An Advance Directive in Seven Steps

IntroductionThe Gift Initiative is a community education

collaborative in Tennessee led by Alive Hospice with partners from Vanderbilt University, Saint Thomas

Health, PearlPoint Cancer Support and a growing list of individuals who recognize the critical need for

education about advance planning for serious illness and end-of-life care. Alive Hospice is grateful for the generosity of HUMANA for their recognition

of the serious need for better and earlier communication between patients, families, and

health care providers.

Why is it a “Gift” to discuss and plan for end-of-life care?

What is an Advance Directive and who should have one?

What forms are involved, where do I get them, and will I need a lawyer to complete them?

Step 1:What Constitutes an Advance Directive?

• The Advance Care Plan • The Appointment of Health Care

Agent• Both forms can be found on The Gift

Initiative Website or at www.Alivehospice.org

Advance Care Plan

Health Care Proxy

Step 2:Personal Reflection Exercise

Personal ReflectionExercise

• Three things I value most about my life are:

• I hope that between now and the time when I die,

I will have a chance to:• When I hear the phrase “good death”, I

think of: When I hear the phrase “bad death”, I think of:

• The thing I worry about most when I imagine dying is:

• I hope that when I am near death, I will:

Step 3:Appointment of Health Care Agent

• Formerly “Durable Power of Attorney for Health Care” Changed in 2004.

• A Health Care Agent (also known as a Health Care Proxy) is the person appointed by a competent adult to make health care decisions on their behalf in the event that one becomes unable to make and/or communicate decisions themselves.

Choosing your Health Care Agent

• Your Health Care Agent should be someone who will be able to clearly communicate your wishes.

• Do not assume that because a person is your next of kin that they are necessarily best suited to serve as your agent.

• Do not assume that because a person knows you well, and agrees to be your agent that they “know” exactly what you would want.

• Completing the form is not enough, CONVERSATIONS ARE VITAL!

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] [No] Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma

[Yes] [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 Illness: 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 or lungs, where oxygen is needed most of the time and activities are limited due to the feeling of suffocation.

Step 4:Discussion of Quality of Life

Step 5:Discussion of Treatment Options

If my quality of life becomes unacceptable to me and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. Checking “yes” means I WANT the treatment. Checking “no” means I DO NOT want the treatment.[Yes] [No] CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore

breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.

[Yes] [No] Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys and other organs to continue to work.

[Yes] [No] Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness.

[Yes] [No] Tube feeding/IV fluids: Use of tubes to deliver food and water to patient’s stomach or use of IV fluids into a vein which would include artificially delivered nutrition and hydration.

Step 6:Completing The TN Advance Care Plan• Review and discuss the forms other instructions,

such as burial arrangements, hospice care, etc.• Organ donation• Signatures:

*Note: Your signature should either be witnessed by two competent adults or notarized. If witnessed, neither witness should be the person you appoint as your agent, and at least one of the witnesses should be someone who is not related to you or entitled to any part of your estate.

• You do not need a lawyer

• Conversations are key , families and those closes to you need to understand your choices.

• Give a copy of the form to your Health Care Agent

• Discuss your wishes with your physician• Keep a copy in your personal files –What about my safety deposit box? (NO!)

• Take time to review your plan in the future, your wishes might change. You can change your plan at any time. Destroy outdated copies.

Step 7:Communication, Distribution, Review and Revision of your Advance Care Plan

Additional tools and resources