1. Wisconsin Advance Directives for EMS Providers Baraboo District Ambulance Service Fall 2015 Bob Kelter, NREMT-P, LCSW

2. What are you planning?

3. All Care is Personal Concept of Self- Determination paramount to EMS/health care providers Nancy Cruzan case Patient Self-Determination Act, effective November 1991, Terry Schaivo case 1990 - 2005 Bobbi Kristina Brown 2015

4. Purpose of Advance Directives Provide written notice of intent for end of life care. Typically not an ER reference. Defines the trigger to activate intentions Defines specific health care ie: Nursing homes, feeding tubes or others. Revocable Does not require an Attorney or Notary Available free to adults over the age of 18

5. Types of WI Advance Directives Health Care Power of Attorney Living Will ( Declaration to Physicians) Do Not Resuscitate orders

6. Health care Power of Attorney Identifies and authorizes a “Health Care Agent” to communicate on the Patient’s behalf after decisional capacity is lost. Specifies wishes regarding residential care, feeding tubes or other wishes. Is NOT a financial instrument Requires 2 witnesses who meet specific qualifiers

7. Health Care Power of Attorney Selection of Agent is important Agent’s authority begins only when activation occurs Activation can be revoked if decisional capacity is regained Next of Kin status does not necessarily apply

8. Living Will Does Not identify a Health Care Agent Same Witnessing Requirements Establishes direction to any Physician responsible for the Patient’s care if two conditions are found: – Terminal Condition – Permanent Vegetative State

9. Do Not Resuscitate (DNR) MD authorized under Wis. Statutes for distinct populations Identifying bracelet either paper or metal must be visible and worn by patient Does not exclude comfort measures such as 02, positioning, hospice care Also revocable by patient

10. Statutory Provisions All Advance Directives apply exclusions during pregnancy All are revocable Advance Directives can be verbal as in refusal of care by a patient with capacity Good Samaritan principles apply to bystanders See Wis SS Chapter 154

11. Bringing AD’s into our Care Implied and explicit consent to touch/treat Engagement is our 1 st and ongoing goal Assessment of capacity to consent to or refuse care Minors without parent or guardian present How to inquire about advance care planning

12. Make it part of the Assessment “I see you’re wearing a DNR bracelet…” “Do You have an Advance Directive?” To a family member who announces their POA status: “ Do you have a copy of the activation certificate?” Activated POA’s speak the Patient’s health care choices, not their own preferences.

13. When In Doubt or Dispute Contact Medical Control/ BDAS Captain Provide comfort measures to qualified DNR patients and consider transport after consultation with Medical Control. Encourage patients with capacity to complete an AD. Advance Directive information packet to be developed and stocked on Ambulances for general distribution pending.

14. References http://www.nytimes.com/1990/12/27/us/nan cy-cruzan-dies-outlived-by-a-debate-over-the- right-to-die.html http://www.nytimes.com/1990/12/27/us/nan cy-cruzan-dies-outlived-by-a-debate-over-the- right-to-die.html https://www.law.cornell.edu/supct/html/88- 1503.ZO.html https://www.law.cornell.edu/supct/html/88- 1503.ZO.html http://www.nbcnews.com/health/health- news/bioethicist-tk-n333536 http://www.nbcnews.com/health/health- news/bioethicist-tk-n333536

15. References 2/2 http://www.nbcnews.com/pop- culture/celebrity/bobbi-kristina-brown- moved-emory-hospital-rehabilitation-facility- n327606 http://www.nbcnews.com/pop- culture/celebrity/bobbi-kristina-brown- moved-emory-hospital-rehabilitation-facility- n327606 https://www.dhs.wisconsin.gov/ems/dnr.htm