advance directives for beginners

Beginner’s Guide to Advance

DirectivesKelly Welton BA, RRT-NPS

© 2015 The Breathing Specialist

© 2015 The Breathing Specialist

© 2015 The BreathingSpecialist

When Am I Going To Talk About This ?


“I have a Living Will, do I need an Advance Directive also” ? DPAHC- Appoints someone straightaway to make

the decisions AD- Outlines their wishes Living Will- Outlines what you do or do not want,

and appoints someone to make those decisions if the patient cannot


DECLARATIONI, (Name) , being of sound mind, willfully and voluntarily make this

declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the

circumstances indicated below.I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition

or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might

occur by withholding or withdrawing life-sustaining treatment.In addition, if I am in the condition described above,

Living Will example

Excerpted from LegalTemplates.net


How Do You Feel About Each of These Treatments? Receiving blood or blood products Yes

No Having to have Surgery Yes No Invasive Testing Yes No Cardiac Resuscitation (CPR) Yes No Mechanical Ventilation Yes No BiPap Ventilation Yes No Tube Feeding Yes No Dialysis Yes No IV’s Yes No Antibiotics Yes No


Directive to PhysiciansDirective made this __ day of ____ in the year ____.

I,_____, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth in this

directive. If at any time I should have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the

application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent or will result within a relatively short time without the application of life-

sustaining procedures. I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally.

In the absence of my ability to give directions regarding the use of those life-sustaining procedures, it is my intention that this directive be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical

treatment and accept the consequences form that refusal. .

Advance Directive Sample


This directive is in effect until it is revoked. I understand the full import of this directive and I am emotionally and mentally competent to make this directive I understand that I may revoke this directive as any time. I request that only comfort care be provided to me, no antibiotics, no artificial nutrition, no mechanical ventilation, and no hydration. It is my strong preference to be allowed to die outside of a care facility if possible, even if that preference is determined by my physician to shorten my period of dying. The only condition under which I desire these preferences for end of life care to be altered is in the case of possible organ and tissue donation. I request that any and all organs and tissue that may be salvaged be provided for transplant. My remains may then be cremated.Signed ______________ in the City of ____________etc.

http://www.medicinenet.com/script/main/art.asp?articlekey=61982


What Does all of this Mean? What am I signing? Revocable: If you can say it, we will do it But, saying yes to one thing often means saying

yes to many things that are connected


BiPap- The new cover-all solution (NOT!) Bipap is ventilation without the endotracheal

tube =ventilator=life support Often done for the family

Photo courtesy of Respironics


Photo courtesy of Respironics Inc.


What in the world is “The Peri-operative Period?” Pre-hospital DNR or Advance Directive in place Procedures, surgeries, etc.


Surgery = -pre, -peri, and –post op DNR or any limitations gets rescinded during any

‘procedure’ in many hospitals Immediate post-operative time is considered “the

extended peri-operative period” Aggressive treatment to ensure success of the

procedure Once treatment is started, very difficult to stop After a ‘procedure’, when will the full Advance

Directive kick in?


Have We Met?

Electronic Medical Records- blessing and nightmare


A Personal Choice

To Live, or to Die Definition of Living -Cultural -Religious -Personal Beliefs about the Afterlife -Fear in the Moment -Understanding of what is available -Understanding your own physiology


How Do You Feel About Each of These Treatments? Receiving blood or blood products Yes

No Having to have Surgery Yes No Invasive Testing Yes No Cardiac Resuscitation (CPR) Yes No Mechanical Ventilation Yes No BiPap Ventilation Yes No Tube Feeding Yes No Dialysis Yes No IV’s Yes No Antibiotics Yes No


Quality of Life

What does ‘quality of Life’ mean to you? Would you want to live on a ventilator? Would you want to live at home as long as

possible? Would you want to live in a Care Facility? If you had solid answers to these questions, who

could you trust to carry out your wishes for you?


DNR variations and choices “Intubation only, no CPR” - Often chosen by those with Asthma or COPD “Chemical Code only”

Use of BiPap

DNR: Do Not Resuscitate orders


What is a “Code Blue” ?

Not like on TV MD comes running to put breathing tube in the

throat RT ventilates with a bag and assists with

intubation and secures the breathing tube Pharmacy team comes running RN comes running with crash cart, starts IV’s and

gives initial meds Someone does chest compressions Defibrillator attached - Ouch!


What if family is present during a code? Violent images that are hard to forget Shock at how violent and/or chaotic it seems Anger – may try to remember all the details Guilt- Things unsaid


The Nightmare

No Advance Directive on file “No specific directions = full code Patient crashes, gets intubated, and sent to ICU Family called Conflicting opinions between family members


A different nightmare

Patient has Advance Directive on file at the Nursing Home or RCF, but becomes unresponsive and gets transferred to ED for ‘further evaluation”

Patient in SNF gets an infection requiring transfer to ER for Antibiotics.

Subsequent decline of the patient requires a full code, because no one can find the original Directive


Worse Nightmare

Patient’s AD is at her primary care MD’s office, or in a safe deposit box or attorney’s office somewhere

Patient’s caregiver get scared, calls 911 despite being told not to.


Worst Nightmare Ever

Patient is stating his/her wishes, family is deciding otherwise

Family’s choices to prolong include tracheostomy and home ventilation, or SNF sentence

Photo courtesy of Allegro Medical


The solutions

Make sure to add a line for Non-Invasive Positive Pressure Ventilation to AD Be sure there are provisions for feeding tubes Include a well-defined peri-operative period (i.e., 24 hours) Include TPN as a choice Educate the public on the amount and extent of choices they have, and the complications of each If bedridden, make provisions for bedsore care


Doctors are trained to save lives, not end them. DNR for end-stage COPD On floor, she gets very short of breath Gets to ICU, and is in progress with MI Cardiologist talks her into a cath Intubated for cath Unable to extubate after procedure Family furious


What Can You Do?

Search for Advance Directive Forms for your State Discuss with family members your wishes Appoint carefully Make sure everyone knows where to find your

document.

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