advance directives

Advance Directives

• Legal documents that allow you to convey your decisions about end-of-life care ahead of time– Dialysis, breathing, resuscitation, tube feeding,

organ donation

Appointed Decision Makers

• When no person has been identified to make decisions for you, if you are unable, the court can appoint someone

Do-Not-Resuscitate (DNR) Order

• Given by a physician stated that in a cardiac or respiratory arrest no resuscitation measures should be taken

Durable Power of Attorney

• A legal document assigning someone to act on your behalf if you are unable to – Estate affairs, money, bills, legal affairs, – Specified amount of time

Euthanasia

• Intentionally ending a life in order to relieve pain and suffering

Futility of Treatment

• Physician recognizes that the effect of treatment will be of no benefit to the patient

Guardianship

• A legal mechanism by which the court declares a person incompetent and appoints a guardian– Financial, living, medical decisions all go to

guardian

Health Care Proxy

• Allows you to appoint an “agent” to make treatment decisions for you in the event you cannot

Living Will

• Legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions

Oregon’s Death with Dignity Act

• Allows a terminally ill Oregon resident to obtain a lethal dose of medication from his or her physician

Patient Self-Determination Act

• Provides that patients have a right to formulate advance directives and to make decisions regarding their health care

Physician-Assisted Suicide

• An action in which a physician voluntarily aids a patient in bringing about his or her own death

Substituted Judgment

• A form of surrogate decision making where the surrogate attempts to establish what decision the patient would have made if that patient were competent to do so.

Surrogate Decision Maker

• An agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision– Limited to specific instructions included in the

proxy document

Withdrawal of Treatment

• A decision to discontinue treatment or medical interventions for the patient

End-of-Life

• “There is nothing more sacred than life and there is nothing more natural in life to wish to cling on to it for those you love! And nothing more cruel than to play god by artificially holding onto that which god wants to bring home.”

Euthanasia

• Intentionally ending a life in order to relieve pain and suffering

• Broad definition– “the mercy killing of the hopelessly ill, injured, or

incapacitated

Euthanatos

• Greek Word: meaning “good death” or “easy death”– Acceptable for incurable diseases

Euthanasia

• Confucian and Buddhist –acceptable for unendurable pain and incurable disease

• Celtics – if you are diseased or senile and do not commit suicide you will be condemned to hell

Euthanasia

• Change in the late 1800’s– Napolean’s physician refused his plea to kill stating

his commitment to cure

Euthanasia

• 2million die each year– 80% die in hospitals or nursing homes– 70% die after forgoing life-sustaining treatment

Active Vs. Passive Euthanasia

• Active: intentional act that results in death

• Passive: lifesaving treatment is withdrawn of withheld

Voluntary or Involuntary Euthanasia

• Voluntary: A person makes the decision to die

• Involuntary: decision to end life of incurable person is made by someone other than that person

Let’s Define Death

• Black’s Law Dictionary: “cessation of respiration, heartbeat, and certain indications of central nervous system activity, such as respiration and pulsation.”

Brain Death

• AMA 1974: Death occurs when there is “irreversible cessation of all brain functions including the brain stem.”

Assisted Suicide

• Physician prescribes a lethal dose of medication to be taken by a mentally competent patient with a terminal illness

• Legal in– Oregon, Washington, and Montana

Physician Assisted Suicide

• Physician Protection: – Patients consent and deliver medication– Therefore physicians are shielded from homicide

liability


• U.S. Supreme Court: ruled that states can allow physicians to assist in the suicide of their terminally ill patients


• Dr. Kevorkian:– As of March 1998, aided in or witnessed more

than 100 suicides– Said “dying is not a crime”– Served 8 years in jail– Michigan did not have a law against it

Dr. Kevorkian

• http://www.cbsnews.com/8301-504803_162-20068720-10391709.html

http://www.cbsnews.com/8301-504803_162-20068720-10391709.html

http://www.cbsnews.com/8301-504803_162-20068720-10391709.html

Homework

• Read and Comment on Hanna, Gary, and Caitlin


• Allows a terminally ill Oregon resident to obtain a lethal dose of medication from his or her physician


• Passed on October 27th 1997• Specifically prohibits euthanasia


• Terminal disease – death within 6months• Mentally competent adult• Resident of Oregon• Attending and consulting physician• Make a written request


• Request witnessed by two individuals• Pt receive full information from physician• Both written and oral request from the patient– First pt makes and oral and written then must

make an additional oral request within 15 days of original request


• Physician give patient the opportunity to rescind the request

• 15 day waiting period

Ethicists View

• Those who advocate the prohibition on taking action to shorten life agree that “where death is imminent and inevitable, it is permissible to forgo treatments that would only provide a precarious and painful prolongation of life, as long as the normal care due to the sick person in similar cases is not interrupted.”


