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Telling Medical Providers What to Do When You Telling Medical Providers What to Do When You Forget What You Want Them to Do: Advance Forget What You Want Them to Do: Advance

Directives & Medical Orders For Scope of Directives & Medical Orders For Scope of Treatment (MOST)Treatment (MOST)

updated 1/16/11updated 1/16/11

Community Challenge: Meeting Community Challenge: Meeting the Needs of Seniors, Providers & the Needs of Seniors, Providers &

Care GiversCare Givers

January 16, 2012January 16, 2012

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Historical PerspectiveHistorical Perspective

• 1930 – my grandfather builds the 1930 – my grandfather builds the first hospital in Wickenburg AZ first hospital in Wickenburg AZ (penicillin not discovered till 1928 (penicillin not discovered till 1928 and not available until 1941)and not available until 1941)

• 1960 – my father dies in the 1960 – my father dies in the Phoenix VA hospital of an MI at Phoenix VA hospital of an MI at the age of 43 (the first ICU was the age of 43 (the first ICU was established in 1958)established in 1958)

• 1972 – I start medical school (high 1972 – I start medical school (high tech life support now available) tech life support now available)

Dr. James Alfred Dr. James Alfred Copeland (1871-Copeland (1871-1941), circa 19371941), circa 1937

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Common Problem Case ScenariosCommon Problem Case Scenarios

• Grandpa breaks his hip.Grandpa breaks his hip.– develops pneumonia and develops pneumonia and

ARDSARDS

– aunt Lucie from California aunt Lucie from California shows up at the 11shows up at the 11thth hour hour

• Persistent Vegetative Persistent Vegetative State (PVS)State (PVS)

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PPersistent ersistent VVegetative egetative SStatetate((PVSPVS))

• due to injury of the upper due to injury of the upper brain sparing the brain stembrain sparing the brain stem

• characterized by the return characterized by the return of sleep-wake cycles and of of sleep-wake cycles and of various reflex activities, but various reflex activities, but wakefulness is without wakefulness is without awareness awareness

• can “live” for years on tube can “live” for years on tube feedings feedings

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Informed ConsentInformed Consent

• the basis for the basis for modern modern medical ethicsmedical ethics

• historically a historically a response to the response to the NuremburgNuremburg

trialstrials

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Informed Consent

• Prior to being treated:

– the patient will receive a description of the treatment to include its risks, benefits and alternatives, and

– the patient will agree to accept the treatment.

MRMC Policy

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Definition Definition of of

Decisional CapacityDecisional Capacity

1)1) the ability to the ability to comprehendcomprehend information relevant to information relevant to the treatment being offered, andthe treatment being offered, and

2)2) the ability to the ability to deliberatedeliberate in accordance with his/her in accordance with his/her own values and goals, andown values and goals, and

3)3) the ability to the ability to communicatecommunicate with care givers. with care givers.

A A patient has decisional capacity to patient has decisional capacity to consent to or to refuse treatment when consent to or to refuse treatment when the patient has:the patient has:

MRMC PolicyMRMC Policy

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Advance DirectivesAdvance DirectivesAvailable in ColoradoAvailable in Colorado

• Living WillLiving Will

• Medical Durable Power of Medical Durable Power of AttorneyAttorney

• CPR DirectiveCPR Directive

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Living WillLiving Will

• a written statement made when a a written statement made when a patient (declarant) has decisional patient (declarant) has decisional capacity which capacity which gives directions for gives directions for withholding or withdrawing certain withholding or withdrawing certain life- sustaining procedureslife- sustaining procedures when when the patient: the patient:

1)1) has a has a terminal conditionterminal condition or PVSor PVS andand

2)2) has has lost decisional capacitylost decisional capacity..

