Advance Directives Medical Orders For Scope of Treatment MOST

1. Advance Directives &Medical Orders For Scope of Treatment (MOST) Falls Creek Homeowners Association October 29, 2010

2. Hippocratic Oath honor teachers and their children benefit patients no deadly medicine no abortion abstain from mischief and corruption abstain from the seduction of patients – female or male keep secret whatever seen or heard in connection with professional service Tuskegee 1939-1973 An agency of the US Public Health Service which later became the CDC “untreated syphilis in the negro male” Quinlan 21 years old - collapsed after swallowing alcohol and tranquilizers at a parts PVS family went to court to remove ventilator Supreme Court appointed father as guardian & told docs and family to consult with the institutional Ethics Committee food and fluids continued died 10 years after removal of “life support” Cruzan automobile accident 1983 PVS no ventilator but food & fluids family went to court to stop food & fluids feeding stopped in 1990 & patient died within the month Hippocratic Oath honor teachers and their children benefit patients no deadly medicine no abortion abstain from mischief and corruption abstain from the seduction of patients – female or male keep secret whatever seen or heard in connection with professional service Tuskegee 1939-1973 An agency of the US Public Health Service which later became the CDC “untreated syphilis in the negro male” Quinlan 21 years old - collapsed after swallowing alcohol and tranquilizers at a parts PVS family went to court to remove ventilator Supreme Court appointed father as guardian & told docs and family to consult with the institutional Ethics Committee food and fluids continued died 10 years after removal of “life support” Cruzan automobile accident 1983 PVS no ventilator but food & fluids family went to court to stop food & fluids feeding stopped in 1990 & patient died within the month

3. Common Problem Case Scenarios Grandpa breaks his hip. develops pneumonia and ARDS aunt Lucie from California shows up at the 11th hour Persistent Vegetative State (PVS)

4. Persistent Vegetative State(PVS) due to injury of the upper brain sparing the brain stem characterized by the return of sleep-wake cycles and of various reflex activities, but wakefulness is without awareness can “live” for years on tube feedings

5. Advance DirectivesAvailable in Colorado Living Will Medical Durable Power of Attorney CPR Directive

6. Living Will a written statement made when a patient (declarant) has decisional capacity which gives directions for withholding or withdrawing certain life- sustaining procedures when the patient: has a terminal condition or PVS and has lost decisional capacity.

7. Living Will must still have 2 witnesses two physicians must certify terminal condition or PVS may include other instructions for care following certification of terminal illness/PVS may include a list of persons to be notified of that certification, as well as a list of persons with whom healthcare providers may discuss the declarant’s condition and care

10. Medical Durable Power of Attorney(MDPA) a written statement made when a patient has decisional capacity which appoints specific surrogate decision-makers (agents) not limited to a terminal condition or PVS takes effect at time of signature or when patient loses decisionality witness recommended but not required

12. Proxy Decision-Makers For Medical TreatmentCRS 15-18.5-103 Used to establish a surrogate decision maker when there is no Medical Durable Power of Attorney or Guardian. Physician must declare that the patient has lost decisional capacity. Physician (or representative) contacts “interested persons.” “Interested persons” choose the proxy decision-maker.

13. Colorado Designated Beneficiary Act (CRS 15-22-101-111) allows for two adult (over 18) persons to designate each other as beneficiaries of a number of items and instruments related to health care, medical emergencies, incapacity, death, and administration of estates the two adults cannot be married to each other or anyone else nor party to any other DB agreement a DB may assign the other DB the right to act s a Proxy Decision-Maker

14. 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.

15. CPR Directive Bracelet or Necklace A unique and easily identifiable logo is engraved on the front side of the metal bracelets and necklaces. The name, birth date, sex, and race of the declarant are engraved on the back side along with the words "DO NOT RESUSCITATE." Wearing a bracelet or necklace is encouraged but not mandatory.

16. Studies on CPR Prehospital Disaster Med Apr-Dec, 1998 832 outpatients with primary cardiac arrest in Kansas City, MO from 1992-1994 18.4% had return of spontaneous circulation prior to ED arrival 8.1% survived to hospital discharge

17. Studies on CPR American Family Physician, December 1991 “CPR in Hospitalized Patients: When Is It Futile?” CPR Failure Rate: 62% 25% of patients who initially survived died before discharge. 13% of all patients who had CPR survived to discharge.

18. Studies on CPR Prehosp Emerg Care Apr-Jun, 1997 “Outcomes of cardiac arrest in the nursing home: destiny or futility?” 182 nursing home patients received CPR from July 1989-December 1993 none survived

20. Medical Orders for Scope of Treatment (MOST) A document that consolidates and summarizes patient preferences for key life-sustaining treatments. Persons may refuse treatment, request full treatment, or specify limitations. It is primarily intended to be used by the chronically or seriously ill person in frequent contact with healthcare providers, or already residing in a nursing facility. Translates patient preferences into physician’s orders. “Travels” with the patient and is honored in any setting: hospital, clinic, day surgery, long-term care facility, rehab facility, hospice, or at home. Prompts patients and providers to regularly review, confirm, or update choices based on changing conditions.

21. MOST Orders CPR Medical Intervention & Transfer re Comfort Measures Only Vs. Full Treatment Antibiotic Use Artificially Administered Nutrition & Hydration