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What you will learn in this class:. Bioethics/Laws Advance Care Planning Completing an Advance Health Care Directive Choosing a health care agent Advance Directive vs. Physician Orders for Life-Sustaining Treatment (POLST). Common Questions. What is Advance Care Planning?
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What you will learn in this class: • Bioethics/Laws • Advance Care Planning • Completing an Advance Health Care Directive • Choosing a health care agent • Advance Directive vs. Physician Orders for Life-Sustaining Treatment (POLST)
Common Questions • What is Advance Care Planning? • How do I complete an Advance Health Care Directive? • How do I go about making such important decisions?
Ethical Duties that Guide Medical Decision Making: • Respect for Persons “autonomy” • Do no harm • Provide Benefit • Fairness
Laws Federal Law: Patient Self-Determination Act of 1991 • Patients right to accept/refuse treatment • Upholds the right to create advance directives California Rights: CA Health Care Decisions Law: AB 891 • The law includes a form-Advance Health Care Directive
Advance Health Care Directive A form you complete that states your desires and beliefs about treatment which includes: • Who will make health care decisions for you • Your beliefs about organ donation • The name of your primary physician • Person completing the advance directive must be: • a California resident • at least 18 years old • of sound mind
When Is Your Advance Directive Activated? When a patient loses “decisional capacity” • Ability to understand • Ability to organize information • Ability to communicate a response • Ability to deliberate according to one’s belief system, values, and attitudes
Advance Care Planning Continuum Age 18 Complete an Advance Directive C O N V E R S A T I O N Update Advance Directive Periodically Diagnosed with Serious or Chronic, Progressive Illness (at any age) Complete a Physician Orders for Life-Sustaining Treatment (POLST) Form End-of-Life Wishes Honored
What is POLST? Physician Order for Life Sustaining Treatment recognized throughout the medical system • Brightly colored, standardized form for entire state of CA • Portable document that transfers with the patient • Provides direction for a range of end-of-life medical treatments
5 “D’s” to Update an Advance Directive When you… Divorce reach a new Decade receive a new Diagnosis have a Decline in your condition experience a Death of a close relative or friend
Complete Advance Directive • The doctor will provide you with all the information necessary to make an informed treatment decision • You should know about your disease process and longevity • What to expect with or without treatment
Complete Advance Directive“Advance Medical Directives” - Staywell Company
Who is the best Health Care Agent for Me? Someone who: • I trust to carry out my wishes • is emotionally stable • is an effective communicator • REALLY knows me and can support my treatment choices Your agent cannot be: • your doctor or health care provider • an employee of your doctor/hospital/ nursing home unless related
Health Care Agent Duties/Obligations To ensure that your medical treatment wishes are followed using two standards: • “substituted judgment” decided as YOU would decide • “best interests assessment” if your wishes are unknown, agent needs to consider your beliefs and what is important to you • quality of life • extent of suffering • prognosis
Can: choose life-sustaining and other treatment for you refuse life-sustaining and other treatment for you agree that a treatment you are having should be stopped access and release your medical records request an autopsy donate your organs (unless stated otherwise) Cannot: commit you to a psychiatric hospital agree to electric shock treatment consent for psychosurgery consent for sterilization consent for abortion Health Care Agent Duties/Obligations
Cure of disease Avoidance of premature death Maintenance or improvement in function Prolongation of life Relief of suffering Quality of life Staying in control A good death Potential Goals of Treatment
Expectations / Quality of Life • A treatment can produce an effect, but, is it providing what I believe to be a benefit? • Contributing to a life that I deem acceptable?
(DNR)Do Not Resuscitate Orders A medical order to refrain from CPR if your heart stops beating -- it does not mean that other treatments will be stopped CPR will be attempted unless there is a DNR order in your medical chart
Why Choose DNR? • When CPR won’t restore function of heart or lungs • When death is expected due to irreversible medical condition • terminal illness • permanent unconsciousness • irreversible organ failure with survival not likely
Palliative Care/ Hospice • Pain/ symptom control • Spiritual Care • Psychosocial Care
Procedures to restart the heart and breathing, like mouth-to-mouth resuscitation, external chest compressions, electric shock, insertion of tube to open airway, injection of medication into the heart, open chest heart massage Cardiopulmonary Resuscitation
Pressors • Medicines that control one’s blood pressure • Use of pressors in the ICU is generally for making blood pressure go up • What are the benefits of pressors? • What are the burdens of pressors?
Quality of Life/ Values • What do you fear most about illness? • How would you feel if you lost your independence? Mental alertness? Physical abilities? Financial independence? • How would you feel if you could not engage in the activities you enjoy? • How would you feel if you could not interact with the people you love? • How do you feel about being cared for in a nursing home?
Beliefs • What are your beliefs about life and death? • Does your religion, culture, spiritual beliefs strongly guide you in decisions about life and death? • What role do pain and suffering occupy in your life? • What is the role of medical technology in prolonging life?
What you learned in class: • Bioethics/Laws • Advance Care Planning • Completing an Advance Health Care Directive • Choosing a health care agent • Advance Directive vs. Physician Orders for Life-Sustaining Treatment (POLST)
Now What do I Do? • Discuss with your primary doctor and/or specialist any questions, worries, issues about your health before you fill out your advance directive • Discuss your wishes and advance directives with your surrogate(s) and close family members, ensuring that they can and will follow your wishes in the event you cannot speak for yourself • Fill out the directive
Now What do I Do? • Sign and date it before 2 witnesses or a notary public • Make copies for yourself, your surrogate (s), your doctor, your family, your lawyer - keep original in an accessible place (not a safe-deposit box) • Mail your form to: Kaiser Medical Office Records 7385 Mission Gorge Road San Diego, CA 92120
Kaiser Permanente Resources • KP Web Site www.kp.org • http://www.permanente.net/homepage/kaiser/pdf/44666.pdf • www.kp.org/healthylifestyles(personalized programs for weight loss, smoking cessation, stress reduction, nutrition) • Healthier Living Class 619-641-4194 • Positive Choice -Weight Mgmt. 858-573-0090 • Health Education - Quit Smoking Program & many other programs for health and well-being 619-641-4194
Paula Goodman-Crews, M.S.W., L.C.S.W. Medical Bioethics Director Kaiser Permanente, San Diego voice-mail: 619-528-5213
Michael Markman MD Division of Pulmonary/Critical Care Medicine Kaiser Permanente, San Diego