Advanced Directives

CAREOLOGY INSTITUTEPresents

ADVANCED DIRECTIVE The Safety Net for Tough Healthcare Decisions For LTC and RCFE Administrators

The purpose of this course is to help students understand the concept and importance of Advanced Directives and know the myths associated with the document.

Course Description

What is an Advance Directive?

An Advance Directive tells the doctor what kind of care you would like if you become unable to make important medical decisions for yourself. A situation that could warrant this is a coma.

Advanced Directive

• An adequate advance directive describes the type of treatment you would want depending on how sick you are. The directives may describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are permanently unconscious.

• Advance directives usually communicate to your doctor that you don’t want certain kinds of treatment. They can also state that you want a certain treatment no matter how ill you are.

What it Means to the Physician?

• As just previously stated, the advance directive tells the doctor what your wishes are should an illness or other emergency emerges in your life.

• By following your advance directive, the doctor can make decisions for your healthcare without overstepping boundaries and infringing on your patient rights.

What it Means to Patients & Families

• Patients with advance directives are able to shield themselves from unwanted medical procedures. Their wishes are well defined and legalized to prevent a family or Physician from interfering with unwanted care decisions (typically end of life issues). Therefore, an advance directive adds dignity and meaningfulness to a patient’s plan of care.

• Families of patients, are less burdened when a advance directive is in place. They no longer have to make difficult healthcare decisions for a loved one.

Types of Advance Directives

There are various types of Advance Directives. We will discuss 5 forms of advance directives: (1) PIC form (Preferred Intensity of Care form), (2) Advanced Healthcare Directive, (3) General Power of Attorney, (4) Living Will, and (5) Do Not Resuscitate order. All play different roles in the arena of Healthcare.

The PIC (Preferred Intensity of Care

Form)

This form is widely seen in Skilled Nursing Facilities and other medical institutions. The PIC form is used to communicate to the Physician and Nursing staff a Patient’s wishes regarding CPR, Tube feeding, IV usage, Comfort Care and other Nursing measures should they be required. The form is not intended to be a permanent record and may be changed at any time, as many times as the Patient desires.

The PIC (Preferred Intensity of Care

Form)

The form is referred to in the event of a medical emergency. A typical use for this form can be described in this scenario:

Mrs. Smith is a resident of a Skilled Nursing Facility. The medication nurse walks into her room and finds her non-responsive. She reports this to the charge nurse who then reviews the PIC form. It reads “Full Code” meaning CPR must be done. Nursing staff proceeds with CPR and calls 911 for emergency transport to the acute Hospital.

Advanced Directives

We should address the term “Full Code” at this point. Full code simply means that a patient wants everything done in the event of an emergency. This includes CPR, transferring to hospital, tube feeding, I.V.s, etc…

The Advanced Healthcare Directive

• The Advanced Healthcare Directive (AHCD) is also known in the healthcare industry as a Durable Power of Attorney for Healthcare (DPAHC). This document states whom you have chosen to make health care decisions for you.

• It becomes active any time you are unconscious or unable to make medical decisions.

The Advanced Healthcare Directive

The AHCD form also contains special circumstances such as options for DNR, life sustaining treatment and limitations on what the appointed healthcare agent can decide on for you.

Two things to keep in mind regarding the AHCD:

1. The AHCD may not be a good choice if you don’t have another person you can trust to make healthcare decisions for you.

2. The AHCD ONLY becomes effective only when you lose capacity to make decisions.

General Power of Attorney

• This document is used for financial purposes. It appoints an agent to gain needed access to bank accounts and other financial documents. The POA can also write checks and pay bills on behalf of the patient.

• In a healthcare setting, this form is often confused with the AHCD (Advance Healthcare Directive). All should keep in mind that the POA is for FINANCIANAL while the AHCD is for HEALTHCARE.

The Living Will

• A living will is a written legal document, that describes the kind of medical treatments or life-sustaining measures you would want if you were seriously or terminally ill.

• The main difference between the Living Will and the AHCD is that the Living Will doesn’t let you select someone to make decisions for you.

