Understanding Advance Directives for Patient Care Decision-Making

1. The Advance Directive INSERVICE TRAINING GUIDE

2. Patient Self Determination Act of 1991 (PSDA) • To ensure individuals entering a healthcare facility were informed about their rights to execute an Advance Directive • Became federal law in 1991 • Helps patients define their healthcare choices in case they become unable to communicate their wishes.

3. What is An Advance Directive ? • A legal document / documents that provides specific, personalized instructions regarding medical care. • Becomes effective only when the patient is unable to communicate their wishes, (incapacitated / unresponsive)

4. Advance Directive Includes: • The Living Will • Durable Power Of Attorney for Healthcare

5. The Living Will Objectives: To establish an individuals wishes concerning; • Pain relief • Mechanical means of prolonging life • Nutrition and hydration • Organ donation • Burial instructions

6. Durable Power Of Attorney for Healthcare • Allows a person to designate another person to make healthcare decisions for them in the event they are unable to do so • Designated person is known as the healthcare proxy • The decisions of the healthcare proxy must reflect the patients best interests and wishes • The healthcare proxy must be given all the information necessary to make informed choices for the patient

7. Living Will vs. Durable Power of Attorney • Two separate legal documents • DPOA allows a named agent to make all healthcare decisions for the patient under certain circumstances • Living Will only gives written instructions but does not name an agent

8. Who can execute a Directive ? The following persons have legal authority; in order of availability: • Legal guardian • Spouse • Majority of adult children participating in the decision • Parents • Majority of adult siblings participating in the decision • Majority of the resident’s adult heirs at law participating in the decision

9. Can a Directive be Revoked? A directive may be revoked: • Only by the declarant • At any time in any manner • Without regard to the declarant’s mental or physical condition • Must be made a part of the resident’s record

10. Important Notes about Advance Directives • It is impossible to know all healthcare situations or medical conditions that may need to be addressed by a living will • When patients create a living will, they should also decide on a durable power of attorney for healthcare decisions • Review and update periodically

11. “FIVE WISHES”Resource Document • The person I want to make care decisions when I can’t • The kind of medical treatment I want or don’t want • How comfortable I want to be • How I want people to treat me • What I want my loved ones to know http://www.agingwithdignity.org/index.php

12. Question • Does a DNR order affect any other medical or therapeutic treatments that a resident may desire or decline?

13. How do Advance Directives differ from DNR ? Advance Directives • Should be considered by anyone & everyone • Applies to all general medical treatments DNR • Should be considered by people who have risk factors for not surviving resuscitation • Applies only in the case of cardiopulmonary arrest

14. DNR Form • Staff need to familiarize themselves with where the DNR form is kept in each resident’s chart and what it looks like. The last thing you want to do is perform CPR on a resident who didn’t want CPR, or not perform CPR on a resident that specifically stated they wanted CPR no matter what !

15. When can a Long Term Care Nursing Facility stop CPR ? • When it locates the DNR physician order • The paramedics assume responsibility for the resident • The physician gives a telephone stop order • A nurse may not pronounce death in a nursing home in Arkansas; the protocols of ACT 718 of 2009; 20-17-104 must be strictly followed

16. ACT 718 of 2009 20-17-104Withholding CPR • Licensed nurses employed by a nursing facilities may withhold CPR from residents of the facility, regardless of the presence of a Do Not Resuscitate (DNR) order when:

17. ACT 718 of 2009; 20-17-104Withholding CPR - continued • The death of the resident was unwitnessed AND • The body evidences clear & unmistakable dependent lividity; OR • The body evidences clear and unmistakable rigor.

18. ACT 718 of 2009; 20-17-104Withholding CPR - continued • Respirations are absent for at least thirty (30) seconds. • Carotid pulse is absent for at least thirty (30) seconds. • Lung sounds auscultated by stethoscope bilaterally are absent for at least thirty (30) seconds; AND • Both pupils, if accessible, are nonreactive to light.

19. AND…….. • Utilizing the ACT 718 of 2009; 20-17-104 does not conflict with your homes Policy and Procedure • It is YOUR responsibility to know what applies to the home where you are working

20. Points to remember regarding a DNR order • A DNR order only applies to cardiopulmonary arrest, it does not mean to not treat infections, other illnesses or injuries. • It does not mean do not transport to the hospital for treatable conditions • It only means not to perform CPR on the patient in the event the patient’s heart stops or they stop breathing • Review and update

21. Resident’s Rights & CPR • Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident’s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times. • Facility CPR Policy –Some nursing homes have implemented facility-wide no CPR policies. Facilities must not establish and implement facility-wide no CPR policies. • Surveyor Implications - Surveyors should ascertain that facility policies related to emergency response require staff to initiate CPR as appropriate and that records do not reflect instances where CPR was not initiated by staff even though the resident requested CPR or had not formulated advance directives.

22. Know your resident’s Advance Directive • The relief of suffering and the cure of disease must be viewed as twin obligations of the medical profession that is truly dedicated to the care of the sick. Physicians and nursing staffs’ failure to understand the nature of suffering can result in medical intervention that (though technically appropriate) not only fails to relieve suffering, but becomes a source of suffering in itself.

23. Your turn….. QUESTIONS? COMMENTS? CONCERNS? DISCUSSION POINTS?

24. Thank You! for all that you do to serve our residents.