Advance Directives: A Medical Perspective Cynthia Horner M.D. August 24,2017

Define the Terms: Advance Directives Legal documents that guide decisions on your healthcare in the event that you are unable to communicate your wishes.

Define the Terms: Living Will An advance directive that guides your family and healthcare team through the medical treatment(s) you wish to receive if you are unable to communicate your wishes.

Define the Terms: Medical Power of Attorney An advance directive designating whom you trust to make decisions about your medical care if you are unable to. This includes not only decisions at the end of your life, but also in other medical situations. Typically a family member or close long term friend. Not your doctor. This document is also known as a “healthcare proxy,” “appointment of healthcare agent” or “durable power of attorney for healthcare.” This document goes into effect when your physician declares that you are unable to make your own medical decisions. The person you select can also be known as a healthcare agent, surrogate, attorney-in-fact or healthcare proxy.

Reasons to Complete Advance Directives and Appoint a MPOA Helps you maintain control of your own healthcare when you are unable to speak for yourself. One of the kindest things you can do for your family members. Your treating doctors need to know your preferences Release family members from the possible burden of guilt over having to make these decisions and either question themselves or be questioned by others whether their motives are pure. Your treating doctor may have never met you

Life-Sustaining Treatment Any treatment intended to prolong life without curing or reversing the underlying medical condition. Mechanical ventilation Artificial nutrition (tube feeding) Artificial hydration (fluids through an IV) Dialysis Some kinds of chemotherapy Even, at times, antibiotics In other words it is not a treatment or cure- it’s goal is to simply keep the body alive. Perhaps one would opt for this to allow a cure time to work- e.g. the otherwise healthy 45 year old who had a heart attack and just came out of heart bypass surgery who is given an extra day on a mechanical ventilator to allow the heart more time to recover, or the 28 year old who was hit by a car and now has swelling of the brain who is kept on a ventilator while they receive medications to reduce the brain swelling. The goal is to keep the body alive while the cure (in this case the medicine to reduce the brain swelling) has time to take effect. If these life sustaining treatments are given to a terminally ill person though they will not effect a cure, they will only keep the body alive for more time. Whether that time has value depends on the circumstance: time might allow family members to arrive from out of town to say their farewells, or it might simply add more days of terminal illness.

Intubation and Mechanical Ventilation Intubation: inserting a tube into the nose or mouth and into the windpipe. Mechanical ventilation: providing oxygen via a machine which forces air into the lungs.

Success depends on how healthy you were before the CPR CPR — techniques to restart your heartbeat and breathing. forceful chest compressions electric shocks to the heart Forced air into the lungs Success depends on how healthy you were before the CPR What are the chances that all of this will work? Statistics show that survival after resuscitation can be as high as 90 % in healthy adults who undergo cardiac arrest outside a hospital (they’re healthy, remember?) if CPR is started immediately. Unfortunately survival rates drop precipitously in most other situations: it’s roughly for 10% for patients already in a hospital and 1-2% for patients in nursing homes. The statistics are the worst for patients who have significant chronic illnesses, cancer or dementia.

If I survive CPR, will I still have the same quality of life? It depends. When breathing stops, oxygen doesn't reach a person’s brain. If this goes on for more than 5 minutes, it often results in severe brain damage or other complications. You should discuss CPR and the quality of life you wish to maintain with your doctor. Television has done an excellent job of distorting true medicine, including the resuscitation of dying patients. The medical shows may depict a man who is in cardiac arrest getting CPR and waking up in the middle of chest compressions. Many of the patients shown on TV in the emergency department are revived and back to their old selves in no time. Is it really that simple, though?

Artificial Hydration and Nutrition Fluids and nutrition delivered through an IV or through a tube to the stomach. What if cure or full recovery is not in the cards? When the body begins to shut down, the brain no longer experiences hunger and thirst as it once did. IV hydration does not help dry mouth but other treatments do. Hydration and nutrition do not reverse the dying process, do not provide comfort and are invasive procedures. Risk v. benefit? After explaining the benefits and risks of artificial nutrition to my patients’ families, I’m often asked, “But won’t he be hungry? I don’t want to see him suffer!” As a caregiver, when you see your loved one unable to eat or drink its natural to be afraid that your loved one is going to suffer without fluids or food- even artificial food. But it is important to understand that loss of appetite and weight loss is a normal part of the dying process. It is gradual for some and quite sudden for others – but all patients with a life-limiting illness will stop eating and drinking at some point. Hunger at this point is a non-issue, and IV’s don’t fix thirst well. The good news is that we can prevent thirst very well with small mouth sponges drenched in water and other non-invasive treatments.

Do-Not-Resuscitate Order (DNR) A physician's order not to attempt CPR if a patient's heart or breathing stops. Must be requested by the patient or Medical POA Must be be signed by a physician Valid only if in writing and presented to medical personnel Tattoos are not enough Having it in a drawer means the medical team doesn’t know about it.

If I refuse life-support treatment, will I still be treated for pain? Absolutely. It is standard of care for all patients to receive comfort care regardless of their decision about life support.

Talking with Medical Providers About Your Choices Give your doctors a copy of your completed directives and contact info. for your MPOA If you have a terminal illness, talk to your doctors about the intent of your directives. Bring your documents to the hospital every and any time you are admitted or have a significant procedure. The law does not force physicians to follow directives, but it does require us to provide you with medical care providers willing to follow your reasonable and legal wishes.

Speaking with Loved Ones About Your Decisions Include those who are most likely to be closely involved in decision making: spouses, adult children and your Medical POA. Set aside dedicated time for a distraction free discussion Key messages: Why now? You have thought a lot about this and these are your own personal choices You want them to understand your choices so they don’t have to guess.

Suggested Questions to Ask of Loved Ones Do you understand what kinds of treatments I do and do not want? Do you understand how I feel about life and my health, even if I haven’t given you directions about specific treatments? How do you feel about being my Medical POA? What, if anything, concerns or bothers you about my choices? If there’s disagreement between what I want and recommendations by other family members, do you feel comfortable standing up for my wishes?