Advance Care Planning Senior Mentor Program

1. Advance Care Planning Senior Mentor Program Gere B. Fulton, Ph. D., J. D. School of Medicine The University of South Carolina

2. Advance Care Planning (ACP) • There are two (2) components to advance care planning: • 1) advance care planning (process) – clarifying one’s values concerning care, including medical treatment, at the end of life • 2) advance care plan (product) – preparation of a document reflecting one’s values, e.g., a living will or a health care power of attorney (HCPOA)

3. Reasons for Advance Care Planning • To assure that your wishes about end-of-life care are known and respected • To facilitate communication and autonomy in the patient-physician relationship • To provide guidance to your family and physician when you are unable to make decisions for yourself

4. Ability to consent • Incompetence – a legal term. Competence is presumed and incompetence can only be pronounced by a court of law. Due process. • Incapacity – a medical term. Inability to make the decision at hand. • Unable to consent – Section 44-66-20(6) • “…unable to appreciate the nature and implications of the patient’s condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner.”

5. Inability to consent • Does not include minors • Certified by two licensed physicians, each of whom has examined the patient • Exception for emergencies if physician puts in writing that delay would be detrimental to the patient’s health • Record should include an opinion regarding the cause and nature of the inability to consent, its extent, and its probable duration

6. Four Statutes • Adult Health Care Consent Act (44-66-10) • Declaration of a Desire for a Natural Death (44-77-50) • Health Care Power of Attorney (62-5-501) • Emergency Services Non-Resuscitation Order (44-78-10)

7. Adult Health Care Consent Act • Allows a surrogate to make all health care decisions when the patient has permanently lost capacity to do so • Creates broader authority to withhold or withdraw LSMT than exists under the Living Will statute • Any decision must be based on 1) the patient’s wishes (if known), or 2) the patient’s best interest. • Establishes an order of priority for identifying the proper surrogate

8. Order of Priority • Guardian • Attorney-in-fact (?) • Person with statutory authority (?) • Spouse, unless separated (with qualifications) • Parent or adult child of the patient • Adult sibling, grandparent or adult grandchild • Any other relative by blood or marriage who is believed to have a close personal relationship

9. Declaration of a Desire for a Natural Death • Living Will • Applicable only to terminal illness or permanent unconsciousness • Permanent unconsciousness cannot be certified until the declarant has remained unconscious for 90 consecutive days or another characteristic allows the diagnosis to be made with a high degree of medical certainty • Diagnosis must be made by two physicians who have personally examined the patient

10. Living Will (continued) • Intention to refuse food or water by tube must be specifically authorized • Comfort care can never be refused • Document must be appropriately witnessed and notarized • If the declarant is a patient in a hospital or nursing home, one of the two witnesses must be an ombudsman

11. Witnessing the Living Will • Not related to declarant by blood, marriage or adoption, either as spouse, lineal ancestor, descendant of the parents of the declarant, or spouse of any of them • Not directly responsible for declarant’s medical care • Not entitled to a portion of the estate under will or intestate succession • Not a beneficiary of a life insurance policy

12. Witnesses (continued) • No more than one witness an employee of health facility in which the declarant is a patient • Not the attending physician or an employee of the attending physician • No claim upon the estate (not a creditor)

13. Health Care Power of Attorney • The HCPOA allows you to appoint a surrogate decision maker, i.e. attorney-in-fact. • The powers of the surrogate are broader than the terms of the living will, i.e. not limited to terminal illness or permanent unconsciousness. • Since it is not limited to terminal illness or permanent unconsciousness, the legislatively-imposed waiting period for PVS would not apply. • Arguably, unlike the living will, the HCPOA does not require notarization.

14. Emergency Services Non-Resuscitation Order • Allows for a person with a terminal illness to refuse out-of-hospital CPR • Must be ordered by physician (health care provider) and entered into the patient’s file • Status may be identified by a form, a bracelet, or a necklace • If there is a form, it should be transported with the patient if the patient is taken to a hospital

15. For DNR patients the following procedures shall not be performed… • CPR • Endotracheal intubation and other advanced airway management • Artificial ventilation • Defibrillation • Cardiac resuscitation medication • Cardiac diagnostic monitoring

16. The following procedures may be provided as appropriate… • Suctioning • Oxygen • Pain medication • Non-cardiac resuscitation medication • Assistance in the maintenance of an open airway, but not intubation or advanced airway management • Control of bleeding • Comfort care • Support to patient and family

17. Planning for End-of-Life Care in South Carolina • USC Institute of Public Affairs (2002) • 18.7 % with living will (17.9% in 2001) • 7.1% (18 to 29) to 45.3% (65 and older) • 2001 figures were 7.2% and 45.2% • 3.8% with health care power of attorney (7.5% in 2001!) • 10.6 % with both (up from 7.6% in 2001) • Percentage with “nothing” increased from 58.9% to 59.2%! • ^ better educated

18. Gere B. Fulton, Ph. D, J. D. Palmetto Professor of Clinical Internal Medicine School of Medicine The University of South Carolina Columbia, SC 29208 Telephone: 803.419.4106 E-mail: gereburke@aol.com