strategies for advance care planningelderaffairs.state.fl.us/doea/pubs/pubs/eol.pdf · your wishes....

Strategies for Advance Care Planning

Advance Directives - Terms to Understand

Making Choices 2005

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Message from Governor BushFloridians are living longer today than at any point in our history. Andthanks to advances in technology, we are living a better quality of life.With these advances often come difficult decisions about end-of-lifecare, and the effect it will have on our families and loved ones. Bytalking with family members and planning for our care we ease theburden of making some of life’s most difficult decisions. Florida istaking the lead in helping caregivers and individuals prepare for thesechallenging choices. In an effort to continue helping our most vulner-able citizens, I encourage all Floridians to begin discussing end-of-lifecare with your family and loved ones.

Florida Department of Elder Affairs

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Message fromSecretary Carole GreenThis second edition of “Making Choices” is designed to help you askthe right questions about life planning and reach the answers mostappropriate for you. Decisions regarding end-of-life care can be dif-ficult to make; however, understanding your options and where youcan turn for help may allow you to make a more informed decision.We hope this updated edition of “Making Choices” will assist you asyou begin to define your wishes and share them with your family andloved ones.

Florida Department of Elder Affairs4040 Esplanade WayTallahassee, FL 32399(850) 414-2000

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TTTTTable of Contentsable of Contentsable of Contentsable of Contentsable of Contents

Life Planning Perspective ................................. 1

Last Will & Testament ...................................... 2

Beyond a Last Will & Testament Terms to Under-stand ......................................................... 3

Communicating End-of-Life Choices to Familyand Loved Ones ........................................ 5

Strategies for Advance Care Planning .............. 9

Emergency Medical Services & The Do Not Re-suscitate Order ........................................ 14

End-of-Life Preparations and Hospice Care .... 22

Bereavement and Final Arrangements ............ 23


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The articles contained in this publication have beenexcerpted from Making Choices (2002) and the 2003-2004Consumer Resource Guide published by the Department ofElder Affairs. For questions or to order free copies of thesepublications, please contact the Florida Department of ElderAffairs at 850-414-2000 or visit our web site atwww.elderaffairs.state.fl.us.

The Vision of the Departmentof Elder Affairs is “to leadthe nation in providing olderpersons with information,choices and opportunities.”

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Life Planning Perspectiveof medical care or services do wewant to receive and what serviceswould we refuse? Defining ourwishes and communicating themto our family and loved ones is ofvital importance when addressingend-of-life issues. Although thedecision making process may bedifficult emotionally, taking thor-ough and thoughtful actions nowcould ensure clarity later.

The most important aspectsof life planning and end-

of-life preparation should beginwell before we enter the finalstages of our lives. In fact, life plan-ning should begin while we havegood health and are consideredto be of sound mind. Unless wecarefully and deliberately plan andexpress our wishes in writing andin the appropriate legal format,there is no guarantee that ourwishes will be correctly inter-preted and honored.

As we get older, there are twoimportant things we must do. First,give ample consideration as to theway we want our assets managedif we should become sick or in-capacitated and are no longer ableto manage them ourselves. Whodo we know and trust who willact in our best interest? We mustalso consider the way we want ourassests distributed upon ourdeath. Secondly, give ample con-sideration to the way we want ourhealth managed if we are not ableto manage it ourselves. What kind

Common LifePlanning Mistakes

! Not keeping records up-to-date and current

! Not sharing the locationof vital records/documents

! Letting emotions rule yourdecisions

! Not getting legal affairs inorder (e.g. property titles)

! Naming inexperienced orirresponsible executors

! Waiting too late to beginthe planning process


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Last Will & Testament

you have very little property orpossessions, to ensure that yourthings are passed on according toyour wishes. Examples of prop-erty include stocks, bonds, cer-tificates of deposit and real estate.Most people wish to pass theirpossessions on to their childrenand/or family members.

