Personal Choices in Advance Care Planning Presentation

Presentation in PDF format.

Objectives

  • Define Life Sustaining Treatment
  • Define Terminal Condition
  • Define Irreversible Condition
  • Identify three types of Advance Directives recognized by Texas law
  • Identify at least one resource to obtain assistance with making advance directive decisions

Case Presentation #1

Mrs. Anderson is an older adult, widowed and residing in a nursing facility who falls and breaks her hip. After surgery at the hospital, she has a heart attack, she is resuscitated, and she is placed on a breathing machine in the ICU. After two weeks, she remains unresponsive on the machine and her condition continues to deteriorate despite maximum medical treatment. Her physicians feel it is time to allow a gentle and peaceful death. Her family knows nothing of her wishes about further treatment in such circumstances, as she had never discussed an advance care plan nor completed an advance directive of any sort.

Case Presentation #2

Mr. Smith resides in a nursing facility. Two years ago, he was very active, able to recognize and interact socially with friends and family. After a series of strokes, his health has gradually declined and he no longer recognizes his family, he is unable to speak, and he has lost his mobility. He is now incontinent, has difficulty swallowing, often refuses to eat, and has been hospitalized several times in the last 6 months for pneumonia and dehydration. Each time he is treated and then returned to the facility where he further declines. Should he again be treated for pneumonia? Should a "feeding tube" be placed? When his heart stops, should doctors attempt to restart it and support him with machines?

What is Advance Care Planning?

  • A process of informed decision-making that acknowledges the person's autonomy and right of choice
  • A process for planning ahead to specify individual treatment choices when very ill or near death
  • A process that is initiated while the resident is of sound mind and not under stress
  • A conversation between the individual, family members, and health care providers
  • A process that may conclude with legal documentation known as Advance Directives

Why Participate in Advance Care Planning?

  • To explore beliefs and values about life, death, and medical treatment at the end of life.
  • To inform others of their beliefs, values, and wishes.
  • To document their health care choices.
  • To decrease potential conflict and emotional burden for family members.
  • To ensure wishes are respected.

Advance Care Planning 5-Step Process

  1. Exploration of beliefs and values
  2. Knowledge of health care choices
  3. Discussion with family and physician
  4. Completion of Advance Directives
  5. Informing others of choices

Advance Care Planning Step #1: Explore Beliefs & Values

  • Health care decisions can prolong life or not prolong life.
  • Beliefs and values can guide medical decisions.
  • This issue is best faced with careful consideration and not in a crisis situation.

Consider what basic life qualities are important.

Sample Questions:

  • How important is independence and the ability to feed, walk, and otherwise care for yourself?
  • How important is it to have your personal preferences for social, cultural, and health needs met?
  • How important is it for you to be able to recognize or respond to your loved ones?

Advance Care Planning Step #2: Know The Health Care Choices

Health care decisions should be based upon the benefits and disadvantages of treatment. There are three basic choices concerning the level or intensity of the treatment:

  1. Palliative Treatment or Comfort Care
  2. Limited Life Sustaining Treatment
  3. Intensive Life Sustaining Treatment

Palliative or "Comfort Care"

The goal of palliative care is to keep the individual comfortable by relieving pain, symptoms, and stress so that when death is imminent, the person may have a peaceful and dignified death.

Life Sustaining Treatment:

Texas law defines life sustaining treatment as "a treatment that, based on reasonable medical judgment, sustains the life of the individual and without which the individual will die. The term includes both life sustaining medications and artificial life support, such as mechanical breathing machines, kidney dialysis treatment, and artificial nutrition and hydration."

Texas Health and Safety Code, Chapter 166, Subchapter A, 166.002 relating to Definitions

Limited Life Sustaining Treatment:

  • Transfer to the hospital or remain at the facility
  • Trial of antibiotics or other medication to sustain life: may be oral or IV
  • Artificial Life Support for a short time to determine effectiveness

Intensive Life Sustaining Treatment:

  • Transfer to the hospital with possible admission to the ICU, if medically appropriate.
  • Intravenous therapies, mechanical breathing machines, artificial nutrition and hydration (ANH), surgery, blood transfusions, dialysis and cardiopulmonary resuscitation (CPR) may be used as appropriate for the individual's particular condition.

