments Download a legal form for any state from: www.caringinfo.org Five Wishes (see Resources page) American Bar Association (see Resources page) 7/22/2015 13

What to do with the Advance Directive: Original is kept with the individual (or Proxy) & stored where it can be easily found Copies to Proxy, health care provider, hospital, others Carry an Advance Directive wallet card Notarized version if traveling out of state 7/22/2015 14

Physician Orders for Life-Sustaining Treatment (POLST) A. CPR B. MEDICAL INTERVENTIONS C. ANTIBIOTICS D. ARTIFICIALLY ADMINISTERED NUTRITION/HYDRATION E. BASIS FOR ORDERS F. SIGNATURES 7/22/2015 15

Role of Advance Directives & Transitional Care: Case scenario Provides clear direction for health care personnel regarding EOL care Keeps care consistent with patient s wishes POLST provides clear and mandatory documentation Needs to accompany the patient during transitions when the Proxy/family are unavailable 7/22/2015 16

Role of the PCP Patients want their primary care doctor to initiate advance care planning while they are in good health. Most patients feel that it is the physician s responsibility to initiate the discussion about advance care planning. The most successful interventions incorporate direct patient-healthcare provider interactions over multiple visits. Medicare Annual Wellness Visit (Ramsaroop, SD, et. al. Completing an advance directive in a primary care setting: what do we need for success? JAGS55:277-83, 2007.) 7/22/2015 17

In conclusion: Modern medicine may have made dying harder, but it has also given us the gift of time- the time to prepare, the time to heal family wounds, the time to bring psychological and spiritual closure. If we can take advantage of it, it has given us something unique in history: the time to tie up loose ends and orchestrate a death that is good. Marilyn Webb, The Good Death 7/22/2015 18

RESOURCES Five Wishes Guidance on advance care planning available in 26 languages. http://www.agingwithdignity.org/five-wishes.php Consumer s Toolkit for Health Care Advance Planning Developed by the American Bar Association Commission on Law and Aging. http://apps.americanbar.org/aging/publications/docs/consumer toolkitbk.pdf State Specific Advance Directive Form Free downloadable advance directive forms and information from state bar associations. http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289 7/22/2015 19

REFERENCES 1. Ramsaroop SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geritric Soc 55:227-283, 2007. 2. Gozalo P, et. al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011;365:1212-21. 3. Hammes BJ, et. al. A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem. J Am Geriatr Soc 2010; 58:1249-2010. 7/22/2015 20

REFERENCES 4. Physician orders for Life-Sustaining Treatment (POLST). POLST Web site. http://www.polst.org/. Accessed 11/2/14. 7/22/2015 21

THANK YOU! PAOLINI@CAMPBELL.EDU 7/22/2015 22