1. 1 Telling Medical Providers What to Do When You Forget What You Want Them to Do: Advance Directives & Medical Orders For Scope of Treatment (MOST) updated 1/16/11 Community Challenge: Meeting the Needs of Seniors, Providers & Care Givers January 16, 2012

2. 2 Historical Perspective 1930 – my grandfather builds the first hospital in Wickenburg AZ (penicillin not discovered till 1928 and not available until 1941)1930 – my grandfather builds the first hospital in Wickenburg AZ (penicillin not discovered till 1928 and not available until 1941) 1960 – my father dies in the Phoenix VA hospital of an MI at the age of 43 (the first ICU was established in 1958)1960 – my father dies in the Phoenix VA hospital of an MI at the age of 43 (the first ICU was established in 1958) 1972 – I start medical school (high tech life support now available)1972 – I start medical school (high tech life support now available) Dr. James Alfred Copeland (1871- 1941), circa 1937

3. 3 Common Problem Case Scenarios Grandpa breaks his hip.Grandpa breaks his hip. –develops pneumonia and ARDS –aunt Lucie from California shows up at the 11 th hour Persistent Vegetative State (PVS)Persistent Vegetative State (PVS)

4. 4 Persistent Vegetative State (PVS) due to injury of the upper brain sparing the brain stemdue to injury of the upper brain sparing the brain stem characterized by the return of sleep-wake cycles and of various reflex activities, but wakefulness is without awarenesscharacterized by the return of sleep-wake cycles and of various reflex activities, but wakefulness is without awareness can “live” for years on tube feedingscan “live” for years on tube feedings

5. 5 Informed Consent the basis for modern medical ethicsthe basis for modern medical ethics historically a response to the Nuremburg trialshistorically a response to the Nuremburg trials

6. 6 Informed Consent Prior to being treated: –the patient will receive a description of the treatment to include its risks, benefits and alternatives, and –the patient will agree to accept the treatment. MRMC Policy

7. 7 Definition of Decisional Capacity 1)the ability to comprehend information relevant to the treatment being offered, and 2)the ability to deliberate in accordance with his/her own values and goals, and 3)the ability to communicate with care givers. A patient has decisional capacity to consent to or to refuse treatment when the patient has: MRMC Policy

8. 8 Advance Directives Available in Colorado Living WillLiving Will Medical Durable Power of AttorneyMedical Durable Power of Attorney CPR DirectiveCPR Directive

9. 9 Living Will a written statement made when a patient (declarant) has decisional capacity which gives directions for withholding or withdrawing certain life- sustaining procedures when the patient:a written statement made when a patient (declarant) has decisional capacity which gives directions for withholding or withdrawing certain life- sustaining procedures when the patient: 1)has a terminal condition or PVS and 2)has lost decisional capacity.

10. 10 Living Will must still have 2 witnessesmust still have 2 witnesses two physicians must certify terminal condition or PVStwo physicians must certify terminal condition or PVS may include other instructions for care following certification of terminal illness/PVSmay include other instructions for care following certification of terminal illness/PVS may include a list of persons to be notified of that certification, as well as a list of persons with whom healthcare providers may discuss the declarant’s condition and caremay include a list of persons to be notified of that certification, as well as a list of persons with whom healthcare providers may discuss the declarant’s condition and care

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13. 13 Medical Durable Power of Attorney (MDPA) a written statement made when a patient has decisional capacity which appoints specific surrogate decision-makers (agents)a written statement made when a patient has decisional capacity which appoints specific surrogate decision-makers (agents) not limited to a terminal condition or PVSnot limited to a terminal condition or PVS takes effect at time of signature or when patient loses decisionalitytakes effect at time of signature or when patient loses decisionality witness recommended but not requiredwitness recommended but not required

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15. 15 Proxy Decision-Makers For Medical Treatment CRS 15-18.5-103 Used to establish a surrogate decision maker when there is no Medical Durable Power of Attorney or Guardian.Used to establish a surrogate decision maker when there is no Medical Durable Power of Attorney or Guardian. Physician must declare that the patient has lost decisional capacity.Physician must declare that the patient has lost decisional capacity. Physician (or representative) contacts “interested persons.”Physician (or representative) contacts “interested persons.” “Interested persons” choose the proxy decision-maker.“Interested persons” choose the proxy decision-maker.

16. 16 Colorado Designated Beneficiary Act (CRS 15-22-101-111) allows for two adult (over 18) persons to designate each other as beneficiaries of a number of items and instruments related to health care, medical emergencies, incapacity, death, and administration of estatesallows for two adult (over 18) persons to designate each other as beneficiaries of a number of items and instruments related to health care, medical emergencies, incapacity, death, and administration of estates the two adults cannot be married to each other or anyone else nor party to any other DB agreementthe two adults cannot be married to each other or anyone else nor party to any other DB agreement a DB may assign the other DB the right to act as a Proxy Decision-Makera DB may assign the other DB the right to act as a Proxy Decision-Maker

17. 17 CPR Directive A written order signed by a patient with decisional capacity and his/her physician instructing pre-hospital emergency personnel and other providers to withhold CPR (cardiopulmonary resuscitation). May be signified by wearing a necklace or bracelet.

