1. End-of-Life Choices Natalie Beal, Lisa Cabrera, Katrina Leong, Charity Smith, Stephanie Wizel

2. Quick Survey Who has lost a loved one? Who has an advanced directive or a living will? Who knows that California is not a state that allows for physician assisted death?

3. Advance Directives

4. Definition & Purpose ❏ Are the legal right to express your wishes in situations when you are unable to make decisions. ❏ Ensure your quality of life and avoid having your family guess what your wishes might be in times of emotional turmoil.

5. Food for Thought Do you know now what might be important to you later? Are there specific medical treatments that you would want or not want? Have you considered what environmental setting you might feel most comfortable in, such as your own home, a nursing home, or a hospital?

6. Physician Orders for Life- Sustaining Treatment (POLST)

7. Purpose ❏ Offer more control for seriously-ill patients during their end-of-life care. ❏ Prevent unwanted or ineffective treatments. ❏ Reduce patient and family suffering (honor the patient’s wishes).

8. Living Wills

9. Definition & Purpose ❏ Written legal document. ❏ Details specific medical treatments you would or would not want implemented to keep you alive.

10. Topics Addressed ❏ Resuscitation ❏ Mechanical Ventilation ❏ Pain Management ❏ Tube Feeding ❏ Dialysis ❏ Comfort Care/Palliative Care ❏ Organ Donation

11. Food for Thought Would you want to receive treatment to extend your life in any situation? Would you want to receive treatment only if a cure was possible?

12. Do Not Resuscitate (DNR)

13. Definition & Purpose ❏ An order written in a patient's medical chart (or stated in an Advance Directive) that explicitly states that CPR, intubation, pounding, and defibrillation, should not be initiated if a patient is found in cardiac arrest. ❏ An end-of-life decision that anyone of legal age can make at any point in their life. ❏ DNR does not mean that care has stopped. There is simply a change in the goal of treatment.

14. Allow Natural Death (AND)

15. Definition & Purpose ❏ An AND order is meant to ensure that only comfort measures are provided. ❏ By using AND, physicians and other medical professionals would acknowledge that the person is dying and that everything that is being done for the patient - including the withdrawal of nutrition and hydration - will allow the dying process to occur as comfortably as possible.

16. DNR vs AND ❏ Terminally ill DNR patients might be put on a ventilator, given artificial hydration, or have a feeding tube inserted. ❏ Whereas a terminally ill AND patient would have all of those things withdrawn, discontinued, or not even started, since such treatments would be painful and burdensome for the patient. ❏ Having an AND order would prevent this unintentional pain and simply Allow a Natural Death instead.

17. Palliative Care

18. Definition & Purpose ❏ Comfort (non-curative) care provided to the dying or to terminally ill people with an incurable disease. ❏ Is intended to improve the quality of remaining life by: ❏ Relieving pain and other distressing symptoms such as nausea, incontinence, etc. ❏ Addressing the physical, emotional, social and spiritual needs of the patient and their family.

19. Collaborative Care ❏ Partnership of patients, specialists, and family. ❏ Doctor, nurse, social work palliative care specialist, pharmacist, nutritionist, massage therapist, chaplain, and others: ❏ Provide patient and family support. ❏ Assist in explaining treatment options and goals.

20. Kay’s Story Kay has primary pulmonary hypertension, a rare condition of the blood vessels in her lungs. There are no treatments that can cure her illness, and she needs multiple medicines. She is admitted to the hospital almost every month because she has a hard time breathing. Episodes can be brought on by a mere cold or changes in the weather. During these hospitalizations she receives extra doses of medication, but it takes a few days for her to feel better. Each time she is hospitalized, the palliative care team works with her heart and lung doctors to treat her breathlessness. The medications they prescribe allow Kay to feel calm and comfortable. With the team’s help, Kay filled out an advance directive to make sure her doctors know she would never want to be on a ventilator. This does not change Kay’s treatment when she is admitted. But now the doctors understand what she would want if she were too sick to breathe on her own. getpalliativecare.org/stories

21. Hospice Care

22. Definition & Purpose ❏ Hospice care is a type of medical care provided to patients with terminal illnesses who generally have less than six months to live. ❏ It is characterized as a philosophy of care during the "end-of-life" and provides care 24 hours, seven days a week.

23. Considerations ❏ Hospice can be in the home, the hospital or in a skilled nursing facility. ❏ Think about what work best for you and your family.

24. Summary & Additional Resources

25. Five Stages of Grief ❏ Is a series of emotional stages experienced when faced with impending death or the death of someone (or something) else. ❏ Normal coping process that affects anyone at any age. ❏ Denial ❏ Anger ❏ Bargaining ❏ Depression ❏ Acceptance

27. Death Over Dinner ❏ Who's Coming to Dinner? ❏ Set Your Intention. ❏ Select a short piece for you and your guests to watch, listen to, and read. ❏ Activate your dinner!

28. Additional Resources ❏ Advance Health Care Directive Form Instructions: ag.ca.gov/consumers/pdf/AHCDS1.pdf Advance Health Care Directive Form Instructions: ❏ American Association of Retired People (AARP): www.aarp.orgwww.aarp.org ❏ American Bar Association: http://www.americanbar.org/aba.htmlhttp://www.americanbar.org/aba.html ❏ California Coalition for Compassionate Care: http://coalitionccc.org/http://coalitionccc.org/ ❏ Center for Practical Bioethics: http://www.practicalbioethics.org/http://www.practicalbioethics.org/ ❏ Dinner Over Death: deathoverdinner.org ❏ DNR versus AND: www.hospicepatients.org/and.html ❏ Five Stages of Grief: psychcentral.com/lib/the-5-stages-of-loss-and-grief ❏ Hospice and Palliative Care: www.calhospice.orgwww.calhospice.org ❏ Living Will forms: www.uslegalforms.com/livingwills ❏ POLST California: www.capolst.org/polst-for-patients-loved-ones/www.capolst.org/polst-for-patients-loved-ones/ ❏ POLST Forms (different languages available): www.capolst.org/polst-for-healthcare- providers/forms/www.capolst.org/polst-for-healthcare- providers/forms/ ❏ The Conversation Project: http://theconversationproject.org/http://theconversationproject.org/

29. Questions?