Patient focused presentation on Advance Directives.

1. Have YOU Had the
Conversation?
Lindsay Bergmann & Emily Fraser
NURS 810
Families in Health and Illness
The University of New Hampshire
Department of Nursing
July 15, 2014

2. What if…
• What if something happened to you
tomorrow?
• What if that something left you unable to
voice or make decisions about your own
personal medical care?
• What if that something happened today?

3. Would your loved ones
know what your wishes were?

4. We know we should talk about
what we would want at the
end of life, but it can be hard.
Preparing helps.

5. Help ease your family's pain over questions
like these when making difficult decisions for
you and take comfort in knowing that
your wishes are honored by
talking about Advance Directives.

6. Advance Care Planning
• The process of planning ahead for medical
care in the event that you are unable to
communicate your wishes to your family
and your healthcare providers.
• It involves having conversations about your
values and wishes for care with your family
and healthcare providers before you
become ill.
(4)

7. Advance Care Planning
Please click on the BLUE hyperlink below to
learn more about Advance Care Planning.
https://www.youtube.com/watch?v=eMU8hS_Ia60

8. What is an Advance Directive?
• A legal document outlining your wishes for
health care, so they will be known in the
event you are not able to communicate
those choices. An Advance Directive usually
consists of two parts:
– Durable Power of Attorney for Health Care
(DPOAHC)
– Living Will or Statement of Treatment Wishes
(4)

9. Durable Power of Attorney
for Health Care
(DPOAHC)
• Also referred to as your healthcare agent,
proxy, or surrogate.
• Document where you name a person you
trust and would want to make healthcare
decisions for you if you become unable to
make or communicate them yourself.
(4)

10. Living Will or Treatment Wishes
• A document that helps you define your
written wishes about life-sustaining
treatments and comfort care, if you are
permanently unconscious or near death and
unable to speak for yourself.
(4)

11. Advance Directive
• A copy of your completed Advance Directive
should be provided to:
– Healthcare providers
– Local hospital
– Family
– Chosen DPOAHC
– And a copy for yourself
(4)

12. Patient Self-Determination Act
(PSDA)
• Started in 1990, encourages everyone to decide now about the
types and extent of medical care they want to accept or refuse if
they become unable to make those decisions due to illness.
• Requires all health care agencies to recognize the living will and
durable power of attorney for health care.
• Under the PSDA, health care agencies must:
– Ask you whether you have an advance directive
– Give you information about your rights under state law to
make decisions about medical care and create an advance
directive
(1)

13. Physician Orders for Life-Sustaining
Treatment (POLST)
• A set of specific medical orders that if you are seriously
ill person you can complete and ask your doctor to sign.
• It is kept with you, and can be used in different health
care settings.
• It is NOT an Advance Directive.
• Emergency personnel - like paramedics, EMTs, and
emergency room doctors - must follow these orders.
– Without a POLST form, emergency care staff are generally
required to provide every possible treatment to keep you
alive.
(1)

14. I’m Confused…
• An Advance Directive sounds like the same
thing as a POLST?

15. Advance Directive vs. POLST
• ADVANCE DIRECTIVE
– For anyone 18 and older
– Provides instructions for future treatment
– Appoints a Health Care Representative
– Does not guide Emergency Medical Personnel
– Guides inpatient treatment decisions when made available
• POLST
– For persons with serious illness — at any age
– Provides medical orders for current treatment
– Guides actions by Emergency Medical Personnel when made
available
– Guides inpatient treatment decisions when made available
(10)

16. Understanding the
Importance of
Advance Directives

17. It’s Been Shown That…
• If you have an Advance Directive you are more
likely to receive end-of-life care consistent with
your preferences:
– 83.2% of patients who requested limited care
received it
– 97.1% of patients who requested comfort care
received it
• Without an advance directive, 32% of the time
your chosen DPOAHC will incorrectly choose the
treatment you desire.
– This can be due to emotional closeness, stress, or
religious beliefs.
(12)

18. 92% of adults have heard of
living wills,
but only 36% have actually
completed one.
(12)

