2. ADVANCE DIRECTIVES PLANNING FOR DYING

3. PREPARING FOR THE ONSET OF INCAPACITY DEFINITION AND TASK INCAPACITY OCCURS WHEN AN INDIVIDUAL IS UNABLE TO RECEIVE INFORMATION ABOUT HIS/HER CARE, UNDERSTAND AND PROCESS ITS CONTENT, AND COMMUNICATE ABOUT HIS/HER WISHES IN LIGHT OF THE INFORMATION AVAILABLE CLEAR COMMUNICATION DURING THE TIME OF CAPACITY IS THE KEY TO PREPARING FOR A TIME OF INCAPACITY ADVANCE DIRECTIVES ARE TOOLS TO GENERATE COMMUNICATION AND “INSURE” THAT ONE’S WISHES ARE HONORED

4. TAKING RESPONSIBILITY PLANNING OR VICTIMIZATION LIVING WILL AS ADVANCE DIRECTIVE SURROGATE DECISION MAKERS –GUARDIAN –DURABLE POWER OF ATTORNEY FOR HEALTHCARE AS ADVANCE DIRECTIVE –FAMILY MEMBER TESTS FOR SURROGATE DECISION MAKING –SUBSTITUTED JUDGMENT –BEST INTERESTS

5. STANDARDS FOR SURROGATE DECISION MAKING SUGSTITUTED JUDGMENT SURROGATE ATTEMPTS TO REPLICATE FAITHFULLY THE DECISION THAT THE INCAPACITATED PERSON WOULD MAKE IF HE/SHE WERE ABLE TO MAKE A CHOICE SURROGATE LOOKS AT THE DECISION THROUGH THE “VALUE EYES” OF THE INCAPACITATED PERSON GROUNDED IN THE PRINCIPLE OF AUTONOMY BASED UPON –DIRECT STATEMENTS BY PATIENT –INFERENCES FROM VALUE CHOICES OF PATIENT SUBSTITUTED JUDGMENT STANDARD IS PREFERABLE BUT BEST INTEREST STANDARD IS PERMITTED AND OFTEN NECESSARY

6. STANDARDS FOR SURROGATE DECISION MAKING BEST INTERESTS SURROGATE MAKES THE DECISION, FROM AN OBJECTIVE STANDPOINT, WHICH APPEARS TO PROMOTE A PATIENT’S GOOD WITHOUT REFERENCE TO THE INCAPACITATED PATIENT’S ACTUAL OR SUPPOSED PREFERENCES WEIGHING BENEFITS AND BURDENS FROM THE STANDPOINT OF A “REASONABLE” PERSON LOOKING AT THE CLINICAL OUTCOMES –“REASONABLE” = SELF-REFLECTIVE, RELATIVELY UNBIASED, ATTEMPTING FACT-BASED OBJECTIVITY, SETTING ASIDE SELF-INTEREST GROUNDED IN THE PRINCIPLE OF BENEFICENCE

7. GUARDIANSHIP WHEN PREPARATIONS FOR INCAPACITY ARE NOT MADE AN APPOINTMENT BY THE COURT OF AN INDIVIDUAL WHO WILL MAKE DECISIONS FOR PATIENTS BECAUSE OF THE INCAPACITY (INCOMPETENCE) OF PATIENTS TO MAKE DECISIONS FOR THEIR OWN WELFARE REQUIRES PHYSICIANS TO HONOR THE DECISIONS OF THE GUARDIAN AS THEY WOULD IF THE PATIENTS THEMSELVES HAD MADE THE DECISIONS DISADVANTAGES –TIME-CONSUMING PROCESS –EMOTIONALLY DIFFICULT FOR THE FAMILY –PATIENT MAY BECOMES A VICTIM OF THE GUARDIAN’S AGENDA

