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Effective Planning for Health Care Decision-Making at the End of Life American Bar Association Revised 2007

Effective Planning for Health Care Decision-Making at the End of Life American Bar Association Revised 2007. The Legislative Landscape of Surrogate Decision-Making. Default Surrogate Laws Health Care Advance Directives Health Care Durable Powers of Attorney Living Wills

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Effective Planning for Health Care Decision-Making at the End of Life American Bar Association Revised 2007

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  1. Effective Planning for Health Care Decision-Making at the End of Life American Bar Association Revised 2007

  2. The Legislative Landscape of Surrogate Decision-Making • Default Surrogate Laws • Health Care Advance Directives • Health Care Durable Powers of Attorney • Living Wills • Mental Health Advance Directives • Out-of-Hospital DNR Laws • Organ Donation Laws • Guardianship Laws • Physician Assisted Suicide (Oregon)

  3. Why Advance Directives Do Not Work as Well as Hoped A great idea but: • Most people don’t complete • Standard forms do not provide much guidance • People who name an agent seldom explicitly explain their wishes • People fail to let health care providers know about the directive • Directives, when they exist, often are not in medical record • When the directive is in the record, it often is not consulted.

  4. Starting Point:What Advance Directives Cannot Do They cannot: • Provide cookie-cutter directions • Change fact that dying is complicated • Eliminate personal ambivalence • Serve as a substitute for discussion • Control health care providers

  5. What Advance Directives Can Do • Serve as an integral, important part of advance planning communication • Encourage discussion as these directives are less about specific medical decisions and more about values and priorities • Empower and give directions that reflects the patient’s voice

  6. How to Select a Proxy • Name one person • Have a back-up choice • Evaluate potential proxies based on: • Meeting legal criteria in your state • Willingness to speak on your behalf • Ability to act on your wishes, not theirs • Located near by or able to travel to you • Knows you and what is important to you • Available into the future • Willing to serve as a strong advocate with physicians and medical staff ?

  7. Scope of Proxy’s Authority or Discretion • Be explicit to maintain clarity on your wishes • Provide details on level of discretion for proxy. For example, do you want proxy to be able to override written instructions

  8. Scope of Authority Consider giving express authority to: • Make anatomical gifts, autopsy, disposition of remains • Contract for, hire, fire health care and support personnel • Change domicile • Execute releases and waivers • Institute legal action on your behalf • Consent to experimental treatment • Delegate decision-making during absence • Care for pets • Determine visitation policy • Make mental health decisions • Coordinate authority with person who holds Durable Power of Attorney for property

  9. Other Questions • When does the proxy document take effect? • Who determines decision-making capacity? • What specific treatment instructions should be included? • Medical history • Values history • Impact of secondary illnesses

  10. Other Points • Describe level of pain control • Designate primary physician • Provide for pets • Discuss emotional and environmental needs • Consider Five Wishes, a living will recognized in 40 states

  11. Five Wishes • The person I want to make health care decisions when I can’t • The kind of medical treatment I want or don’t want • How comfortable do I want to be • How I want people to treat me • What I want my loved ones to know www.AgingwithDignity.org

  12. Communicating After completing your advance directive, • Tell you family and friends • Talk with your physician or agent • Consider a wallet card • Register your advance directive with one or more: • Your state • www.USLivingWillRegistry.com • www.Docubank.com • Full Circle Registry: www.protectedlivingwill.com • www.NationalLivingWills.com • America Living Will Registry: www.ALWR.com

  13. When to Review your Choices Review when any of the 5 Ds occur: You reach a new DECADE You experience a DEATH of family or friend You DIVORCE You receive a new DIAGNOSIS You have a significant DECLINE in your condition

  14. HIPAA Issues Access to protected health information by: RelationshipStatus • Agent under health care DPANot a problem durable power of attorney • Putative agent under springing powerProbably a problem • Close family member Probably a problem www.hhs.gov/ocr/hipaa

  15. Physicians Orders for Life-Sustaining Treatment (POLST) Standardizing patient communications = advance directive Standardizing physicians end-of-life orders = POLST Oregon’s POLST requires: • Physician to ask about patient’s wishes re: CPR, care goals (comfort vs. treatment), antibiotics, nutrition and hydration • Physician to translate wishes into orders on distinct (bright pink) file cover sheet • All providers must ensure form travels with patient. www.ohsu.edu/ethics/polst/

  16. Advance Planning Summary • Create your own directive: • Complete values worksheet • Consider different versions of advance directives accepted by your state • Talk to lawyer, proxy and physician • Explain your viewpoints to lawyer, proxy and physician • Periodically review the 5 Ds

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