19. According to the American Medical
Association (AMA):
• You have the right to participate in decisions about
your own health care.
• Discussing your goals and values will help you
maintain a high quality of life as long as possible.
• Advance Care Planning is shown to work best as it
allows you to explore, discuss, and articulate
preferences regarding future medical care, including
life-sustaining treatments, in the event that you
become unable to make your own decisions.
(2)

20. Understanding Your
Choices

21. Cardiopulmonary Resuscitation
(CPR)
• Emergency medical procedure used to try and
restart heartbeat and breathing.
• Involves:
– Vigorous compressions of the chest
– Use of electrical stimulation
– Medications to support or restore heart function
– Rescue breaths (forcing air into lungs)
– Insertion of a breathing tube into your windpipe
(6, 13)

22. Here’s What You Should Really
Know About CPR…
• Approximately 15% of all adults who have CPR
performed in the hospital survive and are discharged.
• 0-5% of elderly adults who have CPR performed in a
nursing facility survive.
• Other potential complications related to CPR include:
– Rib or breastbone fracture
– Neurological damage
– Abdominal injuries
– Damage to the trachea, esophagus, lips, teeth, and lungs
(3)

23. Do Not Resuscitate
(DNR)
• A medical order that in the event your heart or
breathing stop, CPR is not be started.
– No attempt should be made to resuscitate you with
chest compressions, insertion of a breathing tube, or by
giving resuscitation drugs.
(4)

24. Variations of DNR
• DNI: Do Not Intubate
– No breathing tube will be inserted, but chest
compressions and medications may be used.
• Partial DNR
– Allows you to specifically state what aspects of
resuscitation you want and don’t want
• Chest compressions
• Breathing tube/Breathing machines
• Medications
• Electric shock

25. Terminal Condition or Illness
• An irreversible illness that in the near future will result in death
or a state of permanent unconsciousness from which the person
is unlikely to recover. Examples of terminal conditions include:
– Advanced cancers
– Head injuries
– Multiple organ failures
– Massive heart attacks and strokes.
• But in many states, a terminal illness is defined as one in which
the patient will die “shortly” whether or not medical treatment
is given.
• These definitions can complicate or delay the use of a living will.
(1)

26. Life-Sustaining Medical Treatment
• In most cases life-sustaining medical treatment is anything
mechanical or artificial that sustains, restores, or substitutes for
a vital body function and would prolong the dying process for a
terminally ill patient.
• It may include:
– Cardiopulmonary resuscitation (CPR)
– Artificial respiration (mouth-to-mouth breathing, manual
ventilation, or a ventilator or respirator – a machine that pushes air
into your lungs)
– Medicine to help with blood pressure and heart function
– Artificial nutrition or hydration (liquid food or fluids given through
a tube to the stomach or into a vein)
– Dialysis (a process that does the job the kidneys normally do)
– Certain surgical procedures (such as amputation, feeding tube
placement, tumor removal, or organ transplant)
(1)

27. Palliative Care
• Taking care of the whole person – body,
mind, and spirit. This approach views dying
as natural and personal; its goal is to
provide you with relief of symptoms.
• Can be given along with aggressive
treatment or when aggressive treatment
stops.
(6)

28. Hospice Care
• A team approach to provide comprehensive
medical, nursing and social services,
spiritual care and bereavement support for
you and your family near the end of life.
(6)

29. Comfort Measures Only
(CMO)
• Also referred to as Comfort Care
• Keeping you as comfortable and peaceful as
possible, including pain medication, giving
you ice chips and lip ointment, turning your
body to prevent bed sores and bathing you.
(6)

30. Understanding Your Choices
• CPR: Emergency procedure to restart your heart and breathing.
• DNR: A medical order if you wish for CPR to not be started.
– Variations of DNR
• DNI: States you do not want a breathing tube placed.
• Partial DNR: Specifies what aspects of resuscitation you would like.
• Terminal Condition or Illness: Illness that will ultimately cause death.
• Life-Sustaining Medical Treatment: Treatment at all means to keep you alive
when you otherwise may not be.
• Palliative Care: Care of the body, mind, and spirit.
• Hospice Care: Team approach to care for you and your loved ones.
• Comfort Measures Only: Keeps you comfortable and peaceful.