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Living WillLiving Will

• must still have 2 witnessesmust still have 2 witnesses• two physicians must certify terminal two physicians must certify terminal

condition or PVScondition or PVS• may include other instructions for care may include other instructions for care

following certification of terminal following certification of terminal illness/PVSillness/PVS

• may include a list of persons to be may include a list of persons to be notified of that certification, as well as a notified of that certification, as well as a list of persons with whom healthcare list of persons with whom healthcare providers may discuss the declarant’s providers may discuss the declarant’s condition and carecondition and care

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MMedical edical DDurable urable PPower of ower of AAttorneyttorney((MDPAMDPA))

• a written statement made when a patient has a written statement made when a patient has decisional capacity which decisional capacity which appoints specific appoints specific surrogate decision-makers (agents)surrogate decision-makers (agents)

• not limited to a terminal condition or PVSnot limited to a terminal condition or PVS• takes effect takes effect at time of signatureat time of signature or when or when

patient loses decisionalitypatient loses decisionality• witness recommended but not requiredwitness recommended but not required

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Proxy Decision-Makers Proxy Decision-Makers For Medical TreatmentFor Medical Treatment

CRS 15-18.5-103CRS 15-18.5-103

• Used to establish a surrogate Used to establish a surrogate decision maker when there is no decision maker when there is no Medical Durable Power of Attorney or Medical Durable Power of Attorney or Guardian.Guardian.

• Physician must declare that the Physician must declare that the patient has lost decisional capacity.patient has lost decisional capacity.

• Physician (or representative) contacts Physician (or representative) contacts ““interested personsinterested persons.”.”

• ““Interested persons” choose the Interested persons” choose the proxy decision-maker.proxy decision-maker.

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Colorado Designated Beneficiary Act Colorado Designated Beneficiary Act (CRS 15-22-101-111)(CRS 15-22-101-111)

• allows for two adult (over 18) persons to allows for two adult (over 18) persons to designate each other as beneficiaries of a designate each other as beneficiaries of a number of items and instruments related to number of items and instruments related to health care, medical emergencies, incapacity, health care, medical emergencies, incapacity, death, and administration of estatesdeath, and administration of estates

• the two adults cannot be married to each other the two adults cannot be married to each other or anyone else nor party to any other DB or anyone else nor party to any other DB agreementagreement

• a DB may assign the other DB the right to act as a DB may assign the other DB the right to act as a Proxy Decision-Makera Proxy Decision-Maker

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CPR Directive• A written order signed by a patient with

decisional capacity and his/her physician instructing pre-hospital emergency personnel and other providers to withhold CPR (cardiopulmonary resuscitation).

• May be signified by wearing a necklace or bracelet.

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CPRCPR Directive Directive Bracelet or Necklace Bracelet or Necklace

A unique and easily identifiable logo is engraved on A unique and easily identifiable logo is engraved on the front side of the metal bracelets and necklaces. the front side of the metal bracelets and necklaces. The The namename, , birth datebirth date, , sexsex, and , and racerace of the of the declarant are engraved on the back side along with declarant are engraved on the back side along with the words "the words "DO NOT RESUSCITATEDO NOT RESUSCITATE." Wearing a ." Wearing a bracelet or necklace is encouraged but not bracelet or necklace is encouraged but not mandatory.mandatory.

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Out-of-Hospital Out-of-Hospital CPR CPR OutcomesOutcomes

UpToDate 9/12/11UpToDate 9/12/11• ““resuscitation from out-of-resuscitation from out-of-

hospital Sudden Cardiac hospital Sudden Cardiac Arrest (SCA) is successful in Arrest (SCA) is successful in only only one-thirdone-third of patients” of patients”

• ““only about only about 10 percent10 percent of all of all patients are ultimately patients are ultimately dischargeddischarged from the hospital, from the hospital, many of whom are many of whom are neurologically impaired”neurologically impaired”

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In-Hospital In-Hospital CPR CPR OutcomesOutcomes

UpToDate 9/12/11UpToDate 9/12/11• ““the outcome of patients who experience the outcome of patients who experience