8. ADVANCE DIRECTIVES DEFINITION A STATEMENT (WRITTEN OR ORAL) MADE BY A PATIENT BEFORE THE ONSET OF DECISIONAL INCAPACITY WHICH INDICATES THE DIRECTION THE PATIENT WOULD LIKE HIS/HER TREATMENT TO TAKE (OR THE INDIVIDUAL WHO SHOULD MAKE SUCH DECISIONS FOR THE PATIENT) WHEN HE/SHE IS NO LONG ABLE TO PARTICIPATE IN THE HEALTHCARE DECISIONS DIRECTING HIS/HER CARE –STATEMENTS/DOCUMENTS SHOULD STIMULATE COMMUNICATION

9. ADVANCE DIRECTIVES CENTRAL CHARACTERISTICS SPECIFICITY - - - REGARDING TREATMENTS AND/OR OUTCOMES –CLARITY OF WISHES ABOUT TREATMENTS –CLARITY OF WISHES ABOUT POSSIBLE OUTCOMES –DIFFICULTY IN ACHIEVING SPECIFICITY –RECOMMENDATIONS - - - MINIMALLY ADDRESS CPR/DNR, ARTIFICIAL NUTRITION/HYDRATION, PAIN CONTROL CREDIBILITY - - - REGARDING INTENT AND VALUE CONTEXT –MOTIVATION AND INTENTION OF AUTHOR –BELIEFS OF THE AUTHOR –INSUFFICIENCY OF SIGNATURE ON A FORM

10. KINDS OF ADVANCE DIRECTIVES UNWRITTEN INFORMAL STATEMENTS MADE TO FAMILY AND FRIENDS –INEFFECTIVE IN CASES OF CONFLICT STATEMENTS MADE TO PHYSICIANS WHICH ARE DOCUMENTED IN THE PATIENT’S CHART –SAME STATUS AS WRITTEN ADVANCE DIRECTIVES

11. KINDS OF ADVANCE DIRECTIVES WRITTEN LIVING WILL DECLARATIONS A DOCUMENT WRITTEN AND/OR SIGNED BY INDIVIDUALS WHILE THEY ARE CAPABLE OF MAKING DECISIONS ABOUT THEIR HEALTHCARE WHICH ORDINARILY DIRECTS THEIR PHYSICIANS TO USE RESTRAINT IN EMPLOYING AGGRESSIVE TREATMENTS TO PROLONG THEIR LIVES IF THEY ARE IN A TERMINAL OR IRREVERSIBLE CONDITION AND UNABLE TO MAKE DECISIONS ON THEIR OWN BEHALF AT THE TIME THE TREATMENTS ARE BEING CONSIDERED.

12. KINDS OF ADVANCE DIRECTIVES APPOINTMENT OF AN ATTORNEY-IN-FACT IN A DURABLE POWER OF ATTORNEY FOR HEALTHCARE A DOCUMENT SIGNED BY INDIVIDUALS WHILE THEY ARE CAPABLE OF MAKING DECISIONS ABOUT THEIR HEALTHCARE DESIGNATING A PERSON WHO WILL HAVE AUTHORITY TO MAKE HEALTHCARE DECISIONS FOR THEM IN THE EVENT THAT THEY MIGHT BECOME INCAPABLE OF MAKING THOSE DECISIONS AT THE TIME THEY ARE BEING CONSIDERED. –IMPORTANCE OF TRUST

13. POWER OF ATTORNEY TERMINOLOGY PRINCIPAL –THE PERSON WHO APPOINTS ANOTHER TO ACT ON HIS/HER BEHALF –[THE PATIENT IN HEALTHCARE MATTERS] ATTORNEY-IN-FACT –THE PERSON WHO IS APPOINTED TO ACT ON BEHALF OF ANOTHER WHEN THE OTHER IS INCAPABLE OF ACTING ON HIS/HER OWN BEHALF –[THE SURROGATE/PROXY IN HELATHCARE MATTERS]

