ADVANCE DIRECTIVES

1
ADVANCE DIRECTIVES Health Care Providers MDs,
NPs, PAs

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
  patients medical record.

.
3
ADVANCE DIRECTIVES

• Advance directives are legal documents that
  communicate the patients
• 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.

3
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!!

4
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
5
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

6
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)

7
8
Situation 1

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

8
9
Situation 2

• Patient has a Health Care Proxy which states no
  artificial nutrition.
• Patients status changes is no longer able to
  make decisions.
• Agent is requesting patient be given artificial
  nutrition.
• What do you do?
• The patients 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
  patients care.

9
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.

10
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

11
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 patients decisions
• must be respected
• If no pulse, no breathing,
• then no resuscitation

12
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.

13
14
Artificial Nutrition and Hydration
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 patients 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 patients
wishes specific to artificial nutrition
hydration (e.g., an account of a specific
discussion with the patient.
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.

15
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.

16
17
Advance Directives/
Goals of Care
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

18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
Information about advance directive and where it
is obtained by the registrar appears here
23
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
Each provider can add a column to personal
patient list showing whether advance directives
note has any content in the description of
discussion box
25
view
column selection
highlight and "add"
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
FINALLY,
All in virtually real time, providing opportunity
of tracking floor, service, individual doctor
compliance in addressing these issues
28
References

• New York Advance Directive (2005). Advance
  Directive Planning for important healthcare
  decisions. Retrieved from www.caringinfo.org.
  January 24, 2010.
• 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.