1 HEd 5/2010 Advance Care Planning Paula Goodman-Crews Medical Bioethics Director San Diego

2  Bioethics/Laws  Advance Care Planning  Completing an Advance Health Care Directive  Choosing a health care agent  Advance Directive vs. Physician Orders for Life-Sustaining Treatment (POLST) What you will learn in this class:

3 Common Questions 1)What is Advance Care Planning? 2)How do I complete an Advance Health Care Directive? 3)How do I go about making such important decisions?

4 Ethical Duties that Guide Medical Decision Making:  Respect for Persons “autonomy”  Do no harm  Provide Benefit  Fairness

5 Laws Federal Law: Patient Self-Determination Act of 1991  Patients right to accept/refuse treatment  Upholds the right to create advance directives California Rights: CA Health Care Decisions Law: AB 891  The law includes a form-Advance Health Care Directive

6 Advance Health Care Directive A form you complete that states your desires and beliefs about treatment which includes:  Who will make health care decisions for you  Your beliefs about organ donation  The name of your primary physician  Person completing the advance directive must be:  a California resident  at least 18 years old  of sound mind

7 When Is Your Advance Directive Activated? When a patient loses “decisional capacity”  Ability to understand  Ability to organize information  Ability to communicate a response  Ability to deliberate according to one’s belief system, values, and attitudes

8 Advance Care Planning Continuum Complete an Advance Directive Complete a Physician Orders for Life-Sustaining Treatment (POLST) Form Age 18 End-of-Life Wishes Honored Diagnosed with Serious or Chronic, Progressive Illness (at any age) Update Advance Directive Periodically C O N V E R S A T I O N

9 What is POLST? Physician Order for Life Sustaining Treatment recognized throughout the medical system Brightly colored, standardized form for entire state of CA Portable document that transfers with the patient Provides direction for a range of end-of-life medical treatments

10 Advance Directive vs POLST Advance DirectivePOLST For every adultFor the seriously ill Requires decisions about myriad of future treatments Decision among presented options Clear statement of preferencesChecking of preferred boxes Needs to be retrievedStays with the patient Requires interpretationActionable medical order

11 5 “D’s” to Update an Advance Directive When you… D ivorce reach a new D ecade receive a new D iagnosis have a D ecline in your condition experience a D eath of a close relative or friend

12  The doctor will provide you with all the information necessary to make an informed treatment decision  You should know about your disease process and longevity  What to expect with or without treatment Complete Advance Directive

13 Complete Advance Directive “Advance Medical Directives” - Staywell Company If I Had A….. I Would Want……. CPRPressorsVentilator/ Respirator Tube Feeding Kidney Dialysis Pain Medication No Treatment Sudden Complication ·With no other severe problem With other severe problem Chronic Illness  Controlled  Uncontrolled Deadly Illness ·Treatment keeps me comfortable Treatment cannot comfort Endless Coma  No other problems  Deadly illness

14 Who is the best Health Care Agent for Me? Someone who:  I trust to carry out my wishes  is emotionally stable  is an effective communicator  REALLY knows me and can support my treatment choices Your agent cannot be:  your doctor or health care provider  an employee of your doctor/hospital/ nursing home unless related

15 Health Care Agent Duties/Obligations To ensure that your medical treatment wishes are followed using two standards: 1.“substituted judgment” decided as YOU would decide 2.“best interests assessment” if your wishes are unknown, agent needs to consider your beliefs and what is important to you  quality of life  extent of suffering  prognosis

16 Health Care Agent Duties/Obligations Can:  choose life-sustaining and other treatment for you  refuse life-sustaining and other treatment for you  agree that a treatment you are having should be stopped  access and release your medical records  request an autopsy  donate your organs (unless stated otherwise) Cannot:  commit you to a psychiatric hospital  agree to electric shock treatment  consent for psychosurgery  consent for sterilization  consent for abortion

17 Making Treatment Decisions

18 Potential Goals of Treatment  Cure of disease  Avoidance of premature death  Maintenance or improvement in function  Prolongation of life  Relief of suffering  Quality of life  Staying in control  A good death

19 Expectations / Quality of Life  A treatment can produce an effect, but, is it providing what I believe to be a benefit?  Contributing to a life that I deem acceptable?

20 (DNR) Do Not Resuscitate Orders A medical order to refrain from CPR if your heart stops beating -- it does not mean that other treatments will be stopped CPR will be attempted unless there is a DNR order in your medical chart

21 Why Choose DNR?  When CPR won’t restore function of heart or lungs  When death is expected due to irreversible medical condition  terminal illness  permanent unconsciousness  irreversible organ failure with survival not likely

22 Palliative Care/ Hospice Pain/ symptom control Spiritual Care Psychosocial Care

23 Procedures to restart the heart and breathing, like mouth-to-mouth resuscitation, external chest compressions, electric shock, insertion of tube to open airway, injection of medication into the heart, open chest heart massage Cardiopulmonary Resuscitation

24 Mechanical Lung Ventilation

25 Nasal Gastric Tube Feeding

26 Percutaneous Gastric Tube Feeding

27 Kidney Dialysis

28 Pressors Medicines that control one’s blood pressure Use of pressors in the ICU is generally for making blood pressure go up What are the benefits of pressors? What are the burdens of pressors?

29  What do you fear most about illness?  How would you feel if you lost your independence? Mental alertness? Physical abilities? Financial independence?  How would you feel if you could not engage in the activities you enjoy?  How would you feel if you could not interact with the people you love?  How do you feel about being cared for in a nursing home? Quality of Life/ Values

30  What are your beliefs about life and death?  Does your religion, culture, spiritual beliefs strongly guide you in decisions about life and death?  What role do pain and suffering occupy in your life?  What is the role of medical technology in prolonging life? Beliefs

31  Bioethics/Laws  Advance Care Planning  Completing an Advance Health Care Directive  Choosing a health care agent  Advance Directive vs. Physician Orders for Life-Sustaining Treatment (POLST) What you learned in class:

32  Discuss with your primary doctor and/or specialist any questions, worries, issues about your health before you fill out your advance directive  Discuss your wishes and advance directives with your surrogate(s) and close family members, ensuring that they can and will follow your wishes in the event you cannot speak for yourself  Fill out the directive Now What do I Do?

33  Sign and date it before 2 witnesses or a notary public  Make copies for yourself, your surrogate (s), your doctor, your family, your lawyer - keep original in an accessible place (not a safe-deposit box)  Mail your form to: Kaiser Medical Office Records 7385 Mission Gorge Road San Diego, CA Now What do I Do?

34 Kaiser Permanente Resources KP Web Site (personalized programs for weight loss, smoking cessation, stress reduction, nutrition) Healthier Living Class Positive Choice -Weight Mgmt Health Education - Quit Smoking Program & many other programs for health and well-being

35 Paula Goodman-Crews, M.S.W., L.C.S.W. Medical Bioethics Director Kaiser Permanente, San Diego voic

36 Michael Markman MD Division of Pulmonary/Critical Care Medicine Kaiser Permanente, San Diego