18. 18 CPR Directive Bracelet or Necklace A unique and easily identifiable logo is engraved on the front side of the metal bracelets and necklaces. The name, birth date, sex, and race of the declarant are engraved on the back side along with the words "DO NOT RESUSCITATE." Wearing a bracelet or necklace is encouraged but not mandatory.

19. 19 Out-of-Hospital CPR Outcomes UpToDate 9/12/11 “resuscitation from out-of- hospital Sudden Cardiac Arrest (SCA) is successful in only one-third of patients”“resuscitation from out-of- hospital Sudden Cardiac Arrest (SCA) is successful in only one-third of patients” “only about 10 percent of all patients are ultimately discharged from the hospital, many of whom are neurologically impaired”“only about 10 percent of all patients are ultimately discharged from the hospital, many of whom are neurologically impaired”

20. 20 In-Hospital CPR Outcomes UpToDate 9/12/11 “the outcome of patients who experience SCA in the hospital is poor, with reported survival to hospital discharge rates of 6 to 15 percent”“the outcome of patients who experience SCA in the hospital is poor, with reported survival to hospital discharge rates of 6 to 15 percent” “overall survival to hospital discharge was 15 percent”“overall survival to hospital discharge was 15 percent”

21. 21 Nursing Home CPR Outcomes Prehosp Emerg Care Apr-Jun, 1997 “Outcomes of cardiac arrest in the nursing home: destiny or futility?” 182 nursing home patients received CPR from July 1989-December 1993182 nursing home patients received CPR from July 1989-December 1993 none survivednone survived

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23. 23 CPR Directive Legislative Changes 2010 ANY form clearly stating refusal of CPR, signed by patient and patient’s physician is valid.ANY form clearly stating refusal of CPR, signed by patient and patient’s physician is valid. Even if NOT signed by physician, any form signed by a patient should be honored.Even if NOT signed by physician, any form signed by a patient should be honored. Copies, faxes, scans are just as valid as original.Copies, faxes, scans are just as valid as original. Downloadable template on Iris Project and CDPHE Web site.Downloadable template on Iris Project and CDPHE Web site. Do Not Resuscitate ≠ Do Not Treat! Palliative care should always be provided.Do Not Resuscitate ≠ Do Not Treat! Palliative care should always be provided.

24. 24 Medical Orders for Scope of Treatment (MOST) A document that consolidates and summarizes patient preferences for key life-sustaining treatments.A document that consolidates and summarizes patient preferences for key life-sustaining treatments. Persons may refuse treatment, request full treatment, or specify limitations.Persons may refuse treatment, request full treatment, or specify limitations. It is primarily intended to be used by the chronically or seriously ill person in frequent contact with healthcare providers, or already residing in a nursing facility.It is primarily intended to be used by the chronically or seriously ill person in frequent contact with healthcare providers, or already residing in a nursing facility. Translates patient preferences into physician’s orders.Translates patient preferences into physician’s orders. “Travels” with the patient and is honored in any setting: hospital, clinic, day surgery, long-term care facility, rehab facility, hospice, or at home.“Travels” with the patient and is honored in any setting: hospital, clinic, day surgery, long-term care facility, rehab facility, hospice, or at home. Prompts patients and providers to regularly review, confirm, or update choices based on changing conditions.Prompts patients and providers to regularly review, confirm, or update choices based on changing conditions.

25. 25 MOST Orders 1.CPR 2.Medical Intervention & Transfer re Comfort Measures Only Vs. Full Treatment 3.Antibiotic Use 4.Artificially Administered Nutrition & Hydration

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28. 28 Practical Suggestions Consider Five Wishes – it incorporates a Living Will and A Medical Durable Power of Attorney.Consider Five Wishes – it incorporates a Living Will and A Medical Durable Power of Attorney. Discuss your Advance Directives with close friends and family – especially with the agent(s) designated in your Medical Durable Power of Attorney.Discuss your Advance Directives with close friends and family – especially with the agent(s) designated in your Medical Durable Power of Attorney. Talk to your physician if you are considering a CPR Directive.Talk to your physician if you are considering a CPR Directive.

29. 29 Iris Project http://www.irisproject.net/linksandresource s.htmlhttp://www.irisproject.net/linksandresource s.htmlhttp://www.irisproject.net/linksandresource s.htmlhttp://www.irisproject.net/linksandresource s.html website contains great sample forms and educational materials from Colorado Advance Directives Consortiumwebsite contains great sample forms and educational materials from Colorado Advance Directives Consortium