Advance Healthcare Planning Law & Ethics 2010 OKAHSA Annual Meeting March 10-11, 2010 Presented by Annette Prince,

1. Advance Healthcare PlanningLaw & Ethics2010 OKAHSA Annual Meeting March 10-11, 2010Presented byAnnette Prince, J.D., L.C.S.W.

2. Disaster Planning: Be Prepared • Tornado, Ice Storm, Earthquake, Bioterrorism • Shelter • Water • Food • Flashlight • Radio • Batteries

3. Disaster Planning: Be PreparedDeath is not an OPTION ! But there are optional ways to die. It doesn’t have to always be a disaster !

4. Best Option: Make Your Own Medical Decisions If you can still decide for yourself, tell your doctor, and she will put your decisions about end of life treatment in your medical chart !or not. . .

5. AVOID: Unpalliative Options 80% say we want to die at home, without pain, surrounded by family and/or friends. But we end up in: Emergency Room I.C.U. and/or Long-Term Care Just Puleez

6. Palliative Care Option Serious, Chronic, Life-limiting IllnessTerminalPersistent UnconsciousEnd Stage

7. BUT, LESS THAN 30 % OF US COMPLETE ADVANCE DIRECTIVES! WHAT ARE THE MYTHS? • You will die within 30 minutes after you sign it. • You will change your mind and you can’t revoke it. • Modern medicine will find a cure for your terminal illness or vegetative state if you suffer as long as humanly possible without pain medication. • You hate your spouse and kids and want to spend all your money prolonging your death if you can’t take it with you.

8. BUT, If you die in Oklahoma You must prepare if you want a palliative death in Oklahoma. NO JOKE ! The Oklahoma legislature presumes that everyone wantstube feeding. The Oklahoma legislature does not provide family members with legal authority to make medical decisions!

9. Be Prepared For Palliative Care ! Get your ducks in a row, and documents in order.

10. Next Best Options: If you are no longer able to make your own decisions 1.Pack your bags and move to a state that got an “A” in palliative care (New Hampshire, Vermont, Montana). Oklahoma, Mississippi and Alabama earned “F’s” in hospital palliative care. (Upside: More scenic environment)

11. EASY OPTION IF YOU’RE DETERMINED TO DIE IN OKLAHOMA ! Complete “Advance Directives” to make your own wishes for medical treatment known. (Upside: Lower cost of “living” until you die.)

12. Revocation of Advance Directive An advance directive may be revoked in whole or in part at any time and in any manner by the declarant, without regard to the declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health care provider by the declarant or a witness to the revocation.

13. What are “Advance Directives”? • Living Will • Appointment of Health Care Proxy • Donation of Organs • Durable Power of Attorney for Health Care • Do-Not-Recusitate ; Do-Not-Intubate • Physicians Orders for Life-Sustaining Treatment (POLST)

14. Living Will or Proxy or Both • "Advance directive for health care" means any writing executed in accordance with the requirements of Section 3101.4 of this title and may include a living will, the appointment of a health care proxy, or both such living will and appointment of a proxy;

15. Oklahoma Advance Directive Act2006 “When” does it take effect after I sign it? ONLY “If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions”. If I die with sufficient mental capacity to make my own decisions, it never goes into effect.

16. What does it look like? An advance directive may be in substantially the following form:

17. LIVING WILL If my attending physician and another physician determine that I am no longer able to make decisions regarding my health care, I direct my attending physician and other health care providers, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below:

18. (1) Terminal Condition • (1) If I have a terminal condition, that is, an incurable and irreversible condition that even with the administration of life-sustaining treatment will, in the opinion of the attending physician and another physician, result in death within six (6) months: • (Initial only one option)_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. • _____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration. • _____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. • (Initial only if applicable)__AP_ See my more specific instructions in paragraph (4) below.

19. (2)Persistently Unconscious • (2) If I am persistently unconscious, that is, I have an irreversible condition, as determined by the attending physician and another physician, in which thought and awareness of self and environment are absent:(Initial only one option)_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration._____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration._____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. • (Initial only if applicable)__AP_ See my more specific instructions in paragraph (4) below.

20. (3)End-Stage Condition • (3) If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, which results in severe and permanent deterioration indicated by incompetency and complete physical dependency for which treatment of the irreversible condition would be medically ineffective:(Initial only one option)_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. • _____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration. • _____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. • (Initial only if applicable)__AP_ See my more specific instructions in paragraph (4) below.

21. (4)Other Conditions Here you may: (a) describe other conditions in which you would want life-sustaining treatment or artificially administered nutrition and hydration provided, withheld, or withdrawn, (b) give more specific instructions about your wishes concerning life-sustaining treatment or artificially administered nutrition and hydration if you have a terminal condition, are persistently unconscious, or have an end-stage condition, or (c) do both of these:

22. I authorize my health care proxy or alternate to make all health care decisions on my behalf, including decisions regarding life-sustaining treatment, including the provision, withholding or withdrawal of artificially administered nutrition and hydration. • I want effective pain management even if it hastens my death.In the event that I am diagnosed with any of the above 3 conditions, I do not want antibiotics administered. • In the event that I am diagnosed with any of the above 3 conditions, and my heart stops beating or I stop breathing, do not resuscitate or intubate me, or I will sue you. • If my son from California objects to my directions, he inherits nothing, zip, zero, nada. __AP__

23. Health Care Proxy Appointment If my attending physician and another physician determine that I am no longer able to make decisions regarding my health care, I direct my attending physician and other health care providers pursuant to the Oklahoma Advance Directive Act to follow the instructions of David Boren, whom I appoint as my health care proxy. If my health care proxy is unable or unwilling to serve, I appoint Steve Crawford as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatever health care decisions I could make if I were able, except that decisions regarding life-sustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as I have indicated in the foregoing sections if indicated.If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.