14. POWER OF ATTORNEY REGULAR POWER OF ATTORNEY APPOINTMENT OF ANOTHER TO PERFORM SPECIFIC TRANSACTIONS –E.G., SELL PROPERTY, MANAGE FINANCIAL AFFAIRS AUTHORITY CEASES WHEN PRINCIPAL BECOMES INCOMPETENT (LOSES DECISIONAL CAPACITY)

15. POWER OF ATTORNEY DURABLE POWER OF ATTORNEY APPOINT OF ANOTHER TO PERFORM SPECIFIC TRANSACTIONS –E.G., SELL PROPERTY, MANAGE FINANCIAL AFFAIRS AUTHORITY CONTINUES PAST THE ONSET OF INCOMPETENCE (LOSS OF DECISIONAL CAPACITY) OF THE PRINCIPAL

16. POWER OF ATTORNEY SPRINGING DURABLE POWER OF ATTORNEY APPOINTMENT OF ANOTHER TO PERFORM SPECIFIC TRANSACTIONS –E.G., SELL PROPERTY, MANAGE FINANCIAL AFFAIRS –HEALTHCARE DECISIONS AUTHORITY BEGINS ONLY WHEN THE PRINCIPAL BECOMES INCOMPETENT (LOSES DECISIONAL CAPACITY) DURABLE POWER OF ATTORNEY FOR HEALTHCARE

17. WHY AN ADVANCE DIRECTIVE TO EXTEND THE AUTHORITY OF THE PATIENT BEYOND THE ONSET OF DECISIONAL INCAPACITY TO EXPRESS CLEARLY THE WISHES OF THE PATIENT SO THEY WILL BE HONORED BY CAREGIVERS, FAMILIES, AND OTHERS –TO AVOID BECOMING A VICTIM OF ANOTHER’S AGENDA ARBITRARY DECISIONS PATIENT WOULD NOT WANT DECISIONS MADE OUT OF GUILT OR FEAR PRESSURE FROM SPECIAL INTEREST GROUPS PROTRACTED OR UNDESIRABLE COURT DECISIONS TO AVOID THE NECESSITY OF GOING TO COURT --- OFTEN INAPPROPRIATE DECISIONS CONSERVE RESOURCES, PARTICULARLY WHEN FURTHER TREATMENT IS FUTILE

18. TYPES OF ADVANCE DIRECTIVES INFORMAL STATEMENTS ADVANTAGES –INSURES COMMUNICATION HAS OCCURED DISADVANTAGES –NO DOCUMENTATION IN CASE OF CONFLICT WHEN ADVANCE DIRECTIVE IS TO BE IMPLEMENTED –OFTEN CASUAL COMMENT WITH LITTLE REFLECTION OR SPECIFICITY

19. TYPES OF ADVANCE DIRECTIVES DOCUMENTED STATEMENTS TO PHYSICIANS ADVANTAGES –NO NEED TO LABOR OVER A WRITTEN DOCUMENT – NO NEED TO SECURE WITNESSES TO A SIGNED DOCUMENT –CAN DISCUSS IMMEDIATELY TREATMENT DIRECTIONS WITH PHYSICIAN DISADVANTAGES –PHYSICIAN’S RECORDS MAY BE INACCESSIBLE WHEN THEY ARE NEEDED, E.G., RETIREMENT –STATEMENTS MADE TO SEVERAL PHYSICIANS MAY CONFLICT

