Advance Care Planning NALS by xeniawinifredzoe


									Advance Care

              October 13, 2011
         Deana Birkenheuer, BSN, RN

“It’s not that I am afraid
to die, I just don’t want to
be there when it

      - Woody Allen
  1975 Landmark Case

      Right to Die
Karen Ann Quinlan Case
          Karen Ann Quinlan
• A 21 year old who became unresponsive to
  painful stimuli after taking Valium while
  drinking alcohol
• Placed on a ventilator for breathing and
  administration of artificial nutrition and
• After several days, it was determined that she
  was in a persistent vegetative state with no
  chance of recovery
• Her parents requested removal of the
  ventilator as they believed this is not how
  Karen Ann would have wanted to live
          Karen Ann Quinlan
• Initially, the hospital agreed to remove the
  respirator but then later refused
• Quinlan’s parents took their request to a
  Morristown, NJ courtroom which refused
  their right to make this decision for Karen
• They then took the case to the New Jersey
  Supreme Court which sided with the parents
  and ruled in favor of removing the ventilator
• Even with removal of the ventilator, Karen
  Ann actually lived for almost ten more years
  on artificial nutrition and hydration, dying
  June 11, 1985
         Karen Ann Quinlan

• Quinlan’s case was the first right-to-die
  case to reach a higher court within the
  United States
• Quinlan’s case led to the development
  of ethics committees in healthcare
  institutions as well as the development
  of advance directives
1989/1990 Landmark Case

       Right to Die
  The Nancy Cruzan Case
             Nancy Cruzan
• Profoundly injured in a car accident
• She was not diagnosed as terminally ill
• Dependent on artificial hydration and nutrition
• Persistent vegetative state for five years
  before her parents requested removal of her
  feeding tube
• A Missouri trial court gave permission for the
  artificial hydration and nutrition to be
  removed, but the Missouri Supreme Court
  overturned this decision
             Nancy Cruzan
• The Missouri Supreme Court based its decision
   – Cruzan had no constitutional right to die
   – There was no clear and convincing evidence
     that she would not wish to continue her
     vegetative existence
   – Her parents, or guardians, had no right to
     exercise substituted judgment on their
     daughter's behalf.

• Missouri wanted further proof that Cruzan would
  not want to have lived her life in this manner.
            Nancy Cruzan
• Cruzan’s parents took their request to the
  U.S. Supreme Court in December 1989
  but they refused to rule on removal of the
  feeding tube

• However, they did rule in a 5 to 4 decision,
  that the state of Missouri did have the right
  to request convincing evidence that an
  incompetent person wants life-
  sustaining treatment withdrawn before
  making a decision
            Nancy Cruzan
• On December 14, 1990 a Missouri circuit
  court ruled that new evidence presented by
  three more friends constituted "clear and
  convincing" evidence that Nancy would not
  want to continue existing in a persistent
  vegetative state.

• The feeding tube was removed nearly eight
  years after her accident

• Nancy died on December 26, 1990
  surrounded by her family
Patient Self-Determination Act -1991

• Goal: Educate patients on their healthcare
  decision making rights

• As a condition of Medicare and Medicaid
  payment, health care providers in hospitals,
  skilled nursing facilities, hospices, etc. are
  required to:
   Patient Self-Determination Act -1991
  – Develop written policies concerning advance
  – Ask all new patients whether they have prepared
    an advance directive and include this information
    in their chart
  – Educate the staff and community about advance
  – Give patients written materials regarding the
    facility’s policies on advance directives and the
    patient’s right (under applicable state law) to
    prepare these documents

• However, this does not require patients to
  have or complete advance directives
Advance Directives
  National Advance Directives

• No uniform advance directives
  throughout the United States
• State laws for advance directives can
  vary and sometimes, even conflict
• Some believe that Congress has not
  addressed the issue due to fear of
  facing political resistance as being
  perceived of overstepping states’ rights
Barriers to National Advance Directives

• Different requirements about who can
  serve as a health care agent
• Different requirements for who qualifies
  as a witness for the advance directives
• Differing definitions of conditions that
  lead to implementation of the advance
• Differing language utilized in the
   Ohio Advance Directives