• Physician recognizes that the effect of treatment will be of no benefit to the patients

• Inform patient of little likelihood of success


• Forgoing life-support measures is simply a decision that the dying process will not be artificially extended

• Decision can be made only be the surrogate• Decision as to futility of tx can be made only

by the physician p 148


• Considered when:– 1) terminal condition and reasonable expectation

of imminent death– 2) pt in a noncognitive state with no reasonable

possibility of regaining cognitive function


• Decision to discontinue treatment or medical interventions for the patient– Death is imminent & cannot be prevented

Persistent Vegetative State

• Disorder of consciousness in which patients with sever brain damage are in a state of partial arousal rather than true awareness

• Deals with a syndrome = uncertainty• 4 wk VS = persistent

– 1year VS = permanent– Not recognized as death

Pt not in a persistent vegetative state

• Guardian may not withdraw life-sustaining medical treatment if pt is not in a persistent vegetative stated

Removal of Life-Support Equipment

• There is no duty to continue the use of life-sustaining equipment after it has become futile and ineffective to do so in the opinion of a qualified medical personnel

Ombudsman

• Acts as an intermediary between the state and an individual

• Investigate and resolve, usually through recommendations

Feeding Tubes

• Considered Ordinary care p 151• Notify Ombudsman• Tube feeding is a medical treatment and is just

as intrusive as other life-sustaining measures

Feeding Tubes

• 1986 AMA changed code of ethics– Physicians may ethically withhold food, water, and

medical treatment from patients in irreversible comas or persistent vegetative states with no hope of recovery even if death is not imminent

Do-Not-Resuscitate Orders

• Given by physician• In event of cardiac or respiratory arrest• NO resuscitation measures should be used to

revive the patient


• “Heroic: rescue methods no longer in the best interest of a patient

• Appointed decision maker can make decision• Written & signed consent


• Payne v. Marion General Hospital– Payne could communicate prior– Physician determined Payne to be incompetent– No advance directives– Relative gave DNR order

Advanced Directives

• Comes in the form of “living will” or “durable power of attorney”

• Can appoint an agent• State in advance what medical care is desired

Advanced Directives

• Patients have a right to make decisions about their health care with their physician

• You still have a right even if incapacitated• Advance directives allow you to make your

wishes known

Advanced Directives

• Should be requested on admission• If no- then hospital should provide info and

opportunity to create one• It is a guideline for caregivers describing your

wishes

Advanced Directives

• Copy is kept in patient record• Documentation in the patient record should

re-highlight immediate care– Help adhere to advance directive

Advanced Directives

• Can create a new directive at any time• Continual education regarding content of

directive• Patient should be periodically given the

opportunity to make changes

Living Will

• Legal document• Describes treatments individuals wish or do

not wish to receive– If incapacitated and unable to communicate

Living Will

• Withholding and withdrawing life-supporting treatment– Nutrition & hydration

• Provides legally valid instructions about treatment– Protects patients and providers

Living Will

• Signed and dated by two witnesses not blood relatives or beneficiaries of property

• Discussed with physician• Signed copy placed in chart• Copy given to agent/proxy

Living Will

• Update regularly– Your views can change

• Becomes effective when– In a terminal condition, permanently unconscious,

or suffering irreversible brain damage– http://www.youtube.com/watch?v=5hGWKEM7l8

s

http://www.youtube.com/watch?v=5hGWKEM7l8s

http://www.youtube.com/watch?v=5hGWKEM7l8s


• Legal device permits you to given another person the authority to act on your behalf

• Attorney – in – Fact – Handle banking, real estate affairs, incur

expenses, pay bills, wide variety of legal affairs– Specific Period of Time


• May continue indefinitely• Limited by the competency of the principal• General in scope – wide range of situations• Each state has a durable power of attorney

statute


• Attorney should draw up• In Health care – durable power of attorney for

health care is a legal instrument that designates and grants authority to an agent


• The agent when the attending physician certifies in writing that the “principle” is incompetent

• Can limit agents decision-making authority

Decision Makers

• Surrogate Decision Making• Substituted judgment• Guardianship• Health Care Proxy

Surrogate Decision Making

• An agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision– Limited to specific instructions in the proxy

document– Base decision on patients moral and religious

beliefs

Substituted judgment

• Form of surrogate decision making• Agent attempts to establish what decision the

patient would have made• Taking into account patient’s beliefs & values• http://www.youtube.com/watch?v=IytNBm8

WA1c

http://www.youtube.com/watch?v=IytNBm8WA1c

http://www.youtube.com/watch?v=IytNBm8WA1c

Guardianship

• Court declares a person incompetent• Court appoints a guardian– Financial, living, medical

Health Care Proxy

• An individual appoints another individual to make health care decisions for them in the case that they are unable to– Be made aware of patients wishes– Differs from living will – do not have to have

everything mapped out

Health Care Proxy

• Consent through durable power of attorney

• Oral declaration- pt declared terminally ill• State determines length of effectiveness

advance directives

Documents