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A brief introduction as to the importance of understanding “Advanced Directives.” It is not just the signing of the form and getting two friends to witness. It is understanding “Ethical” issues like what our moral issues and obligations are. It not only addresses your values and views about your health and end-of-life issues. It also addresses your family’s interpersonal relations and addresses the big picture of its impact both logistically and financially- on the “Healthcare” of our nation. We spend millions of dollars on the people who linger on sometimes for years who are either brain dead or in a vegetative state. This is not primarily an issue of seniors, but it is of all age groups.

This whole concept of addressing end-of-life issues is gradually changing. Prior to 1990, when the Supreme court enacted the “Patients self- determination Act,” patients and their families could not decide how they should be treated at the end-of-life. During the past 30 years, our thinking is changing, and most of our placing in writing the “advanced directive.” As we go forward in the next 10 to 20 years, we will be seriously thinking about “Physician-assisted suicide” and “Euthanasia.” Nearly nine states have legally enacted and approved “Physician-assisted suicide.

Death with Dignity!�Let your wishes be known!�Complete your Living Will!� 

Advance Directives and Living Wills:

Making sure your wishes are honored for end-of-life care

Types of Advance Directives

• Durable Power of Attorney for Health Care/Appointment of Health Care Agent
• Living Will/Advance Care Plan
• POST (Physician’s order of scope of treatment)form/ Universal DNR

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Five Reasons Why You Need A Living Will

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Many people think that

“ Living will” is not something they need unless they reach senior citizen age. Life is unpredictable and often uncontrollable which is enough reason for adults of any age to invest in a “Life will” in order to protect themselves when bad fortune arises.

1.  Protects You When You No Longer Can Communicate

The most advantageous part of having a living will is that it protects you in a future situation in which you no longer can communicate your wishes.

2.  Prevents Major Arguments Between Family Members

Having a living will prevents major arguments between family members This is the last thing you want happening during such a tough and difficult time. With a living it will be your choice and no one else's. This will eliminate any argument or debate as to what should happen to you.

3.  Gives You Control Over Medical Treatments/Procedures

A living will also give you control over what medical treatments and procedures take place. In this situation a living will orders doctors to fulfill your wishes in writing. This way you take the decision out of their hands.

4.  Reduce Potentially Unwanted Medical Bills for Your Family

. The reason being is because if they are on life support it will rack up enormous medical bills in which their family will have to pay.

5.  Gives You Peace of Mind

Last of all, making out a living will give you peace of mind. These are designed to give you the control to prevent more bad things from happening in tragic

Terri Schiavo, a 41-year-old Florida woman who had a cardiac arrest at home was in a persistent vegetative state for the 15 years before her death on Mar. 31, 2005, was at the center of a political, legal and media tempest over the removal of a feeding tube.

Karen Ann Quinlan:After consuming alcohol and sedative this 21-year-old stopped breathing and lapsed into a coma. After five months, doctors diagnosed Quinlan as being in a persistent vegetative state; her parents, who believed there was no chance of her returning to consciousness requested that Quinlan be disconnected from the life sustaining machines. When her doctors refused, they took the case to court — in what became one of the first "right to die" case in U.S. legal history. Court ruled that she should be taken off life support. Her story made headlines and provided the groundwork for numerous similar cases. But Quinlan's story didn't end there: weaned from the respirator, she survived for nearly 10 more years, dying of pulmonary failure on .

Nancy Cruzan

Eight years after the auto crash that left her in a vegetative state, six months after the United States Supreme Court's ruling on her right to die and 12 days after her parents won their fight to remove the feeding tube that was keeping her alive, Nancy Beth Cruzan died at the age of 33 .

Miss Cruzan's case became the centerpiece of a bitter debate about how and when families can decide to withdraw nourishment or medical treatment to bring about the death of an incapacitated loved one.

The U.S. Supreme Court case of Nancy Cruzan

not only changed the path of the Cruzan family;

it also resulted in the Patient Self-Determination Act (1990)

Act that affirms the rights of adults in the United

States regarding their healthcare wishes. Specifically,

adults with capacity:

• May choose or refuse any medical or

surgical procedure,

• May make advance directives and transfer their

decision-making authority.

Durable power of attorney for healthcare�Also known as�Healthcare Agent

Who makes the decision about your Healthcare?

• You will the primary decision maker for your healthcare, however you need to express ahead of time to your family, healthcare providers, close friends etc.
• You will have put this in writing and witnessed by two people.
• If you are not capable of making this decision, then you need to appoint a “Healthcare Agent” who will make decision at that time.

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CARING CONVERSATIONS

As you begin to think about who you want to speak for you, think of the following:

• Reflect – on your personal experiences, values, desires and preferences.
• Talk – to the person you are considering as your Agent.
• Appoint – the person who will speak for you when you cannot speak for yourself using the Durable Power of Attorney for Healthcare Decisions.
• Act – by sharing your decisions about your healthcare preferences with family, friends, healthcare providers, clergy or attorneys if desired and reviewing your preferences on a regular basis.

What your Agent should know about you

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• When – they will have the power to act as your Agent,
• How – he or she can be your voice when you cannot speak for yourself, and
• What – your Agent needs to know about you, your values and your current health status.

When you are ready, take the time to write out your

thoughts. It will be helpful when you talk

about your ongoing and future healthcare wishes with

family and friends:

1. What concerns do you have about making decisions for yourself later in your life? Are there certain relationships

that concern you? Are you worried about being a burden to someone? How do you feel about others, especially loved ones, caring for you?

2) What concerns do you have about your health or future healthcare?

3)Where do you want to receive care? What are your preferences and expectations about being cared for at home

or another location?

4)Who do you want to be with you? Who do you want to talk to?

Which group are you in?

Important consideration of aligning with one group or another is whether a person’s illness is reversible or irreversible.

• Group A: Some people say the only way they want to die, even if their condition is irreversible, is with aggressive maximum medical intervention. (Do everything!)
• Group B: Some people say that aggressive intervention is only for reversible conditions. If they were not getting better with a particular intervention they would not want to continue it.
• Group C: Some people feel strongly that they do not want any forms of artificial life support under any circumstance.

In which Group (A, B or C) would you put yourself? What do you want your agent and your loved ones to know about your choice?

Defining some important terms

• Brain death: Irreversible cessation of all functions of the entire brain, including the brain stem. A person who has brain death is dead, with no chance of revival.
• Coma: A state of profound unresponsiveness because of severe illness or brain injury. Patients in a coma do not open their eyes or speak, and they do not exhibit purposeful behaviors. Some patients need ventilators while others do not.. In general, comas last just a few days or weeks. Patients either die or regain consciousness, or in some cases progress to a vegetative state.
• Vegetative state: The person has depressed consciousness, brain stem function and can breathe without support. Patients in a vegetative state may respond to pain or loud sounds, go through sleep-wake cycles, and exhibit involuntary motions. A person in a vegetative state for more than a year is considered to be in a permanent vegetative state with extremely low chance of recovery.

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More terms

• Patients self-determination Act (1990) also known as “Right to Die.”
• Withholding and Withdrawing (Pulling the plug) life supporting treatment.
• Physician assisted suicide.
• Euthanasia
• Reversible and Irreversible

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Tennessee Law

• Effective May 9, 2017, the Advance Directive for Health Care form has combined the content of the “Living Will” or “Advance Care Plan” and “Medical Power of Attorney” or “Appointment of Health Care Agent” into one model form adopted by the Board for Licensing Health Care Facilities.

Advance Directives are your written wishes about what you want to happen, if you get too sick to be able to say. Advance directives addresses issues regarding the use of life-saving machines and medicine those keep people alive when they otherwise might die.

A Living Will or Advance Care Plan needs to be filled out while you can still think for yourself. These papers tell your friends and family what you want to happen to you, if you get too sick to be able to say. Your papers have to be signed, and either witnessed or notarized.

If your papers are witnessed, your papers need to be signed in front of two people who will be your witnesses. These people:  One of these people cannot be related to you by blood or marriage.

 Cannot receive anything you own after you die.

 Cannot be your doctor or any of the staff who work in the place where you get health care. Once they are signed by everyone, it is your rule. It stays like this unless you change mind.

If you fill out these papers, make 3 copies:  Give 1 copy to your Primary Care Provider to put in your medical file.  Give 1 copy to the person who will make a medical decision for you.  Keep a copy with you to put with your important papers. Important! You do not have to fill out these papers. It is your choice. You may want to talk to a lawyer or friend before you fill out these papers.

Part 2 Indicate Your Wishes for Quality of Life: By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an unacceptable quality of life).

� Yes or No. Permanent Unconscious Condition: I become totally unaware of people or surroundings with little

chance of ever waking up from the coma.

 Yes or No. Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.

 Yes No. Dependent in all Activities of Daily Living: I am no longer able to talk or communicate clearly or move

by myself. I depend on others for feeding, bathing, dressing, and walking. Rehabilitation or any other

restorative treatment will not help.

 Yes No. End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment.

Examples: Widespread cancer that no longer responds to treatment; chronic and/or damaged heart and

lungs, where oxygen is needed most of the time and activities are limited due to the feeling of suffocation.

POST FORM

Physician Order of Scope of Treatment

How does this affect me?

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How POST form came about?

• Tennessee needed one form to address DNR and other resuscitative services
• Tennessee needed one form utilized by all healthcare entities in the state i.e. EMS, Nursing Homes, Hospitals, etc.
• Tennessee needed a universal form which could travel and be recognized across state lines

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Purpose of POST

• To provide a mechanism to communicate patients’ preferences for end-of-life treatment across treatment settings

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• To improve implementation of advance care planning

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Basis of POST

Encourages discussion with patient and family or surrogate decision maker of key end-of-life care issues

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Impact of Tennessee Law

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• Acknowledged “Universal Do Not Resuscitate Order”
• Means a written order that applies regardless of the treatment setting and that is signed by the patient’s physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted.

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• The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative services from patients

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T.C.A. 68-11-224 (e), (5) & (i), (1)

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What is POST?

• POST – Physician Orders for Scope of Treatment
• What purpose POST form serves
• Standardized form containing orders by a physician who has personally examined a patient regarding that patient’s preferences for end-of-life care
• Complements, but does not replace Appointment of Health Care Agent &/or Living Will/Advance Care Plan
• Effective immediately upon order written and when all requirements met
• Requirements for valid POST:
• Patient’s name and signature (Patient signature optional according to facility policy)
• Orders
• Physician’s signature (MD/DO)
• Basis for orders

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POST Description cont.

• POST Format cont.
• CPR: Code or No Code?
• Level of intervention (i.e. comfort measures, limited additional interventions, and full tx)
• Comfort care level stipulates: “Not to be hospitalized unless comfort interventions in the present setting fail” – as applicable to the facility /resident patient is located in.
• Use or withholding of antibiotics, IV fluids, and feeding tubes

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Tennessee Physician Orders for Scope of Treatment

(POST, sometime called “POLST”)

Section A Check One

CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.

 Resuscitate (CPR)  Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)

When not in cardiopulmonary arrest, follow orders in B, C, and D.

Section B

Check One Box Only

MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.

 Comfort Measures Only. Relieve pain and suffering through the use of any medication by any route,

positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway

obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer

only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through

symptom management.

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• POST Format cont. Section B:
• Medical Interventions�Comfort Interventions: Treat with dignity and respect. Keep clean, warm, dry. Use medication by any route, positioning, wound care & other measures to relieve pain/suffering. Use oxygen, suction, manual tx of airway obstruction as needed for comfort. Do not transfer to hospital for life sustaining tx. Transfer only if comfort needs cannot be met in current location.
• �Limited additional Interventions: Includes care described above. Use medical tx, IV fluids and cardiac monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care.

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POST Description cont.

• POST Format cont.
• Check 1 box each section

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• SECTION A: Code Status
• Resuscitate or …
• Do Not Attempt Resuscitate

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If neither is marked, patient is to be resuscitated

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POST Description cont.

• POST Format cont.
• Full TX: All above plus CPR, intubation, defibrillation
• Other instructions_______________

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POST Description cont.

• POST Format cont.
• Section C: Antibiotics
• Treatment for new medical conditions
• No antibiotics
• Antibiotics
• Other instructions____________

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POST Description cont.

• POST Format cont.
• Section D: Medically Administered Fluids & Nutrition
• No IV fluids
• IV fluids for a defined trial period
• IV fluids long term
• No feeding tube
• Feeding tube for a defined trial period
• Feeding tube long term
• Other instructions__________

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Impact of Tennessee Law

• Acknowledged “Universal Do Not Resuscitate Order”
• Means a written order that applies regardless of the treatment setting and that is signed by the patient’s physician which states that in event the patient suffers cardiac or respiratory arrest, cardiopulmonary resuscitation should not be attempted.
• The law also indicated the Board for Licensing Health Care Facilities shall promulgate rules and create forms regarding procedures for the withholding of resuscitative services from patients

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T.C.A. 68-11-224 (e), (5) & (i), (1)

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• POST Format cont.
• Where does the Physician Sign?
• Section E:
• By a physician who has examined the patient (Mandatory)
• Discussed with….
• Physician’s printed Name/Phone #
• Basis for Orders
• Patient’s preferences
• Patient’s best interest (Patient lacks capacity or preferences unknown)
• Medical indications
• Other (specify)

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