1. Advance Directives Ethics Champion Program Carol Bayley, PhD VP Ethics and Justice Education Catholic Healthcare West

2. (add poll) How many of you have an advance directive? • Living will • Durable Power of Attorney for Health Care • I don’t have an advance directive

3. What percentage of Americans have an advance directive? • 38% • 20% • 15% • 6%

4. Which federal law authorizes advance directives? • 1976 Quinlan (U.S. Supreme Court) • 1989 EMTALA • 1991 Patient Self-Determination Act • No federal law; advance directives are regulated by the states

5. Which does the law NOT require: • Hospital patients must be advised that they can refuse treatment • Patients must be advised that they can make an advance directive • Nursing home patients must make an advance directive witnessed by an ombudsperson.

6. Who can create an advance directive? • Only the patient’s physician • Any person • Any person with capacity to make medical decisions

7. Advance Directives 101 • Written document of person’s wishes for treatment or non-treatment • Two forms • Living Will • Durable Power of Attorney for Health Care • Only a competent person may create AD. • Only takes effect when the patient does not have capacity to make a medical decision. • One of the conditions of participation in Medicare/Medicaid for hospitals and nursing homes

8. What about witnesses? • Two witness; at least one of them must not be related to the person (by blood, marriage, or adoption—it’s about the estate…) • Witnesses only attest identity of person creating AD; can be total strangers • In nursing home, ombudsperson must also sign

9. What problems can an Advance Directive solve? • Family does not know how long to continue treatment • Family feels guilty about terminating treatment • Patient wished to avoid specific types of treatment

10. What problems ADs cannot solve • Appointed agent who cannot follow patient’s wishes • Dysfunctional families (!) • Doctors who only stop when they think further treatment is useless • Doctors who believe ADs are only for dying patients

11. More things ADs won’t solve • The difficulty of value -laden decisions under conditions of uncertainty • Loss of meaning; loss in general • Grief

12. Advance Directives are not a substitute for • Care plans to carry forward a patient’s goals for treatment • DNR orders • Family conversation about end of life care