The Advance Directive

1. The Advance Directive

2. Under the self determination act patients/residents are guaranteed the right to participate in healthcare decisions, including the right to prepare advance directives. The Act says that facilities must provide resident�s with information concerning their rights, under state law, to participate in and direct healthcare decisions, accept or refuse medical treatment and initiate an Advance Directive. This document provides healthcare personnel with your personal instructions as to what medical treatments you do or don�t want, where and how in the event of your death you want to be taken care of etc.Under the self determination act patients/residents are guaranteed the right to participate in healthcare decisions, including the right to prepare advance directives. The Act says that facilities must provide resident�s with information concerning their rights, under state law, to participate in and direct healthcare decisions, accept or refuse medical treatment and initiate an Advance Directive. This document provides healthcare personnel with your personal instructions as to what medical treatments you do or don�t want, where and how in the event of your death you want to be taken care of etc.

3. What is An Advance Directive ? A legal document / documents that provides specific, personalized instructions regarding medical care. Becomes effective only when the patient is unable to communicate their wishes, ( incapacitated / unresponsive)

4. Advance Directive Includes: The Living Will Durable Power Of Attorney for Healthcare Although advance directives are often oversimplified and misunderstood, these documents include a lot more than just the single decision to terminate a patient�s life-support . These documents can include very specific instructions, such as whether or not you want a blood transfusion, mechanical ventilation, artificial nutrition, whether you want to be cremated or buried in the event of your death, or even whether you would want a limb amputated. Some religions do not believe in amputations, so the list goes on. If a person wants to create an advance directive, he or she must be considered competent at the time the document is created We will discuss later why you should have both a living will and a durable power of attorney, although there is no rule mandating you have both, it is recommended.Although advance directives are often oversimplified and misunderstood, these documents include a lot more than just the single decision to terminate a patient�s life-support . These documents can include very specific instructions, such as whether or not you want a blood transfusion, mechanical ventilation, artificial nutrition, whether you want to be cremated or buried in the event of your death, or even whether you would want a limb amputated. Some religions do not believe in amputations, so the list goes on. If a person wants to create an advance directive, he or she must be considered competent at the time the document is created We will discuss later why you should have both a living will and a durable power of attorney, although there is no rule mandating you have both, it is recommended.

5. The Living Will Objectives: To establish an individuals wishes concerning; Pain relief Mechanical means of prolonging life Nutrition and hydration Organ donation Burial instructions

6. Durable Power Of Attorney for Healthcare Allows a person to designate another person to make healthcare decisions for them in the event they are unable to do so Designated person is known as the healthcare proxy The decisions of the healthcare proxy must reflect the patients best interests and wishes The healthcare proxy must be given all the information necessary to make informed choices for the patient So, although the living will explains exactly what you want done in the event you are unable to speak for yourself , it does not designate someone to make sure your wishes are carried out nor does it allow someone to speak for you in the event that something happens to you that you did not anticipate, thus left no instruction for care. Keep in mind though, if you were designated as the DPOA, your decisions must be based on the patients desires and wishes not on what you think you want, this could be a very difficult role to be in if the patient is say your parent or spouse.So, although the living will explains exactly what you want done in the event you are unable to speak for yourself , it does not designate someone to make sure your wishes are carried out nor does it allow someone to speak for you in the event that something happens to you that you did not anticipate, thus left no instruction for care. Keep in mind though, if you were designated as the DPOA, your decisions must be based on the patients desires and wishes not on what you think you want, this could be a very difficult role to be in if the patient is say your parent or spouse.

7. Living Will vs. Durable Power of Attorney They are two separate legal documents The DPOA allows a named agent to make all healthcare decisions for the patient under certain circumstances The Living Will only gives written instructions but does not name an agent So now you see why it is important to have both of these documents. Now, what if let say a family member becomes injured or ill and is unable to speak for themselves and they have not created a living will or a DPOA, can someone execute one for that person, The answer is yes, BUT��. go to next slideSo now you see why it is important to have both of these documents. Now, what if let say a family member becomes injured or ill and is unable to speak for themselves and they have not created a living will or a DPOA, can someone execute one for that person, The answer is yes, BUT��. go to next slide

8. Who can execute a Directive for a Resident if the resident lacks capacity and has not previously executed an Advance Directive? The following persons have legal authority; in order of availability: Legal guardian Spouse Majority of adult children participating in the decision Parents Majority of adult siblings participating in the decision Majority of the resident�s adult heirs at law participating in the decision