The Do Not Resuscitate Order (DNR)

• The DNR is a form requesting not to have cardiopulmonary resuscitation (CPR), if your heart stops or if you stop breathing.

• Unless other instructions are given, the medical staff will try to help all patients whose heart has stopped or who have stopped breathing. Therefore, this document is vital to protecting your medical treatment wishes.

The Do Not Resuscitate Order (DNR)

In most cases, the AHCD states a patient’s wishes regarding CPR. In this case, the DNR order is placed in your medical chart by your doctor. A DNR order often accompanies the AHCD.

When Should One Have an Advanced Directive?

• By creating an advance directive, you are making your wishes about medical care known before you’re faced with a serious injury or illness. This will spare your loved ones the stress of making decisions about your care while you are incapacitated.

• Any person 18 years of age or older can prepare an advance directive.


• People who are seriously or terminally ill are more likely to have an advance directive. Someone with terminal cancer might write that she does not want to be put on a respirator if she stops breathing. This action can reduce her suffering, increase her peace of mind and increase her control over her death.

• Even if you are in good health, you may want to consider writing an advance directive. An accident or serious illness can happen suddenly, and if you have an AHCD, your wishes are likely to be followed.


REMEMBER:

You can only form an advance directive during the time you have capacity. The document only becomes effective when you lose capacity to make decisions. Individuals who do not have capacity are legally unable to form an AHCD with their signature.

Preparing the Advanced Directive

Advance directives do not have to be complicated legal documents. They can be short, simple statements about what you want done or not done if your incapacitated.


Advance directives can be prepared in several ways:

1. Use a form provided by your doctor.

2. Write your wishes down yourself generically.

3. Call your health department or state department on aging to get a form (i.e. Ombudsman).

4. Call a lawyer.

5. Use a computer software package for legal documents.


• If you use computer software, it’s important to follow your state’s guidelines on preparing an AHCD.

Legalizing the Advance Directive• Advance directives can be legalized in various ways

and often this depends on the type of institution it is developed in.


Patients in a LTC facility wishing to form an AHCD, only the Ombudsman can legalize the document. Individuals outside of a LTC facility, the AHCD must be notarized and witnessed by two people other than the primary and secondary designated decision makers. All other advance directives must be notarized as well, whether it be a living will, DNR order or general power of attorney.

Can One Change His or Her Advanced Directive?

• You may change or cancel an advance directive at any time, as long as you’re considered of sound mind to do so. If an individual lacks capacity, the advance directive cannot be changed and current wishes must be carried out.

• When changes are made they must be signed and notarized according to the laws in your state. It’s also important to let your doctor and family know of any changes.

When it’s Too Late to Form an Advanced Directive

We must remember, that the individual creating the advance directive must be able to decide on a primary as well as a secondary decision maker. Since, individuals who lack capacity cannot legally make decisions any advance directive created by them would be null and void.

The Alternative Option – Conservatorship

• For families and friends wishing to obtain an advance directive pertaining to an incapacitated individual, the only option is Conservatorship.

• In most cases, a family or close friend can petition to the court for Conservatorship. If approved, a court representative will have to personally serve the incapacitated individual with Conservatorship papers.

• Conservators are responsible for all health and financial aspects of the client. Conservators are also known as “Legal Guardians.”

10 Myths About Advanced Directives Unveiled

This section addresses popular legal myths regarding advance directives. It is meant to answer the most common questions among the elderly and their families.


Myth #1

Everyone should have a Living Will.

• A living will is not the document most people need. As an ultimate goal, most people should have an Advanced Health Care Directive (AHCD) that names a trusted person as agent.

• The reason for the primary importance of the agent is simple. Most standardized living will forms are quite limited in what they can accomplish and what conditions they cover.


• For example, most living wills provide instructions that apply only if the individual is in a terminal condition or permanently unconscious, yet the majority of health care decisions that need to be made for patients lacking capacity concern questions about day-to-day care, placement options and treatment options short of “pulling the plug.”

• One caveat: If there is no one close to the individual whom he or she trust to act as the health agent, then the AHCD should not be used. In this case, the living will is safer, despite its limitations.


