Advance Care Planning Care Coordination Collaborative April 5, 2017

What is Advance Care Planning? It’s the process of planning ahead for medical care in the event that you are unable to communicate your wishes to your family and your healthcare providers. It involves having conversations about your values and wishes for care with your family and healthcare providers before you become ill.

Why do we need to talk about advance care planning? Dying has changed… 1900 2016 Age at Death 46 years 81 years Leading Causes Infection Accident Childbirth Cancer Heart Disease Stroke/Dementia Disability before Death Unusual & Brief On Average, > 4 years Costs Low & Affordable Very High & Long Periods

Where do we die today? 88% say they want to die at home 20% actually die at home

“A Soul Doctor and a Jazz Singer”

One conversation can make all the difference. 90% of people say that talking with their loved ones about end-of-life care is important. 27% have actually done so. Source: The Conversation Project National Survey (2013). One conversation can make all the difference. 80% of people say that if seriously ill, they would want to talk to their doctor about wishes for medical treatment toward the end of their life. 7% report having had this conversation with their doctor. Source: Survey of Californians by the California HealthCare Foundation (2012). 82% of people say it’s important to put their wishes in writing. 23% have actually done it. Source: Survey of Californians by the California HealthCare Foundation (2012).

Do Not Resuscitate Orders (DNR) Types of Advanced Directives MOLST Do Not Resuscitate Orders (DNR) Health Care Proxy Power of Attorney Living Will

Health Care Proxy The New York Health Care Proxy Law allows you to appoint someone you trust (a family member or close friend) to make health care decisions for you if you lose the ability to make decisions for yourself. Encourage all of your patients to complete a health care proxy! Appointing a health care agent is a good idea even if you are not elderly or terminally ill Anyone 18 years of age or older can be a health care agent A Health Care Proxy is different than a living will. A Health Care Proxy does not require that you know in advance all the decisions that may arise- instead, the health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health Care Proxy Does not require a lawyer or notary; just two adult witnesses

Living Will A Living Will is a written declaration of your health care wishes Serves as evidence of your wishes about medical treatments you may or may not want, when you are no longer able to decide for yourself New York does not have a statute governing Living Wills, the Court of Appeals states that Living Wills are valid as long as they provide “clear and convincing” evidence of your wishes There is no standard Living Will form

How do I help my patient decide what advance directive is best for them? If you are in a coma or vegetative state or otherwise incapacitated, would you want someone you trust to make medical decisions for you? If the answer is YES, consider a Health Care Proxy that is appointing someone you trust as your Health Care Agent to speak and decide for you when you are unable to do so. If the answer is NO because you have no one you trust to act as your Health Care Agent, consider a Living Will so that your medical instructions are clear and can be read by your care givers when you are unable to communicate your wishes.

If NO, then maybe just a Health Care Proxy will meet your needs. How do I help my patient decide what advance directive is best for them? Even though you want someone you trust to make medical decisions, do you still have strongly held views about specific situations? If YES, you may consider being more specific on the Health Care Proxy form, so that the person you appoint to act on your behalf can also rely on your written instructions to make decisions for you. If NO, then maybe just a Health Care Proxy will meet your needs.

Medical Orders for Life-Sustaining Treatment (MOLST) Form Allows doctors to record your preferences regarding life sustaining treatments on to one form as a physician order MOLST must be completed by a health care professional and signed by a New York State licensed physician to be valid Intended for patients with chronic, serious, advanced illnesses Not intended to replace a Health Care Proxy and/or Living Will MOLST translates your current medical treatment preferences into physician orders whereas a Health Care Proxy and/or Living will guides future medical care

Do Not Resuscitate Orders (DNR) A DNR Order instructs medical professionals not to perform emergency treatment to restart your heart or lungs when your heartbeat or breathing stops Doctors, nurses, paramedics will not initiate emergency procedures such as mouth-to-mouth resuscitation, external chest compression, electric shock, insertion of tube to open your airway, or injection of medication into your heart or open chest In New York, any adult 18 years or older can get a Hospital or Non-Hospital DNR Order Hospital DNR Non-Hospital DNR Issued if you are in a health care facility such as a hospital or nursing home EMS must honor your Hospital DNR Order during transfer Must make Hospital DNR wishes known in your health care proxy, living will or a MOLST form If you are outside of a hospital or nursing home, consider a Non-Hospital DNR Must be recorded on a state specific form (DOH-3474)

Power of Attorney Under New York State law, you can designate a person to make property, financial, and other legal non-healthcare decisions on your behalf through a Power of Attorney. Durable Power of Attorney: allows you to appoint an Agent to act for you immediately upon its execution or the occurrence of some future event identified b you and lasts until cancellation by you or upon your heath; this power continues when you are mentally or physically incapacitated. Power of Attorney: can be used to grant any and all of the following legal powers: buy/sell your real estate, manage your property, banking transactions, invest/not invest your money, make legal claims Power of Attorney is often used to plan for one’s future incapacity or disability of competence resulting, for example, from Alzheimer’s disease or a catastrophic accident. Power of Attorney cannot be used to make medical decisions on your behalf.

You play a very important role! The people you serve may feel more comfortable with you given your personal relationship and YOU can encourage them to start these difficult conversations. You can act as an advocate! You do not need a clinical background to initiate Advance Care Planning. Call to Action: You are encouraged to identify and assist 3 patients with completing a Health Care Proxy.