20. TYPES OF ADVANCE DIRECTIVES LIVING WILL DECLARATIONS ADVANTAGES –DOCUMENTED PROTRAIT OF PATIENT’S WISHES AND VALUES –PROMOTES AUTONOMY BEYOND OF POINT OF INCAPACITY –ENHANCES REFLECTIVE LIFE OF AUTHOR –PROMOTES DIGNITY BY ALLOWING RISK-TAKING BY AUTHOR –ACCEPTS CONTEXT OF NATURAL RHYTHMS OF LIFE DISADVANTAGES –IMPOSSIBLE TO ANTICIPATE ALL CONTINGENCIES –NO COMPETENT PERSON WITH AUTHORITY TO ASSESS PARTICULARS OF A CLINICAL SITUATION AND MAKE DECISIONS –LACK OF SPECIFICITY IF “GENERIC” FORM IS USED –LACK OF CREDIBILITY IF INTENTIONS AND VALUES OF AUTHOR ARE UNKNOWN

21. TYPES OF ADVANCE DIRECTIVES LIVING WILL DECLARATIONS ADVANTAGES (CONT.) –CAN GENERATE AVENUES OF COMMUNICATION AUTHOR AND SIGNIFICANT OTHER/CAREGIVERS –PROTECTION FROM UNDESIRED INTERVENTIONS –RELIEVES SECOND GUESSING –RELIEVES GUILT AND FEAR –PROMOTES CONTINUITY OF CARE –MAY BE COST EFFECTIVE DISADVANTAGES (CONT.) –FREQUENTLY LITTLE COMMUNICTION OCCURS WITH SIMPLY SIGNING A FORM

22. TYPES OF ADVANCE DIRECTIVES DURABLE POWER OF ATTORNEY FOR HEALTHCARE ADVANTAGES –DESIGNATES A PERSON THE PATIENT TRUSTS –GIVES DECISIONAL AUTHORITY TO INDIVIDUAL WHO CAN ASSESS SPECIAL CIRCUMSTANCES IN THE CLINICAL SITUATION –IDENTIFIES AN INDIVIDUAL WITH AUTHORITY WITH WHOM PHYSICIAN CAN COMMUNICATE DISADVANTAGES –IF NO CLEAR COMMUNICATION BEFORE INCAPACITY, PATIENT COULD BECOME VICTIM OF ATTORNEY-IN-FACT’S AGENDA –WITHOUT DOCUMENTATION PHYSICANS CAN QUESTION IF ATTORNEY-IN-FACT IS TRULY REPRESENTING PATIENT’S WISHES –WITHOUT DOCUMENTATION OTHERS MAY OBSTRUCT ATTORNEY-IN-FACT’S DECISIONS

23. TYPES OF ADVANCE DIRECTIVES DURABLE POWER OF ATTORNEY FOR HEALTHCARE ADVANTAGES –REQUIRES PHYSICIANS TO HONOR DECISIONS OF ATTORNEY-IN-FACT AS THEY WOULD IF THE PATIENT HIMSELF/HERSELF HAD MADE THE DECISIONS –REDUCES FEAR OF LAWSUIT BECAUSE OF AUTHORITY OF DECISION-MAKER DISADVANTAGES –WITHOUT PRIOR COMMUNICATION AND DOCUMENTATION ATTORNEY- IN-FACT MAY HESITATE TO MAKE NECESSARY DECISIONS BECAUSE OF GUILT –WITHOUT DOCUMENTATION AUTHORITY OF ATTORNEY-IN- FACT MAY BE WEAKENED A WELL-DESIGNED LIVING WILL MAY NEUTRALIZE DISADVANTAGES

24. ADVANCE DIRECTIVES MOST POWERFUL PROTECTION SIGN THE STATE-APPROVED LIVING WILL DECLARATION FORM APPOINT AN ATTORNEY-IN-FACT IN A DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS USING THE STATE-APPROVED FORMS SPECIFY INTENTIONS AND WISHES IN A DOCUMENTED WAY AND BE AS CLEAR ABOUT THEM AS POSSIBLE CONVERSE OPENLY AND HONESTLY WITH PHYSICIAN, FAMILY, AND SIGNIFICANT OTHERS ABOUT YOUR WISHES REASSESS WISHES PERIODICALLY AS LIFE CIRCUMSTANCES AND HEALTH CONDITIONS CHANGE