24. Witness Signed this ___ day of ________________, 20 ___. _____________________________________________Signature_____________________________________________City of_____________________________________________County, Oklahoma_____________________________________________Date of birth (Optional for identification purposes) This advance directive was signed in my presence. _____________________________________________Signature of Witness____________________________________, OKResidence _____________________________________________Signature of Witness_________________________________, OKResidence

25. General Provisions a. I understand that I must be eighteen (18) years of age or older to execute this form.b. I understand that my witnesses must be eighteen (18) years of age or older and shall not be related to me and shall not inherit from me.c. I understand that if I have been diagnosed as pregnant and that diagnosis is known to my attending physician, I will be provided with life-sustaining treatment and artificially administered hydration and nutrition unless I have, in my own words, specifically authorized that during a course of pregnancy, life-sustaining treatment and/or artificially administered hydration and/or nutrition shall be withheld or withdrawn.d. In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this advance directive shall be honored by my family and physicians as the final expression of my legal right to choose or refuse medical or surgical treatment including, but not limited to, the administration of life-sustaining procedures, and I accept the consequences of such choice or refusal.

26. e. This advance directive shall be in effect until it is revoked.f. I understand that I may revoke this advance directive at any time.g. I understand and agree that if I have any prior directives, and if I sign this advance directive, my prior directives are revoked.h. I understand the full importance of this advance directive and I am emotionally and mentally competent to make this advance directive.i. I understand that my physician (s) shall make all decisions based upon his or her best judgment applying with ordinary care and diligence the knowledge and skill that is possessed and used by members of the physician’s profession in good standing engaged in the same field of practice at that time, measured by national standards.

27. Make it Happen ! A physician or other health care provider who is furnished the original or a photocopy of the advance directive shall make it a part of the declarant's medical record and, if unwilling to comply with the advance directive, promptly so advise the declarant.

28. What is a “Qualified” Patient? • 63 O.S. Section 3101.7 Qualified Patient-Determination-RecordThe determination of the attending physician and another physician that the patient is a qualified patient shall become a part of the patient's medical record.

29. Qualified Patient "Qualified patient" means a patient eighteen (18) years of age or older who has executed an advance directive and who has been determined to be incapable of making an informed decision regarding health care, including the provision, withholding, or withdrawal of life-sustaining treatment, by the attending physician and another physician who have examined the patient.

30. Proxy Power In the case of a qualified patient, the patient's health care proxy, in consultation with the attending physician, shall have the authority to make treatment decisions for the patient including the provision, withholding, or withdrawal of life-sustaining procedures.

31. Title 63 O.S. Section3101.9 – An attending physician or other health care provider who is unwilling to comply with the Oklahoma Advance Directive Act shall as promptly as practicable take all reasonable steps to arrange care of the declarant by another physician or health care provider when the declarant becomes a qualified patient.

32. Penalty for Refusal to Honor AD • Title 63 O.S. Section3101.11 - Sanctions and Penalties for Certain ActsA. A physician or other health care provider who willfully fails to arrange the care of a patient in accordance with Section 3101.9 of this title shall be guilty of unprofessional conduct.

33. Ethics Autonomy • The Oklahoma Advance Directive Act recognizes the patient’s right to refuse any medical treatment in advance of a time when they may not be able to make their health decisions. • The advance directive may be revoked at any time. • The appointed health care proxy is entitled to all medical records and information that the patient would be entitled to if able to make decisions. • Caregivers should be considered.

34. Nonmaleficence The patient may refuse CPR, dialysis or a respirator. The patient is the authority on what is the greater or lesser harm. I might prefer amputation of a leg to death. Lance Armstrong might have other ideas.

35. Beneficence Providing effective pain management is a benefit to a patient if that is their choice. If the physician’s intent is to relieve pain, there is no liability, even if the necessary medication hastens death

36. Justice Autonomy vs. Justice Futile care Limited Resources Costs of Health Care Life prolonging care vs. Death prolonging care

37. Plan in Advance for Palliative Care • Palliative care should be included in every medical treatment plan. • Palliative care is taken for granted when a patient can speak for (defend) themselves. • Palliative care should be a part of every consumer’s disaster plan so that disaster is avoided at the end of life.

38. Root Canal • Dentist doesn’t ask if I want pain management or if I’m afraid of drug addiction during the procedure.

39. Colonoscopy Gimme that drip ! more ! more ! ahhh!

40. Backache Aspirin Morphine Surgery Sometimes it’s just common sense to START with Palliative Care !

41. So, If I Can’t Tell You What I WantWho Will Speak For Me? 1. Health Care Proxy 2. Living Will 3. Legislature= feeding tubes 4. Family= no legal authority 5. Judge 6. Congress 7. Cable News

42. Palliative Care Resource Center Palliative Care is HOPE ! ! ! Discussions Blog Oklahoma Law News & Events Bioethics Videos Advance Planning Videos http://www.fammed.ouhsc.edu/palliative-care/

43. It’s Your Right To Decide. If you don’t use it, You will lose it ! • Questions? • Annette Prince • annette-prince@ouhsc.edu • Dept. of Family Medicine • Room 2308 • (405)271-5362

44. Palliative Care Resource CenterSupplemental web site is http://fammed.ouhsc.edu/palliative-care/