End of Life Conversations & Advance Care Planning Katherine Abraham Evans, DNP, FNP-C, GNP-BC, ACHPN Clinical Assistant Professor and DNP Program Coordinator Byrdine F. Lewis School of Nursing and Health Professions Georgia State University Nurse Practitioner – Optum

Advanced Care Planning A process involving education and decision making about chronic disease trajectories and end of life care options before a health crisis. - These discussions should include a person’s priorities, beliefs, and values - Discussion should include the “ifs” and ambiguities of living with chronic illness - Can include conversation around funeral and memorial services

Advance Directive A general term that describes two kinds of legal documents, living wills and medical powers of attorney. These documents allow a person to give instructions about future medical care, should the person be unable to participate in medical decisions due to serious illness or incapacity. Each state regulates the use of advance directives differently. Five Wishes – A type of advance directive legally recognized by 42 states including Georgia.

Medical Power of Attorney A document that allows an individual to appoint someone else to make decisions about his or her medical care if he or she is unable to communicate. AKA: Healthcare Proxy, Durable Power of Attorney for Healthcare.

Power of Attorney A legal document allowing one person to act in a legal matter on another’s behalf regarding to financial or real estate transaction.

POLST A set of orders implemented after conversation with a healthcare provider and patient or patient surrogate decision maker These orders are signed by the physician Intended for patients with chronic illness with approximately one year of life remaining

Life-Sustaining Treatment Treatments that replace or support an essential bodily function. Examples include: CPR, Mechanical Ventilation, Artificial Nutrition & Hydration, and Dialysis

Withholding or Withdrawing Treatment Forgoing life-sustaining measures or discontinuing them after they have been used for a certain period of time.

Allow Natural Death AND/DNR – Allow Natural Death/Do Not Resituate DNI – Do Not Intubate

AND/DNR / DNI “Do not resuscitate” does not mean, “do not treat.” A DNR order covers only one type of medical treatment— CPR. Other types of treatment, including intravenous fluids, artificial nutrition and hydration, and antibiotics must be discussed with the physician separately. In addition, although CPR will not be given to a person who has a DNR order, all measures can and should be used to keep a person comfortable. AND – Acceptance of Natural Death or Allow Natural Death LIFE-SUSTAINING TREATMENTS End-of-Life Decisions © 2008 National Hospice and Palliative Care Organization.

AND/DNR/DNI When a DNR order is discussed the doctor might ask if a “do-not- intubate” order is also wanted. Intubation may be considered separately from resuscitation because a person can have trouble breathing or might not be getting enough oxygen before the heart actually stops beating or breathing stops (a cardiac or respiratory arrest). If a person does not want life mechanically sustained it is important to be sure that intubation is addressed as part of the discussion of DNR. LIFE-SUSTAINING TREATMENTS End-of-Life Decisions © 2008 National Hospice and Palliative Care Organization.

Living Will A type of advance directive in which an individual documents his or her wishes about medical treatment should the person be at end of life and unable to communicate.

Decisions… Pain Management & Palliative Care Artificial Nutrition & Hydration DNR / DNI Blood Transfusions & Major Procedures Hospitalization Skilled Nursing Facility Placement End-of-Life Care / Hospice

Pain Management & Palliative Care Many people mistakenly think that by refusing life-sustaining medical treatments they could be refusing all medical care. An individual is not refusing pain management and supportive care when they are refusing life support. This kind of care is often called “palliative care.”

Pain Management & Palliative Care Although pain management is an important part of palliative care, it is not all that palliative care encompasses. Palliative care is care for the whole person and includes spiritual and social supports, as well as support for those caring for the person

Artificial Nutrition & Hydration Some Points to Think about When Making Decisions about the Use of Artificial Nutrition and Hydration What are your wishes? What quality of life is important to you? What is the goal or purpose for providing artificial nutrition and hydration? Will it prolong life? Will it bring about a cure? Will it contribute to the level of comfort? LIFE-SUSTAINING TREATMENTS End-of-Life Decisions © 2008 National Hospice and Palliative Care Organization.

Artificial Nutrition & Hydration Are there religious, cultural, or personal values that would affect a decision to continue or stop treatment? Are there any benefits that artificial nutrition and hydration would offer? Artificial Hydration: Short Term Benefit Possible / Not Long-Term Use LIFE-SUSTAINING TREATMENTS End-of-Life Decisions © 2008 National Hospice and Palliative Care Organization.

CPR Discussion Questions to ask your healthcare provider when making a decision regarding CPR: Describe the procedures Address the probability for successful resuscitation based upon the person’s medical condition Define what is meant by “successful” resuscitation; Does “Successful” mean the person will be able to leave the hospital? In what condition? If it is unlikely that the person will be able to leave the hospital, what can the resuscitation attempt accomplish?

Blood Transfusions Objections to blood transfusions may arise for personal, medical, or religious reasons. For example, Jehovah's Witnesses object to blood transfusion primarily on religious grounds—they believe that blood is sacred, although they have also highlighted possible complications associated with transfusion. Risk of infection and transfusion complication should be weighed against potential benefits

Pacemakers An artificial pacemaker is a medical device which uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart. The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's native pacemaker is not fast enough, or there is a block in the heart‘s electrical conduction system.

Surgery The value to having any major surgical procedure should be considered in terms of the patient’s overall quality of life. Surgical risk and potential adverse outcomes should be considered along with alternative options such as palliative care.

Hospitalization At some point during the course of chronic disease trajectories, some patients may prefer to have no further hospitalizations, unless for comfort. This concept may be foreign to loved ones, especially with all of the current technologies available. This stage of illness is not uncommon, and requires the support of family and medical providers.

Skilled Nursing Facility Placement Some people will eventually require 24hr care, and will need skilled nursing facility (SNF) placement. This is a hard decision for families to have to make, but is sometimes inevitable. Sometimes an alternative to SNF placement is home health care, but is usually very expensive.

End-of-Life and Hospice Some patients and families benefit from Hospice during End-of-Life. Hospice involves a team-oriented approach to medical care, pain management, along with emotional and spiritual support. Most hospice services can be delivered as in-patient, in a person’s home, Hospice home, or in a SNF. Palliative care is part of hospice, however if hospice is not appropriate palliative care services can continue

Starting the Conversation Use the facts 70% of Americans want to die at home 70% of Americans die in a hospital or skilled nursing facility 80% of Americans would want to talk to their doctor about end of life wishes if they were seriously ill 7% of Americans have those conversations 23% of Americans have put their wishes in writing Theconversationproject.org

The Conversation Decisions do not need to be made during the first discussion Plant the seed and ask your loved one to start making considerations Schedule a time to revisit the conversation Provide resources that may be helpful

The Conversation Topics to cover How do you envision the last phase of your life? Where would you want to receive care? Is it important that your wishes are honored? Do you prefer a certain person be involved? What types of treatments would you want/not want? What are your goals for care? Comfort, Longevity, Function? Do you envision those goals evolving? Theconversationproject.org

The Conversation Remember the answers may not be what you expect Be respectful – it is ok to disagree on goals Advance directives and goals of care are usually evolving – revisit the conversation after acute illness, hospitalization and other declines Don’t stop with the conversation, Complete an advance directive

It’s About How You LIVE It’s About How You LIVE is a national community engagement campaign encouraging individuals to make informed decisions about end-of-life care and services L earn about options for end-of-life services and care I mplement plans to ensure wishes are honored V oice Decisions to family, friends, and healthcare providers E ngage in personal or community efforts to improve end-of-life care

Resources georgiahealthdecisions.org Georgia Advance Directive: