1

Advance Directives

Ethics Champions ProgramJune 4, 2008

John F. Wallenhorst, Ph.D.Vice President, Mission & Ethics

Bon Secours Health System

2

Case Study – Mr. Smith 91 year-old man with moderate dementia Has an advance directive; does not want

extraordinary interventions Has pneumonia that will require short hospital

stay, and short-term feeding tube and IV for antibiotics

3

Immediate Context Patient Self-Determination Act, 1991 Rights:

Participate in and direct their own health care decisions Accept or reject medical or surgical treatment Prepare an advance directive Information on provider’s policies related to these rights

Also: Must document patient’s wishes and information Must educate

4

Foundations – Catholic Tradition

Dignity of the Person The Human Story: The role of life and death Community Justice Subsidiarity Proportionality Benefit/burden

5

Advance Directives Basics

Written document of person’s wishes for treatment or non-treatment

Only a competent person may create Only takes effect when person does not have the

capacity to make a medical decision Two forms:

Living WillDurable Power of Attorney for Health Care

Condition for participating in Medicare/Medicaid

6

What does it address?

Clarity about wishes Avoiding specific types of treatment Helping family with issues related to continuation and

termination of treatment

7

What does it not address?

Appointed agent who cannot follow patient’s wishes Physicians who are unwilling to stop treatment Physicians who believe that Advance Directives are

only for dying patients Family conflict Loss of meaning; loss in general Grief

8

Still need

Ongoing care planning process

DNR orders, if applicable

Conversations about end of life care

9

“Five Wishes” Program

Aging with Dignity National nonprofit since 1996 Tallahassee, FL “Five Wishes” Program Robert Wood Johnson Grant Source: http://www.agingwithdignity.org/5wishes.html

10

“Five Wishes”

1. Which person you want to make health care decisions for you?

2. What kind of medical treatment you want or don’t want?

3. What sort of comfort measures do you want?

4. How you want people to treat you.

5. What you want your loved ones to know?

11

“Five Promises” Program

LaCrosse Experiment Wisconsin Collaborative, 1991 “Respecting Choices” Program New Hampshire, North Carolina, South Carolina Source: http://www.gundluth.org/eolprograms

12

“Five Promises”

1. We will initiate the conversation

2. We will provide assistance with advance care planning

3. We will help make sure your plan is clear

4. We will maintain and retrieve your plan

5. We will appropriately follow your plan

13

Not About “Getting it Right”

Can Cause Harm:Patients and families feel betrayedHealth professionals feel pressured to “interrogate”Patients and families feel stigmatized if they do not want

to participateDifficulty of applying in clinical setting

Alternative Approach:Spiritual-Existential OrientationHospitality, privacy and calm“L’entourage” – circle of significant others

D. Barnard, “Advance Care Planning Is Not About ‘Getting it Right.’” Journal of Palliative Care, Vol 5. 2002.

14

Beyond Advance Directives

Some Issues:Approaching the matter of complianceComplexity of applying in real-time decision makingEvaluating impact on use of resourcesState variations; application of Catholic tradition

Increased focus:Advance care planningDiscussions about incapacity and deathSolidifying personal relationships

15

Conclusion

Revisiting Mr. SmithWhat are the relevant issues?What are the possible ethical concerns?What is the best approach?

16

Questions & Conversation