Myth #2

Written Advance Directives Are Not Legal in

Every State.

• Every state recognizes both the agent and living will type advance directives, although the laws of each state vary considerably in terminology, the scope of decision making addressed, restrictions and the formalities required for making an advance directive should be the same.


• A more frequent question raised is whether an advance directive written in one state will be recognized in other states. In other words, is the directive portable across state lines. Many states expressly recognize out-of-state advance directives if the directive meets either the legal requirements of the state where executed or the state where the treatment decision arises.


Myth #3

Just telling my doctor what I want is no longer

legally effective.

• While it is better to have a written advance directive, oral statements remain important both on their own and as supplements to written directives.

• Although oral statements may not have the same legal status as written directives, there are two important attributes:


• First, good health care decision making requires adequate communication among all interested parties, and oral communication is our most natural and primary code of communication.

• Second, oral statements constitute important evidence of one’s wishes and help expand upon, clarify and reinforce individual preferences.


Myth #4

An Advance Directive means “Don’t treat”.

• While it is true that most people use advance directives to avoid being kept alive against their wishes when death is eminent, it is a mistake to assume that the existence of an advance directive means, “Don’t treat”.

• Advance directives are also used to say that the individual wants all possible treatments within the range of generally accepted medical standards.


What is said depends upon one’s particular wishes and values. Even when an advance directive declines all life-sustaining treatments, one should always assume (and insist upon) continuing pain control, comfort care and respect for one’s dignity.


Myth #5

When I name an agent in my Advance Directive,

I give up some control and flexibility.

• An individual gives up no authority or choice by forming an advance directive. As long as the patient remains able to make decisions, his or her consent must be obtained for medical treatment.

• Health care providers cannot legally ignore the patient in favor of one’s agent or written instruction.


There are situations in which a competent patient abdicates decision making by stating, for example, “Do whatever my daughter thinks is best”. However, this form of delegation is effective only from moment to moment and needs to be rechecked at every significant decision point. Neither the agent nor a written instruction can override one’s currently expressed choice.


Myth #6

I must use a prescribed Advance Directive form

for my state.

• In most states, you do not have to use a specific form. About 37 state statutes include forms for appointing agents or for creating comprehensive advance directives. In about 18 states, the forms must be “substantially followed” or certain information disclosure language must be included in the form.


• Any form can and should be personalized to reflect the individual’s particular values, priorities, and wishes. If you do not agree with language contained in an approved form, change the language.

• Above all, it is a mistake to pick up an “official” form and just sign it unchanged, without first being sure that it truly reflects one’s specific wishes.


Myth #7

I need a lawyer to do an Advance Directive.

• No, a lawyer is not needed. Yes, a lawyer is a helpful resource, but not the only resource, nor necessarily the best resource for all persons. Advance directives are not difficult to complete, but they require a few steps to do well.


Myth #8

Doctors and other health care providers are not

legally obligated to follow any Advance Directive.

• It is clear that medical providers cannot treat an individual against his or her wishes.


• Consequently, if a physician acts contrary to a patient’s instruction directive or decision of the patient’s authorized agent, the physician risks the same liability he or she would face if the physician were to ignore a refusal of treatment by a fully competent patient. Treatment would constitute a battery.

• There are a few factors that can complicate this situation:


• First, the doctor or health facility sometimes are not aware of the existence of an advance directive. At times, other medical institutions may not forward copies of advance directives to the appropriate record.

• Second, people often do not express their wishes very clearly or precisely in advance directives. Therefore, interpretation problems may arise.


• Third, in most states, if a physician or facility objects to an advance directive based on reasons of conscience, state law permits the physician or facility to refuse to honor it. Facilities must notify the patient of their policies regarding advance directives at the time of admission. If a refusal occurs, the physician and facility should provide assistance in transferring the patient to a provider that will comply with the directive.


• Fourth, the person who is dying, but living in the community, may face problems in having an advance directive followed if a crises occurs and emergency medical services are called (i.e. “911”). EMS personnel are generally required to resuscitate and stabilize patients until they are brought safely to a hospital.


