1. Legal and Ethical Issues Affecting End-of-life Care Advance Directives

2. The Issues The outcomes related to their care should be their own wishes. The outcomes related to their care should be their own wishes. The decisions may involve the choice for: The decisions may involve the choice for: Organ and tissue donations Organ and tissue donations Advance directives Advance directives Resuscitation Resuscitation

3. Advance Directives A general term used to describe the documents that give instructions about future medical care and treatments A general term used to describe the documents that give instructions about future medical care and treatments Advance Directives include: Advance Directives include: Living Will Living Will Do Not Resuscitate Order Do Not Resuscitate Order Withholding or Withdrawing Treatments Withholding or Withdrawing Treatments

4. Living Will Was the first advance directive Was the first advance directive The lay term used frequently to describe any number of documents that give instructions about future medical care and treatments or the wish to be allowed to die without heroic or extraordinary measures should the patient be unable to communicate for self The lay term used frequently to describe any number of documents that give instructions about future medical care and treatments or the wish to be allowed to die without heroic or extraordinary measures should the patient be unable to communicate for self Most states have replaced the idea of living wills with the natural death acts Most states have replaced the idea of living wills with the natural death acts These include: These include: Directive to physicians (DTP) Directive to physicians (DTP) Durable power of attorney for health care (DPAHC) Durable power of attorney for health care (DPAHC) Medical power of attorney (MPOA) Medical power of attorney (MPOA)

5. Directive to physicians A written document specifying the patient’s wish to be allowed to die without heroic or extraordinary measures A written document specifying the patient’s wish to be allowed to die without heroic or extraordinary measures

6. Durable power of attorney for health care A term used by some states to describe a document used for listing the person or persons to make health care decision should a patient become unable to make informed decisions for self. A term used by some states to describe a document used for listing the person or persons to make health care decision should a patient become unable to make informed decisions for self.

7. Medical power of attorney Same as durable power of attorney for health (depends on state) Same as durable power of attorney for health (depends on state) Person appointed may be called a health care agent, surrogate, attorney-in-fact, or proxy Person appointed may be called a health care agent, surrogate, attorney-in-fact, or proxy

8. Do Not Resuscitate A written physician’s order instructing health care providers not to attempt CPR A written physician’s order instructing health care providers not to attempt CPR Often requested by family Often requested by family Must be signed my a physician to be valid Must be signed my a physician to be valid Several types of CPR decisions can be made, including: Several types of CPR decisions can be made, including: Full code Full code Chemical code Chemical code DNR or “no code” DNR or “no code” Out-of-hospital DNR Out-of-hospital DNR

9. Full code Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation Chemical code The use of drugs for resuscitation without the use of CPR The use of drugs for resuscitation without the use of CPR

10. DNR or “no code” Allows the person to die with comfort measures only and without the interference of technology Allows the person to die with comfort measures only and without the interference of technology Becoming known as allow natural death (AND) or comfort code Becoming known as allow natural death (AND) or comfort code Out-of-hospital DNR For use by terminally ill patients who wish to have no heroic measures used to prolong life after they leave an acute care facility For use by terminally ill patients who wish to have no heroic measures used to prolong life after they leave an acute care facility

11. Withholding or withdrawing treatments What is to be done and what is not to be done must be included in clear terms What is to be done and what is not to be done must be included in clear terms Honoring the refusal of treatments that a patient does not desire, are disproportionately burdensome to the patient, or will not benefit the patient can be ethically and legally permissible Honoring the refusal of treatments that a patient does not desire, are disproportionately burdensome to the patient, or will not benefit the patient can be ethically and legally permissible The decision to withhold artificial nutrition and hydration should be made by the patient or surrogate with the health care team The decision to withhold artificial nutrition and hydration should be made by the patient or surrogate with the health care team

12. The Nurse’s Responsibilities Be aware of legal issues and the wishes of the patient Be aware of legal issues and the wishes of the patient Nursing care of dying patients is holistic and encompasses all aspects of psychosocial (grieving process) and physical needs (physical changes that are associated with dying) Nursing care of dying patients is holistic and encompasses all aspects of psychosocial (grieving process) and physical needs (physical changes that are associated with dying) Focus on patient and family: respect, dignity, and comfort Focus on patient and family: respect, dignity, and comfort Recognize own needs when dealing with grief and dying. Recognize own needs when dealing with grief and dying.

13. The End

14. Quiz

15. Question 1 Who makes the decisions regarding end of life care? Who makes the decisions regarding end of life care?

16. Question 2 Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation is referred to as what? Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation is referred to as what?

17. Question 3 What is the lay term used frequently to describe any number of documents that give instructions about future medical care and treatments or the wish to be allowed to die without heroic or extraordinary measures, should the patient be unable to communicate for self? What is the lay term used frequently to describe any number of documents that give instructions about future medical care and treatments or the wish to be allowed to die without heroic or extraordinary measures, should the patient be unable to communicate for self?

18. Question 4 What is another name for DNR or “no code”? What is another name for DNR or “no code”?

19. Question 5 What is the general term used to describe the documents that give instructions about future medical care and treatments? What is the general term used to describe the documents that give instructions about future medical care and treatments?

20. Question 6 Who should be aware of legal issues and the wishes of the patient? Who should be aware of legal issues and the wishes of the patient?

21. Question 7 What has replaced the idea of living wills in most states? What has replaced the idea of living wills in most states?

22. Question 8 Nursing care of dying patients is ________ and encompasses all aspects of psychosocial and physical needs. Nursing care of dying patients is ________ and encompasses all aspects of psychosocial and physical needs.

23. Question 9 What is a written document specifying the patient’s wish to be allowed to die without heroic or extraordinary measures? What is a written document specifying the patient’s wish to be allowed to die without heroic or extraordinary measures?

24. Question 10 What is a written physician’s order instructing health care providers not to attempt CPR? What is a written physician’s order instructing health care providers not to attempt CPR?