1. ADVANCE DIRECTIVES Health Care Providers MDs, NPs, PAs

2. 2 ADVANCE DIRECTIVES New York State and TJC require health care providers to give patients and their families information about advance directives including the right to refuse care, treatment & services Health care providers involve patients in making decisions about their care When the patient is unable to make or communicate their decisions, we involve agents or surrogates in making those decisions Document all appropriate discussion in the patient’s medical record..

3. 3 ADVANCE DIRECTIVES Advance directives are legal documents that communicate the patient’s decisions when the patient cannot communicate. Allow the patient to take control of his/her life and participate in health care decisions. Should be completed by every adult and are not just for the elderly. Should include care & treatment you want and do not want.

4. 4 AN ADVANCE DIRECTIVE… Is one of the most important actions a person can take Is a conversation everyone should have with loved ones and their agents Is a discussion all health care providers should have with all patients Is needed on admission to ensure decisions are known to the healthcare team & instructions followed. Waiting for a crisis is too late!!

5. 5 What types are there? Health Care Proxy* Living will Do Not Resuscitate* Do Not Intubate* No vasopressors No hemodialysis No ICU No artificial nutrition & hydration No pain or suffering Comfort care only Die at home * Forms available in the forms library & ICIS

6. 6 HEALTH CARE PROXY Two witnesses over 18 years old are required Staff can be witnesses An agent cannot be a witness & does not have to sign A notary or lawyer is not required A health care proxy can be changed by patient at any time A copy should be given to the agent and to all healthcare providers

7. 7 LIVING WILL Provides guidance to healthcare providers, family & agents about the type of care patients want should a time come that they are unable to make or communicate their decisions. Does not require the patient to choose an agent Is circumstance specific Considers length and type of intervention Is a written document and should not replace a conversation with the agent (if the person chooses one)

8. 8 Situation 1 Patient has a HCP: who makes decisions? The Healthcare Agent makes decisions only if the patient is unable to communicate decisions.

9. 9 Situation 2 Patient has a Health Care Proxy which states no artificial nutrition. Patient’s status changes & is no longer able to make decisions. Agent is requesting patient be given artificial nutrition. What do you do? The patient’s decision must be respected and followed. Understand how difficult this is for the agent and use appropriate resources to offer support and guidance. Discussions are imperative with the patient, agent and/or family from admission throughout the patient’s care.

10. 10 Situation 3 The patient does not have a proxy, has lost capacity to make decisions and the family is asking to fill out a Health Care Proxy. Only the patient can complete the Health Care Proxy.

11. 11 Situation 4 There is no Proxy completed. The patient does not have capacity to make decisions. Who makes the decisions? In New York State, the surrogate is asked to make decisions for the patient. There is a hierarchical list for decision making. –Healthcare agent –Spouse –Adult child –Parent –Sibling

12. 12 Do Not Resuscitate DOES NOT MEAN… You should not provide treatment The patient cannot be transferred to the ICU or SDU Discontinuing or limiting vital signs, testing or other measures MEANS… The patient’s decisions must be respected If no pulse, no breathing, then no resuscitation

13. 13 Do Not Intubate If the patient has respiratory distress, they do not want to be intubated. You may still treat with oxygen, medication or integrative interventions.

14. The Health Care agent can make decisions about artificial nutrition & hydration, if he/she reasonably knows wishes of the patient. NYS requires that artificial nutrition & hydration be provided unless the patient’s wishes are reasonably known because: (1) they are documented (e.g., - living will) (2) the healthcare provider, the healthcare agent or some other individual can provide clear & convincing evidence of the patient’s wishes specific to artificial nutrition & hydration (e.g., an account of a specific discussion with the patient. Artificial Nutrition and Hydration

15. 15 REMEMBER… Have discussions with your patients upon admission and throughout the care continuum. Document discussions in ICIS using the Advance Directives/Goals of Care section DNR does not mean Do Not Treat. Make appropriate referrals to Patient Advocates, Social Work, Palliative Care, Ethics Consultation Service. Utilize Patient & Family Education material Advance directives are a responsibility of every health care provider.

16. 16 REMEMBER… Effective March 17, 2010, there will be a Goals of Care Note available in ICIS. All members of the multidisciplinary care team can access this note for documentation or information. Please document your discussion with the patient about advance directives in the Goals of Care Note.

17. First of a new kind of document (“wiki”) in which many people contribute to the same note  Intended to advance discussion of directives and care goals on all services  by making the information available in all areas of the chart  by making the information easy to record in a shared format  by empowering different care givers to engage the patients and families on these issues

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22. 22 Information about advance directive and where it is obtained by the registrar appears here

23. 23 Your h & p or progress note In every h-and-p, progress note, nursing flow sheet, etc. the wiki will be minimized into a line that the reader can pop up into a message

24. 24 Each provider can add a column to personal patient list showing whether advance directives note has any content in the “description of discussion” box

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26. 26 An ANALYTICS report will track time to the first note after admission, presence of clerical contribution, role of persons using note, how many entries, etc.

27. 27 All in virtually real time, providing opportunity of tracking floor, service, individual doctor compliance in addressing these issues

28. 28 References New York Advance Directive (2005). Advance Directive: Planning for important healthcare decisions. Retrieved from www.caringinfo.org. January 24, 2010. www.caringinfo.org WebMD (2007). Writing an advance directive: Why an advance directive is important? Retrieved from www.webmd.com/healthy-aging/tc/writing- an-advance-directive. January 24, 2010.