9. Can a Directive be Revoked? A directive may be revoked: Only by the declarant At any time in any manner Without regard to the declarant�s mental or physical condition Must be made a part of the resident�s record Although you must be competent to create an advance directive ,you may revoke that same advance directive with no regard to your mental status, but only the creator of the document can do so, no one else can revoke your advance directive. if you don�t provide very specific directions regarding your care, then decisions could be made regarding your care that you may have not wanted, so be specific !!!!Although you must be competent to create an advance directive ,you may revoke that same advance directive with no regard to your mental status, but only the creator of the document can do so, no one else can revoke your advance directive. if you don�t provide very specific directions regarding your care, then decisions could be made regarding your care that you may have not wanted, so be specific !!!!

10. Important Notes about Advance Directives Because it is impossible to know all of the healthcare situations or medical conditions that may need to be addressed by a living will, the durable power of attorney can complete the picture, based on the guidelines patients establish in their living wills. So, if patients create a living will, they should also decide on a durable power of attorney for healthcare decisions Review and update

11. Is a Do Not Resuscitate (DNR) order the same as an Advance Directive ? NO DNR order only concerns decisions about CPR and does not relate to any other medical or therapeutic treatments that a resident may desire or decline

12. How do Advance Directives differ from DNR ? Advance Directives Should be considered by anyone & everyone Applies to all general medical treatments DNR Should be considered by people who have risk factors for not surviving resuscitation Applies only in the case of cardiopulmonary arrest

13. DNR Form Can be revoked at any time, even if the resident does not have capacity Effective upon resident�s instruction and physician�s order A diagnosis of terminal illness is not necessary Must be a part of the resident�s records Staff need to familiarize themselves with where the DNR form is kept in each resident�s chart and what it looks like. The last thing you want to do is perform CPR on a resident who didn�t want CPR, or worse, not perform CPR on a resident that specifically stated they wanted CPR no matter what !Staff need to familiarize themselves with where the DNR form is kept in each resident�s chart and what it looks like. The last thing you want to do is perform CPR on a resident who didn�t want CPR, or worse, not perform CPR on a resident that specifically stated they wanted CPR no matter what !

14. When can a Long Term Care Nursing Facility stop CPR ? When it locates the DNR physician order The paramedics assume responsibility for the resident The physician gives a telephone stop order A nurse may not pronounce death in a nursing home in Arkansas yes, if you start CPR on a resident because you were not sure what that resident�s code status was, and find out that the resident is a DNR, you can at that point stop CPR. A nurse, RN or LPN cannot pronounce death in a nursing home, although a RN working as a Hospice nurse can pronounce death of the hospice patient if the death occurs in the patient�s private home. There has been a misunderstanding that because the nursing home is considered the resident�s �home� that the RN can pronounce a resident�s death, again , a nurse may not pronounce a resident�s death in the nursing homeyes, if you start CPR on a resident because you were not sure what that resident�s code status was, and find out that the resident is a DNR, you can at that point stop CPR. A nurse, RN or LPN cannot pronounce death in a nursing home, although a RN working as a Hospice nurse can pronounce death of the hospice patient if the death occurs in the patient�s private home. There has been a misunderstanding that because the nursing home is considered the resident�s �home� that the RN can pronounce a resident�s death, again , a nurse may not pronounce a resident�s death in the nursing home

15. Points to remember regarding a DNR order A DNR order only applies to cardiopulmonary arrest, it does not mean to not treat infections, other illnesses or injuries. It does not mean to not transport to the hospital for treatable conditions It only means to not perform CPR on the patient in the event the patient�s heart stops or they stop breathing Review and update

16. Know your resident�s Advance Directive The relief of suffering and the cure of disease must be viewed as twin obligations of the medical profession that is truly dedicated to the care of the sick. Physicians and nursing staffs� failure to understand the nature of suffering can result in medical intervention that (though technically appropriate) not only fails to relieve suffering, but becomes a source of suffering in itself.

17. Resources & References for Advance Directives �Nuts and Bolts of Advance Directives� Mt. Sinai School of Medicine, New York, NY HCpro www.hcmarketplace.com �Evidenced Based Advance Directives� Harden, Jesson & Terry. Plc attorney at law �Advance Directives Generally� Kass LR. JAMA 1980;244:1947

18. Questions? Questions? QUESTIONS?

19. Arkansas Innovative Performance Program401 West Capitol AvenueSuite 400Little Rock, AR 722011-877-375-5700www.afmc.org/aippemail: aipp@afmc.org