SCA in the hospital is poor, with reported SCA in the hospital is poor, with reported survival to hospital discharge rates of 6 to survival to hospital discharge rates of 6 to 15 percent”15 percent”

• ““overall survival to hospital overall survival to hospital dischargedischarge was was 15 percent15 percent””

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Nursing Home Nursing Home CPR CPR OutcomesOutcomes

Prehosp Emerg CarePrehosp Emerg Care

Apr-Jun, 1997Apr-Jun, 1997

““Outcomes of cardiac arrest Outcomes of cardiac arrest in the nursing home: in the nursing home: destiny or futility?”destiny or futility?”

• 182 182 nursing home patientsnursing home patients received CPR from July received CPR from July 1989-December 19931989-December 1993

• nonenone survived survived

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CPR Directive CPR Directive Legislative Changes 2010Legislative Changes 2010

• ANY form clearly stating refusal of CPR, signed ANY form clearly stating refusal of CPR, signed by patient and patient’s physician is valid.by patient and patient’s physician is valid.

• Even if NOT signed by physician, any form Even if NOT signed by physician, any form signed by a patient should be honored.signed by a patient should be honored.

• Copies, faxes, scans are just as valid as original.Copies, faxes, scans are just as valid as original.• Downloadable template on Iris Project and Downloadable template on Iris Project and

CDPHE Web site.CDPHE Web site.• Do Not Resuscitate Do Not Resuscitate ≠ Do Not Treat! Palliative ≠ Do Not Treat! Palliative

care should always be provided.care should always be provided.

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MMedical edical OOrders for rders for SScope of cope of TTreatment reatment ((MOSTMOST))

• A document that consolidates and summarizes patient A document that consolidates and summarizes patient preferences for key life-sustaining treatments. preferences for key life-sustaining treatments.

• Persons may refuse treatment, request full treatment, or Persons may refuse treatment, request full treatment, or specify limitations.specify limitations.

• It is primarily intended to be used by the chronically or It is primarily intended to be used by the chronically or seriously ill person in frequent contact with healthcare seriously ill person in frequent contact with healthcare providers, or already residing in a nursing facility.providers, or already residing in a nursing facility.

• Translates patient preferences into physician’s orders.Translates patient preferences into physician’s orders.• ““Travels” with the patient and is honored in any setting: Travels” with the patient and is honored in any setting:

hospital, clinic, day surgery, long-term care facility, rehab hospital, clinic, day surgery, long-term care facility, rehab facility, hospice, or at home. facility, hospice, or at home.

• Prompts patients and providers to regularly review, Prompts patients and providers to regularly review, confirm, or update choices based on changing conditions.confirm, or update choices based on changing conditions.

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MOSTMOST Orders Orders

1.1. CPRCPR

2.2. Medical Intervention & Transfer re Medical Intervention & Transfer re Comfort Measures Only Vs. Full Comfort Measures Only Vs. Full TreatmentTreatment

3.3. Antibiotic UseAntibiotic Use

4.4. Artificially Administered Nutrition & Artificially Administered Nutrition & HydrationHydration

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Practical SuggestionsPractical Suggestions

• Consider Consider Five WishesFive Wishes – it – it incorporates a Living Will and A incorporates a Living Will and A Medical Durable Power of Attorney.Medical Durable Power of Attorney.

• DiscussDiscuss your Advance Directives your Advance Directives with close friends and family – with close friends and family – especially with the agent(s) especially with the agent(s) designated in your Medical Durable designated in your Medical Durable Power of Attorney.Power of Attorney.

• Talk to your Talk to your physicianphysician if you are if you are considering a considering a CPR DirectiveCPR Directive..

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Iris ProjectIris Project

• http://www.irisproject.net/linksandresources.html

• website contains great sample forms and website contains great sample forms and educational materials from Colorado educational materials from Colorado Advance Directives ConsortiumAdvance Directives Consortium