• Living Will

• Durable Health Care Power of
               Living Will
• Allows you to establish and document, in
  advance, the type of medical care you
  would want to receive if you were to
  become permanently unconscious or if
  you were to become terminally ill and
  unable to tell your physician or your family
  what kind of life-sustaining treatments you
  want to receive
• Allows you to specify your wishes
  regarding anatomical gifts (organ and
  tissue donation)
Durable Health Care Power of Attorney
  • A document that allows you to name a
    person to act on your behalf to make
    health care decisions for you if you
    become unable to make them for
  • Becomes effective even if you are only
    temporarily unconscious and medical
    decisions need to be made
Durable Health Care Power of Attorney
  • You need to have a discussion with
    whomever you choose to make sure
    they understand what your healthcare
    wishes truly are
  • If you have both a Living Will and a
    Durable Health Care Power of Attorney,
    the physician must comply with the
    wishes you state in your Living Will
 Ohio’s Do Not
Resuscitate Law
                DNR Order
• Entered into law in 1998
• Allows an individual to communicate their
  wishes about resuscitation to medical
  personnel inside or outside a hospital or
  nursing home setting
• Allows emergency medical workers to honor an
  individual’s physician-written DNR Order
• Protects emergency squads and other
  healthcare personnel from liability if they follow
  an individual’s DNR Order
• Can be signed by a physician, certified nurse
  practitioner, or clinical nurse specialist, as
               DNR Order
• DNR Comfort Care Arrest
  – The patient will receive all the appropriate
    medical treatment, which may include
    some components of resuscitation, until
    the patient has a cardiac or pulmonary
    arrest, at which point only comfort care will
    be provided
• DNR Comfort Care
  – The patient has chosen only comfort care
    treatments even before the heart or
    breathing stops
  When is a DNR Revoked?
• A patient who is alert and oriented can
  ask to rescind a DNR order at any time
• If there is any reason to suspect that
  documentation has been altered
• Pregnant patients cannot have a DNR
• When abuse is suspected from a
        Advance Directives
• Who Should I Tell?
  – Durable Health Care Power of Attorney
  – Attending physician
  – Family members
  – Health care facility (upon admission)
• Where should I keep them?
  – Give copies to anyone who may be involved in
    assisting to make your healthcare decisions
  – Keep a copy in a place that is easily
    (ex: car glovebox, refrigerator)
What if I Don’t Have Advance Directives?

 • Who will make my healthcare decisions
   for me, if I am unable:

    – According to Ohio Code 1337.16
       • Guardian
       • Spouse
       • Adult children
       • Parents
       • Adult siblings
Have You Completed Your
   Advance Directive?
 Advance Directives Completion

• According to the U.S. Department of
  Health and Human Services, the
  literature suggests that only 18% to
  30% of Americans have completed
  advance directives

• Only 1 in 3 chronically ill individuals
  have completed advance directives
 Reasons Given for Not Completing
       Advance Directives
• Written text of the forms are too difficult to
• Cultural differences in end-of-life care may
  view as negative thinking or giving up too
• Suspicious of this being a cost saving
  initiative for healthcare
• Assume physician and family will know
  what they would or would not want done
• Forms do not apply to every situation
 Major Reason Given by the Elderly

• Most responded that they were waiting
  for their physician to address the matter
  with them during an office visit
   The Difficult Conversation
• Most physicians are not comfortable
  with initiating or having this type of
  conversation with their patients.
• Physicians expect the patient to ask
  limited questions or bring Advance
  Directives to the office, after seeing a
       Healthcare Professionals:
         Advance Directives
• Often hospital staff may not be aware the patient
  has Advance Directives
• Staff may not be aware of who the DPOA is
• Staff is instructed to call a code immediately if the
  patient is found not breathing or not having a
  pulse, then ask questions later
• The Advance Directives are not always referred
  to with the writing of new orders by physicians
• Families are not always told the reasons for
  medications and/or that these treatments may be
  considered aggressive and have risky side
     Healthcare Professionals:
       Advance Directives
• Paramedics cannot utilize a Living Will
• There must be a DNR order signed by a
  physician in the home
• In a medical crisis in the home, when
  911 is called, most DNRs are revoked
  by the family
           What Can You Do?
• Complete your own advance directives and not wait
  until a crisis occurs
• Encourage discussions with friends and family
• Encourage elderly family members to discuss their
  wishes with their physician
• Make sure that your DPOA is someone that will
  be an advocate for you and take this matter
  seriously when the time comes
   Midwest Care Alliance
Choices: Living Well at the End of Life

– Formerly known as Ohio Hospice and
  Palliative Care Organization
– Advance Directives Packet; 5th edition
Do Not Resuscitate Scenario
           DNR Scenario
• A 72 year old male calls 9-1-1 with
• The EMS crew places the patient on
  oxygen and obtains vital signs
• Pulse 172, Respirations 18, BP 90/62
• Skin slightly pale
• Awake, oriented but anxious
• Placed on cardiac monitor which shows
  ventricular tachycardia
• Patient is wearing a state DNR bracelet
  What Care is Appropriate?
• Consider:

  – Patient is not in cardiac arrest
  – Patient is not in respiratory arrest
  – Patient is alert and oriented

  – So….what are his treatment options
    since he is a DNR?
  What Care is Appropriate?
• Cardiac Medications?
• Synchronized cardioversion?
• Transfer to hospital emergency
  department with probable admission?
• Continued oxygen?