Artificial Nutrition & Hydration – Tube Feeding Benefits:

  • Provides fluids and nutrients
  • Potentially life-sustaining

Artificial Nutrition & Hydration – Tube Feeding Disadvantages:

  • Invasive and painful
  • Possible aspiration of formula into the lungs
  • Possible use of restraints

Ventilator Benefits:

  • Life-sustaining

Ventilator Disadvantages:

  • Invasive and painful due to tube in throat
  • Side effects include agitation requiring sedation or restraint, inability to talk
  • Requires specialized treatment

Kidney Dialysis Benefits:

  • Cleans blood
  • Life-sustaining

Kidney Dialysis Disadvantages:

  • Time consuming
  • Requires transfer to dialysis center by ambulance
  • Invasive and painful
  • Side effects such as fatigue, weakness, and nausea

CPR Cardiopulmonary Resuscitation Benefits:

  • May revive breathing or a heart that has stopped

CPR Cardiopulmonary Resuscitation Disadvantages:

  • Injury common ( fractured ribs)
  • Requires hospital transfer
  • Less than 15 — 20% effective in restarting the heart

Advance Care Planning Step #3: Discussion w/Family, Physician or Advisers

  • This step is essential, but may be difficult for some.
  • Discuss with family and physician.
  • Discuss with a spiritual adviser or attorney.
  • Ask the family and physician to respect their health care choices.

Advance Care Planning Step #4: Completion of Advance Directives

What is an Advance Directive?

  • An Advance Directive is a legal document completed by the individual when of sound mind, allowing the person to direct future treatment at a time when the resident is otherwise unable to make their wishes known.
  • With an Advance Directive you may appoint a Health Care Agent or Spokesperson to direct specific treatment decisions.
  • Advance Directives is the final step in the process of Advance Care Planning.

Three important types of Advance Directives under Texas law:

  1. Directive to Physicians and Family or Surrogates
  2. Medical Power of Attorney
  3. Out-of-Hospital DNR

Directive to Physicians, Family, Surrogates:

  • Commonly called a "Living Will"
  • Records the individual's choices in writing
  • Directs the medical care the person wants to receive, or not receive
  • Becomes effective only when:
    • the doctor certifies that the resident has a terminal or irreversible condition and
    • the resident is not able to communicate or otherwise make their wishes known

What is a terminal condition?

According to state law, a terminal condition means an "incurable condition caused by injury, disease, or illness that according to reasonable medical judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care."

Texas Health and Safety Code, Chapter 166, Subchapter A, §166.002 relating to Definitions

What is an irreversible condition?

According to state law, an irreversible condition means a "condition, injury, or illness:

  • that may be treated but is never cured or eliminated;
  • that leaves a person unable to care for or make decisions for their own self; and
  • that, without life-sustaining treatment provided in accordance with the prevailing standard of care, is fatal."

Texas Health and Safety Code, Chapter 166, Subchapter A, §166.002 relating to Definitions

Medical Power Of Attorney

  • Allows the person to appoint a person to speak for them when they can no longer do so
  • Becomes effective when a physician has certified in writing the resident is incompetent
  • The individual's health care agent is required by law to make decisions based on their knowledge of the person's values and preferences, thus the health care agent should be included in discussions related to the creation of this type of document

Out-of-Hospital DNR

  • DNR means Do-Not-Resuscitate
  • No attempt will be made to restart the heart or breathing when the heart stops
  • Note that it does not mean: do not treat for other problems

Advance Care Planning Step #5: Inform Others of Individual's Choices

  • The individual must keep the original copy of the Advance Directives.
  • Provide signed copies to the resident's:
    • official health care agent
    • family members
    • healthcare providers: physicians, clinics, hospitals, nursing facilities, dialysis centers, hospice services, etc.

Key Points to Remember

  • As long as the resident is able, the individual and the individual's physician will make decisions together regarding end of life care.
  • Advance Care Planning relieves the resident and the family of additional emotional distress.
  • Advance Directives are the legal documentation of the persons beliefs and values about end of life issues.
  • Designate facility staff that are available to meet with residents privately to answer questions and assist in completing advance directive forms
  • The person always has the right to cancel or change the Advance Directives.

Where to Get Help With Legal Planning

Information on subject matter was provided by Texas Partnership for End of Life Care (TXPEC).