1. It Starts with a Conversation Maryland MOLST Train the Trainer Program June 2012 (presented at the University of Maryland School of Law on April 2, 2013)

2. Capacity 2

3. What is Capacity? Capacity is rarely “all” or “none.” Individuals with a guardian of person may still be able to make certain health care decisions – –It depends on the individual’s ability to understand the issue and treatment options, including potential benefits, risks, and side effects and likely consequences of the decision 3

4. 4 Individuals Who Lack Capacity If an individual lacks the capacity to make health care decisions, then a health care agent, guardian of the person, or surrogate makes decisions for the individual Even if there is another authorized decision maker, the individual should still be included in the health care decision making process as much as possible

5. Authorized Decision Makers 5

6. How do you help someone make decisions for another individual? Determine if the individual has expressed his or her wishes Acknowledge the stress of the situation and the difficulty of the task Explain the individual’s clinical condition and prognosis Explain treatment options and offer recommendations based on evidence and your clinical judgment 6

7. What is the surrogate’s decision based on? Any guidance from a surrogate decision maker must be within the surrogate’s legal authority and consistent with the patient’s known wishes, including any relevant instructions in an advance directive 7

8. 8 What information shall surrogate decision makers consider? 1. 1. Current diagnosis and prognosis 2. 2. Expressed preferences 3. 3. Relevant religious and moral beliefs and personal values 4. 4. Behavior, attitudes, and past conduct with respect to the treatment at issue 5. 5. Reactions to the treatment at issue or similar treatments 6. 6. Expressed concerns about the effect on the family or intimate friends if a treatment were provided, withheld, or withdrawn

9. 9 What is not a basis for surrogates making health care decisions? An individual’s preexisting, long-term mental or physical disability, or economic disadvantage should not be a basis for surrogates making health care decisions

10. May a surrogate decision maker withhold or withdraw a LST? A surrogate may withhold or withdraw a life-sustaining treatment if the patient has been certified by physicians to be in a qualifying condition: 1. 1. Terminal condition 2. 2. End-stage condition 3. 3. Persistent vegetative state Or two physicians certify that a treatment is medically ineffective 10

11. Who discusses treatment options with individuals? In addition to physicians and nurse practitioners, other health care professionals may have the knowledge, skills, and experience to discuss treatment options with individuals, including CPR and other life-sustaining treatments 11

12. When should treatments be discussed with an individual? If an individual has or is likely to develop a condition that may require a treatment currently or in the near future, then that treatment should be discussed with the individual now – –If an individual with dementia has persistent weight loss without a treatable underlying cause, then the possibility of a feeding tube should be discussed with the individual or authorized decision maker now 12

13. How do you deal with someone who does not want to discuss it? Respect the individual’s right to decline to discuss it, but perhaps ask more general questions about goals of care Readdress the issue at a future time If possible, inform the patient that not limiting care generally means that medically indicated interventions will be provided 13

14. Can all future treatment decisions be anticipated? Despite thoughtful and detailed advance planning, unanticipated events happen Conversations about important, time- sensitive treatments occur in the ED or ICU 14

15. How are conversations about treatment options documented? When a practitioner has a conversation with an individual or authorized decision maker about treatment options, that conversation should be documented in the patient’s medical record The note should contain who participated in the conversation, date/time, and pertinent details of the discussion All appropriate orders should be promptly written 15

16. The Conversation 16

17. Setting for the Conversation Whenever possible, use a quiet, private location Make sure the individual is comfortable Limit unnecessary interruptions Avoid multi-tasking Sit at the individual’s level and at an appropriate distance 17

18. What is your role in helping someone make an informed choice? Be an active listener Frame the conversation Communicate clearly and appropriately Offer the benefit of your knowledge, skills, and experience 18

19. How do you deal with your own biases? Know thyself -- identify your own biases Personal, religious, or cultural views Point of view of your specialty (surgery, oncology, and hospice) 19

20. Insight and Information Determine the individual’s level of insight and understanding into his or her condition and current and future treatment options Determine how much information the individual desires 20

21. The Discussion Your task is to determine the best way to explain issues to the individual or authorized decision maker Verbal, written, or both Photos, other graphics, and charts Use the actual medical equipment 21

22. At the end of the day... 22

23. 23 For More Information marylandmolst.org maryland.molst@maryland.gov Paul Ballard, Assistant Attorney General 410-767-6918