1. 1 Advance Directives Ethics Champions Program June 4, 2008 John F. Wallenhorst, Ph.D. Vice President, Mission & Ethics Bon Secours Health System

2. 2 Case Study – Mr. Smith 91 year-old man with moderate dementia Has an advance directive; does not want extraordinary interventions Has pneumonia that will require short hospital stay, and short-term feeding tube and IV for antibiotics

3. 3 Immediate Context Patient Self-Determination Act, 1991 Rights: Participate in and direct their own health care decisions Accept or reject medical or surgical treatment Prepare an advance directive Information on provider’s policies related to these rights Also: Must document patient’s wishes and information Must educate

4. 4 Foundations – Catholic Tradition Dignity of the Person The Human Story: The role of life and death Community Justice Subsidiarity Proportionality Benefit/burden

5. 5 Advance Directives Basics Written document of person’s wishes for treatment or non-treatment Only a competent person may create Only takes effect when person does not have the capacity to make a medical decision Two forms: Living Will Durable Power of Attorney for Health Care Condition for participating in Medicare/Medicaid

6. 6 What does it address? Clarity about wishes Avoiding specific types of treatment Helping family with issues related to continuation and termination of treatment

7. 7 What does it not address? Appointed agent who cannot follow patient’s wishes Physicians who are unwilling to stop treatment Physicians who believe that Advance Directives are only for dying patients Family conflict Loss of meaning; loss in general Grief

8. 8 Still need Ongoing care planning process DNR orders, if applicable Conversations about end of life care

9. 9 “Five Wishes” Program Aging with Dignity National nonprofit since 1996 Tallahassee, FL “Five Wishes” Program Robert Wood Johnson Grant Source: http://www.agingwithdignity.org/5wishes.html http://www.agingwithdignity.org/5wishes.html

10. 10 “Five Wishes” 1.Which person you want to make health care decisions for you? 2.What kind of medical treatment you want or don’t want? 3.What sort of comfort measures do you want? 4.How you want people to treat you. 5.What you want your loved ones to know?

11. 11 “Five Promises” Program LaCrosse Experiment Wisconsin Collaborative, 1991 “Respecting Choices” Program New Hampshire, North Carolina, South Carolina Source: http://www.gundluth.org/eolprograms http://www.gundluth.org/eolprograms

12. 12 “Five Promises” 1.We will initiate the conversation 2.We will provide assistance with advance care planning 3.We will help make sure your plan is clear 4.We will maintain and retrieve your plan 5.We will appropriately follow your plan

13. 13 Not About “Getting it Right” Can Cause Harm: Patients and families feel betrayed Health professionals feel pressured to “interrogate” Patients and families feel stigmatized if they do not want to participate Difficulty of applying in clinical setting Alternative Approach: Spiritual-Existential Orientation Hospitality, privacy and calm “L’entourage” – circle of significant others D. Barnard, “Advance Care Planning Is Not About ‘Getting it Right.’” Journal of Palliative Care, Vol 5. 2002.

14. 14 Beyond Advance Directives Some Issues: Approaching the matter of compliance Complexity of applying in real-time decision making Evaluating impact on use of resources State variations; application of Catholic tradition Increased focus: Advance care planning Discussions about incapacity and death Solidifying personal relationships

15. 15 Conclusion Revisiting Mr. Smith What are the relevant issues? What are the possible ethical concerns? What is the best approach?

16. 16 Questions & Conversation