But wait…isn’t he a Do Not Resuscitate?
• DNR has no bearing in this situation
  because he is alert, oriented and not in
  any type of arrest.
              DNR Order
• A DNR order is not effective until:
  – Respiratory or cardiac arrest occurs
• A DNR order does not hasten death
  – In the event of arrest, DNR can dictate
    comfort care
• A DNR order does not influence
  therapeutic interventions
  – For example, suctioning or use of oxygen

Medical Orders for Life
Sustaining Treatment
• Based on the POLST paradigm
  – Used to describe programs that have
    consistent components but different names
 POLST In LaCrosse, Wisconsin
• POLST implemented in LaCrosse in 1997 by
  Linda Briggs and Bud Hammes (Respecting
• Research studies have been completed to
  demonstrate that this paradigm is effective in
  determining and implementing “what the
  patient wants for their end-of-life care”

• Further information:
  Goals of the POLST / MOLST
• To provide timely opportunities for informed
  end-of-life treatment decisions
• For patients with:
   – Serious, life-limiting illnesses
   – A terminal illness
   – Advanced frailty
   – Others Interested in defining their care
           POLST / MOLST

• Advance care planning is not a “one size fits
  all” discussion.
• Must be individualized to each patient and
  their goals, values, stage of health, and
• Discussion involves more than just checking
  off a list of questions.

• Serves as a set of medical orders.
• A portable document that transfers with the
  patient from one setting to the next.
            POLST / MOLST

• Requires advanced care planning facilitation
  skills to address the appropriate stage of
• Requires presenting options and discussing
  potential outcomes of decisions.
• Provides directions for providing or forgoing
  aggressive treatment.
Role of Advance Care Planning Facilitator
  • Introduce the MOLST Program to patient/caregiver
  • Explore the understanding of the role of the durable
    power of attorney (DPOA)
  • Explore the patients goals/values regarding
     – Their medical condition
     – Potential complications
     – Past experiences
     – Concept of what it means to live well
  • Support and validate the patient as he/she makes
    informed treatment decisions
  • Make referrals, as necessary for the patient to feel
    comfortable with his/her treatment decisions
           POLST / MOLST
•Discussion involves:    •Discussion includes:
   – Patient                – CPR wishes
   – Durable health care    – Medical
     power of attorney
   – Caregiver
   – Anyone else the        – Antibiotic use
     patient may wish to    – Artificial
     include                  nutrition/hydration
    POLST Use in Long-Term Care:
         A Multistate Study

A Comparison of Methods to Communicate
     Treatment Preferences in Nursing
 Facilities: Traditional Practices Versus the
    Physician Orders for Life-Sustaining
              Treatment Program

                Hickman, Nelson, Perrin, Moss, Hammes & Tolle, 2010
   POLST Use in Long-Term Care:
        A Multistate Study
• Objective
  – To evaluate the effectiveness of the POLST
    program in comparison to traditional advance care
• Design
  – Retrospective observational cohort study
    conducted between June 2006 and April 2007
• Setting
  – Stratified random sampling from 90 long term care
    facilities throughout Oregon, Wisconsin and West
  – 1711 residents
   POLST Use in Long-Term Care:
        A Multistate Study
• Results suggest:
  – Residents with POLST forms were more likely
    to have orders about life-sustaining treatment
    preferences beyond CPR than residents
  – No differences between residents with and
    without POLST forms in symptom assessment
    or management
  – Residents with POLST comfort care only
    orders were 59% less likely to receive life-
    sustaining treatments than residents with
    traditional DNR orders
LaCrosse Advance Directive Study
    A Comparative, Retrospective,
  Observational Study of the Prevalence,
  Availability, and Specificity of Advance
       Care Plans in a County that
     Implemented an Advance Care
          Planning Microsystem

                       Hammes, Rooney, & Gundrum, 2010
LaCrosse Advance Directive Study
• Objective
   – To determine whether outcomes have changed over
     time for a managed, systematic approach to
     advance care planning
• Design
   – Retrospective comparison of medical record and
     death certificate data of adults who died over a
     specified period of time in 2007/2008 compared to
• Setting
   – All healthcare organizations in LaCrosse County,
• Participants
   – 540 adults who died in 1995/1996
   – 400 adults who died in 2007/2008
LaCrosse Advance Directive Study
                   Data collected in   Data collected in   P value
                    95/96 N=540         07/08    N=400