31. Reasons Advance
Directives go
Unaddressed

32. Research Has Proven…
• Three main barriers to completing and effectively
using advance directives:
– Lack of education or knowledge about them.
– Difficulties with the paperwork while completing them.
– Disagreements among patients, family members or
proxy, and providers.
• Other barriers include:
– Socio-demographic factors.
– Patient and provider attitudes.
– Lack of knowledge about the potential financial
benefits.
(8)

33. Fear
• “I’ll get less than maximal medical care if my
preferences are non-aggressive treatment.”
(12)

34. Denial
• “But I’m young and I’m healthy!”
• “It can wait!”
• The growing consensus is that every adult,
regardless of age, should consider preparing an
advance directive because unforeseeable
accidents can and do occur.
– Heat Attack, Stroke
– Car Accident
– Bombings, Shootings
(12)

35. But I Have a DPOA…
• Designating a person to serve as your DPOA
is one part of the Advance Directive.
• This does not sufficiently express what your
wishes are, unless you have previously
discussed this with your DPOA (though it is
best to have your wishes in writing through
a legal document such as the Advance
Directive).
(12)

36. Conclusion

37. • The best time to make healthcare decisions
is before you are ill, when you can carefully
consider your options.
• The best time is now, because you never
know when that something may happen.

38. For More Information…
• American Hospital Association
– www.putitinwriting.org
• The Conversation Project
– http://theconversationproject.org/
• Five Wishes
– www.agingwithdignity.org
• Foundation for Healthy Communities
– http://www.healthynh.com/fhc-initiatives/advance-directives-healthcare-decision-
coalition.html
• National Health Care Decisions Day
– www.nhdd.org
• National Hospice and Palliative Care Organization
– www.nhpco.org
• POLST: Find out if your state utilizes POLST forms and learn more
– www.polst.org

39. References
1. American Cancer Society. (2013). Advance directives: Why do you need an advance
directive? ​Retrieved July 18, 2014, from http://www.cancer.org
2. American Medical Association. (2014). AMA policy on provision of life-sustaining medical treatment.
Retrieved July 17, 2014, from http://www.ama-assn.org/ama/pub/physician-resources/medical-
ethics/about-ethics-group/ethics-resource-center/end-of-life-care/ama-policy-provision-life-
sustaining-medical.page?
3. Cadogan, M.P. (2010). CPR decision making and older adults. Journal of Gerontological Nursing,
36(12), 10-15. doi:10.3928/00989134-20101109-01
4. Dartmouth-Hitchcock Medical Center. (2008). Advance care planning. Lebanon, NH: Dartmouth-
Hitchcock Medical Center.
5. FHCMedia. (2012). Advance care planning. YouTube. Retrieved July 17, 2014, from
https://www.youtube.com/watch?v=eMU8hS_Ia60
6. Foundation for Healthy Communities. (2014). Advance care planning guide. Concord, NH:
Foundation for Healthy Communities.
7. Giovanni, L.A. (2012). End-of-life care in the United Sates: Current reality and future promise - a
policy review. Nursing Economics, 30(3), 127-135.

40. References
8. Glick, K.L., Mackay, K.M., Blasingam, S., Dolan, K.R. & Casper-Isaac, S. (2004). Advance directives:
Barriers to completion. Journal of the New York State Nurses Association, 1, 4-8.
9. Hammes, B. J., Rooney, B. L., Gundrum, J. D., Hickman, S. E., & Hager, N. (2012). The POLST program:
A retrospective review of the demographics of use and outcomes in one community where advance
directives are prevalent. Journal of Palliative Medicine, 15(1), 77-85. DOI: 10.1089/jpm.2011.0178
10. National POLST. (2012). POLST and advance directives. Retrieved July 17, 2014, from
http://www.polst.org/advance-care-planning/polst-and-advance-directives/
11. Phillips, E. (2014). Helping clients initiate their personally chosen end-of-life strategies. Journal of
Financial Service Professionals, 68(3), 63-71.
12. Tejwani, V., Wu, Y., Serrano, S., Segura, L., Bannon, M., & Qian, Q. (2013). Issues surrounding end-of-
life decision-making. Patient Preference and Adherence 7, 771-775. doi:
http://dx.doi.org/10.2147/PPA.S48135
13. Vermont Ethics Network. (2014). Taking steps: Planning for critical health care decisions.
Montpelier, VT: Vermont Ethics Network.