1. ADVANCED HEALTH CARE DIRECTIVES For Health Care Providers at Glide

2. Historical Perspective Patient Self Determination Act(1990) First legislation requiring health care organizations to provide adult clients with written information about their right to make medical treatment decisions. Lead to the establishment of the Patient’s Bill of Rights and current advanced directive laws.

3. Current California Law Health Care Decisions Law (2000) Consolidated California’s previous advance directive laws in order to make it easier for individuals to make their preferences known through written and oral communication. Legally defines an “Advanced Health Care Directive.”

4. What is an Advanced Health Care Directive? (AHCD)

5. AHCD: Definition in California AHCD is a document that provides an individual with the opportunity to express their wishes for future medical care. Two broad categories: Power of Attorney for health care Instructional directives for health care *Best to have both types of AHCD, but may have one or the other.

6. Power of Attorney for Health Care Designates a person to make medical decisions for the client. Usually specified to make decisions only when the client can no longer make decisions for themselves, but may be initiated at any time the client requests. Also referred to as durable attorney for health care, health care agent, or health care proxy.

7. Instructional Directives for Health Care Written instructions describing what treatments the client would want or not want under certain circumstances. Includes instructions on life-sustaining treatment (CPR, feeding tubes, breathing machines), pain medications, and organ donation. Also known as “living wills.”

8. What are the legal requirements for an AHCD?

9. Current California Law An AHCD is valid if it is: 1. Completed by a competent person over 18 years old. 2. Includes a persons name, signature, and the date executed. 3. Is acknowledged by a notary republic OR signed by two witnesses*. *A lawyer is NOT required to make the document legal and binding.

10. Who can witness an AHCD? At least one person must not be related or named in the will of the person. Persons excluded include the: Person’s physician/ health care provider or their employees. Owner, operator or employee of a residential care home or facility that person is living in. In this situation, one witness must be a patient advocate.

11. Why are AHCDs Important?

12. Importance of AHCD Ensures that an individual’s wishes are carried out with respect to their values and beliefs. May prevent unwanted heroic measures or invasive procedures, which would conserve health care resources. Encourages an open, clear dialogue between clients and their providers on what can be a difficult subject matter

13. Who should initiate discussions around AHCDs?

14. Role of the Primary Health Care Team Surveys have indicated that most people would prefer to have advanced care planning discussions with a provider they have known over time. Most say they look to the provider to initiate the discussion.

15. When should advanced care planning begin?

16. Ideally… Clients will discuss AHCDs with their friends, families, and health care providers when they are healthy before the onset of a serious illness. Clients with chronic illnesses, or those at the end-of-life need to be encouraged to set specific goals of care with their providers.

17. What if clients want to change their AHCD?

18. No problem… A person who has cognitive capacity may revoke all or part of the AHCD at any time. The revocation must be clearly documented by health care providers.

19. Barriers to AHCDs Only a small percentage of adults complete advanced directives - about 15% to 25%. End-of-life discussions can be difficult, and emotionally charged for all involved. Many clinics do not have user friendly forms readily available.

20. Communication is Key Open dialogue between health care providers and clients is essential to advanced care planning. Set aside time within an appointment to discuss AHCD. Educate client on what an AHCD entails, provide written form, and ensure that it is part of the medical record. As the end-of-life nears, clarify the goals of care with the individual and family, reassess as needed.

21. Resources Barnes, S. (2003). The advanced directive: a fundamental communication. Journal of PeriAnethesia Nursing,18, 203-205. California Coalition for Compassionate Care: http://www.finalchoices.calhealth.org/advance_health_care_directives.htm http://www.finalchoices.calhealth.org/advance_health_care_directives.htm Wissow, et al. (2004). Promoting advanced directives among elderly primary care patients. Journal of General Internal Medicine, 19, 944-951.