Myth #9

If I do not have an Advance Directive, I can rely

on my family to make my health care decisions

when I am unable to make decisions for myself.

• If an individual does not have an advance directive naming a health decisions agent, several states expressly designate default “surrogates,” typically family members in order of kinship, to make some or all health care decisions.


• Even without such statutes, most doctors and health facilities rely on family involvement in decision making, as long as there are close family members available and there is no disagreement.

• Problems can arise because family members may not know what the patient would want in a given situation, or they may disagree with one another about the best course of action.


Myth #10

Advance Directives are a legal tool for old people.

• One should never think of this as an “old” people’s issue. It may be natural to link death and dying issues with old age, but that is a mistake when it comes to advance directives.

• Consider that stakes are actually higher for younger persons in that, if tragedy strikes, they might be kept alive for decades in a condition they would not want. An advance directive is an important tool for all.

Advanced Directives

What follows are question and answer discussions designed to help students prepare for the final exam:

Advanced Directives

1. The PIC form is a temporary record which may be changed:

A. True

B. False

True. PIC forms are never set in stone and everyone or their applicable representative has a right to change the contents whenever he or she feels it’s necessary. Remember, PIC forms are different from the “legalized” Advance Health Care Directive and Living Wills.

Advanced Directives

2. The General Power of Attorney covers financial as well as medical issues.

A. True

B. False

False. The General Power of Attorney is not designed to address medical issues. For Healthcare, the Advance Healthcare Directive must be obtained.

Advanced Directives

3. The term “full code” means:

A. Comfort care

B. All efforts exhausted to save a patient

C. No CPR status

D. CPR only

B. If one chooses full code, he or she is requesting CPR, Tube Feeding, IV’s, “the whole enchilada.”

Advanced Directives

4. Changing an Advance Directive:

A. Is never possible.

B. Is possible assuming the patient is of

sound mind.

C. Can only be done by a lawyer.

D. Requires court appearances.

B. The patient and only the patient can change an advance directive, but for this to be a valid change, there must be a physician's order stating “has capacity”.

Advanced Directives

5. The best time to form an Advance Directive is:

A. When one develops a terminal disease

B. When one enters a Nursing Facility for LTC

C. As soon as one is legally able to do so

D. When a family is in dispute over future

healthcare decisions

C. Advance Directives can be done by individuals as young as 18. Never wait for a dispute among family or the development of a terminal disease.

Advanced Directives

6. Without specific instructions, medical staff are trained to resuscitate any individual who stops breathing.

A. True

B. False

True. Medical staff must by law assume that a patient is full code unless otherwise specified. Another reason why an Advance Directive is so important.

Advanced Directives

7. Written Advance Directives are not legal in every state.

A. True

B. False

False. An Advance Directive written in one State will be honored by another State. Creating a new Advance Directive is not necessary.

Advanced Directives

8. When forming an Advance Directive, one should always:

A. Consult an Attorney.

B. Check with applicable State laws.

C. Name a decision maker who can be trusted.

D. Both B & C

D. Some States regulate the Advance Directive document differently than others. A trusted decision maker is essential, this is usually a family member, a close friend may also qualify.

Advanced Directives

9. Death and Dying should always be linked to old age:

A. True

B. False

False. Death and Dying is a broad concept and covers any age group including infants, young adults and the elderly. Another reason why the Advance Directive should be formed as soon as possible.

Advanced Directives

10. In most States, if a Physician or facility refuses to honor an Advance Directive based on “conscience,” State law permits this is:

A. The policy is stated at time of admission.

B. The patient is in agreement.

C. The Physician or facility redo the Advance

Directive with the patient and/or family.

D. State laws never permit this, all must follow

the Advance Directive as written.

A. The facility must note this in their admission agreement, otherwise they must always default to the patient’s Advance Directive.

Quiz

You’re Done!!!To successfully complete this course, please take the

following final examination.

You must pass with a 70% or better to receive your certificate of completion and granted CEU.

Advanced Directives

Healthcare

Transcript of Advanced Directives