1 hed 5/2010 advance care planning paula goodman-crews medical bioethics director san diego
TRANSCRIPT
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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 What you will learn in this class:this class:
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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?
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Ethical Duties that Guide Medical Decision Making:
Respect for Persons “autonomy”
Do no harm Provide Benefit Fairness
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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
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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
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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
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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
CC OO NN VV EE RR SS AA TT II OO NN
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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
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Advance Directive vs POLST
Advance Directive POLST
For every adult For the seriously ill
Requires decisions about myriad of future treatments
Decision among presented options
Clear statement of preferences Checking of preferred boxes
Needs to be retrieved Stays with the patient
Requires interpretation Actionable medical order
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5 “D’s” to Update an Advance Directive
When you…
Divorce
reach a new Decade
receive a new Diagnosis
have a Decline in your condition
experience a Death of a close relative or friend
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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
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Complete Advance Directive “Advance Medical Directives” - Staywell Company
If I Had A….. I Would Want…….
CPR Pressors Ventilator/ Respirator
Tube Feeding
Kidney Dialysis
Pain Medication
No Treatment
Sudden Complication·With no other severe problemWith other severe problem
Chronic IllnessControlledUncontrolled
Deadly Illness·Treatment keeps me comfortable•Treatment cannot comfort
Endless ComaNo other problems Deadly illness
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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
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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
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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
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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
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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?
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(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
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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
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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
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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?
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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
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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
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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:What you learned in class:
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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?
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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 RoadSan Diego, CA 92120
Now What do I Do?
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Kaiser Permanente Resources
KP Web Site www.kp.org http://www.permanente.net/homepage/kaiser/pdf/44666.pdf
www.kp.org/healthylifestyles (personalized programs for weight loss, smoking cessation, stress reduction, nutrition)
Healthier Living Class 619-641-4194
Positive Choice -Weight Mgmt. 858-573-0090
Health Education - Quit Smoking Program & many other programs for health and well-being 619-641-4194
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Paula Goodman-Crews, M.S.W., L.C.S.W.
Medical Bioethics Director
Kaiser Permanente, San Diego
voice-mail: 619-528-5213