 Deceased with       459 (85%)           360   (90%)       0.023
    *Advanced       437    (95.2%)       358 (99.4%)       <.001
Directives found
  in the medical
record where the
   person died
*Deceased who        353    (77%)        324 (90%)         <.001
  had DPOA
   Treatment               98%              99.5%           0.13
decisions found
consistent with
LaCrosse Advance Directive Study
• From the data collected in 07/08
  – 67% of deceased patients had a POLST
  – 98.5% of POLST forms were in the medical
    record of the healthcare organization where
    the person died
  – The most recent POLST form was completed
    4.5 months prior to death
  – 96% of all deceased patients (n=400) had
    either an Advance Directive or a POLST form
    at the time of death
LaCrosse Advance Directive Study
• Results suggest:
  – A high prevalence of advance care plans
    can be achieved and these care plans can
    be specific enough to assist with clinical
  – It is possible to achieve a high rate of
    compliance between the patient’s choices
    as outlined on the advance care plan and
    the actual treatment decisions made
   AARP Public Policy Institute
  Improving advanced illness care: The
   evolution of state POLST programs

               Published in April 2011
            MOLST in Ohio

• Introduced as legislation in the summer of
• Introduced by sponsor, Representative Nancy
  Garland (D) in the House Health Committee
• Unable to achieve consensus due to
  objections from special interest groups
• Form continues to be amended in response
  to the objections
• A bill will likely be-reintroduced – time frame
             MOLST in Ohio

• When legislation passes, it will replace the
  current DNR form
• It is not meant to replace the Living Will or
  Durable Health Care Power of Attorney
• Task forces throughout the state are
  encouraging implementation of some type of
  MOLST form within healthcare organizations
  prior to passing the legislation
Ohio MOLST Form – Version 11

• Discussion includes:
  – CPR wishes
  – Medical interventions
  – Antibiotic use
  – Artificial nutrition/hydration
MOLST in Cincinnati

        Health Improvement
        Collaborative of               Respecting
        Greater Cincinnati             Choices

                    Lutheran Medical
            MOLST in Cincinnati
• Linda Briggs (in conjunction with Respecting Choices)
  completed facilitator and train the facilitator programs in
  mid-January 2011
• ? Summer/Fall 2011
   – Pilot project to begin at Mercy West Park LTC Facility
• Other
   – Potential pilot projects at UC Medical Center
   – Various initiatives from the Christ Hospital Palliative
     Care Team
   – Catholic Healthcare Partners are encouraging use in
     their healthcare organizations
   – Hospice of Cincinnati has provided education to
     several physician offices throughout the Greater
     Cincinnati area
• Here is a 10 minute video clip of an example
  of a POLST/MOLST conversation with Linda
  Briggs, an advance care planning facilitator.
  The conversation is being held with two
  daughters of a patient with Alzheimer’s. The
  patient is unable to participate in the
  conversation and prior to being unable to
  make her own healthcare decisions, she
  designated one of her daughters as her
  Durable Health Care Power of Attorney.
American Bar Association. (n.d.). Retrieved from

Briggs, L. & Hammes, B. (2010). Honoring patient preferences. Powerpoint

Cluxton, D. (2008). Program description for Ohio. Retrieved from

Collopy, K. (2010) What you should know about DNRs. EMS Magazine, 30 (8), 52-

Courts and the End of Life - The Case Of Nancy Cruzan. (2011). Retrieved from

Duties of health care providers. 1137.16. Retrieved from

Hammes, B.J., Rooney, B.L. & Gundrum, J.D. (2010). A comparative, retrospective,
  observational study of the prevalence, availability, and specificity of advance
  care plans in a county that implemented an advance care planning microsystem.
  Journal of the American Geriatric Society, 58. 1249-1255.
Health Improvement Collaborative of Greater Cincinnati: http://www.the-

Hickman, S.E., Nelson, C.A., Perrin, N.A., Moss, A.H., Hammes, B.J., & Tolle, S.W.
   (2010). A comparison of methods to communicate treatment preferences in nursing
   facilities: Traditional practices versus the physician orders for life-sustaining
   treatment program. Journal of the American Geriatric Society, 58.1241-1248.

Morrow, A. (2011). Karen Ann Quinlan: A pioneer in the right-to-die movement. palliative care. Retrieved from


Respecting Choices:

Sabatino, C.P., )2004). National advance directives: One attempt to scale the barriers.
   American Bar Association, Commission on Law and Aging.

Wilkinson, A., Wenger, N., & Shugarman, L. R. (2007). Literature review on advanced
   directives. U.S. Department of Health and Human Services. Retrieved from
Thank You!

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