Proper estate planning will enableyou to reduce estate taxes and,thereby, pass on more of yourestate to your loved ones. It isimportant that you execute a willand specify who you want to re-ceive what items.

Over our lifetimes we willinevitably accumulate

property and possessions. A willis a document that directs howyour property will be passed onat the time of your death. It alsodesignates a person to be respon-sible for assembling the property,paying debts and taxes, and dis-tributing what is left. A person whodies without a will dies intestate.Consequently, their propertypasses as designated by the lawsof intestacy, regardless of thewishes of the deceased. It is agood idea to make a will, even if

Ask yourself: “How can I protect my assets, but atthe same time make sure I do not violate laws orrules that may affect my receiving long-term care?”

Consult with an attorney specializing in elder law foran answer to this question and other related “assetprotection” questions. In seeking professional help,make sure that the person you select isknowledgeable of Medicaid rules and regulations.

To find a licensed attorney, contact the Florida Bar LawyerReferral Service at 1-800-342-8011 or visit www.flabar.org.

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Beyond a Last Will & TestamentTerms to Understand

becomes incapacitated or unableto make his/her own decisions.Many living wills include “do notresuscitate orders” (DNRO) thatspell out under what circum-stances an individual does notwant to be revived. More infor-mation about DNROs is includedin this publication.

Health Care Surrogate -An individual you select to makemedical decisions for you whenyou are no longer able to makethem yourself. Your surrogate willbe responsible for communicat-ing your wishes to your doctor.In order to change or revoke thedesignation of a surrogate, you

Advance Directive- A gen-eral term that refers to oral orwritten instructions given by a per-son expressing wishes about fu-ture medical care in the event theyare unable to speak for them-selves. Advance directives can bechanged or modified by the au-thor.

A competent adult has the right ofself-determination regarding de-cisions concerning their health, in-cluding the right to refuse medicaltreatment. Without an advancedirective in place, there is no guar-antee your wishes will be hon-ored. A person’s intent may becommunicated in the followingthree ways: a living will, a healthcare surrogate, and/or a durablepower of attorney. A brief descrip-tion of each of these directives isprovided below.

Living Will - A document thatformalizes an individual’s wishesregarding the medical care that isto be used or withheld if he or she

Advance DirectivesGenerally Must Be:

! In writing

! Signed by the personmaking the will

! Compliant with state laws

! Witnessed


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must provide a signed, dated ac-knowledgment of your wishes.

Durable Power of Attor-ney - A document that can del-egate the authority to make health,financial, and/or legal decisions ona person’s behalf. Unlike a gen-eral power of attorney, a durablepower of attorney continues to beeffective when a person becomesincapacitated. The durable powerof attorney must be in writing andmust show the person’s intent togive specified power if the per-

son is incapacitated. The durablepower of attorney must specifi-cally state that the designated per-son is authorized to make healthcare decisions.

If you choose not to write an ad-vance directive, be sure all of yourfamily and friends clearly under-stand what you wish to have doneif you are incapacitated. Thiscommon understanding amongfamily and friends will help to pre-vent confusion as to the interpre-tation of your wishes.

Ask yourself: “Do I need an attorney to complete myend-of-life documents?”

Consulting with an attorney is recommended.Although an attorney is not required to fill outadvance directive forms, there are specific legalrequirements that vary from document to documentand from state-to-state. Failure to follow thesespecific requirements may invalidate an entiredocument and could result in one’s wishes notbeing observed. An attorney, licensed in Florida,can ensure that your forms are in proper order. Tofind a licensed attorney, contact the Florida BarLawyer Referral Service at 1-800-342-8011 or visitwww.flabar.org. If you cannot afford an attorney,you may contact your local legal aid office.

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something happened to you.Would they know your wishes?

If advance care planning is notdone, wonderful relationships maybecome strained for those left todecide medical treatments forsomeone with an acute or chronicillness, or those at the end-of-life.This is why advance care plan-ning and advance directives areso important. Yet, most adults donot have an advance directive thatstates their preferences regardingthe use of medical treatments toprolong life. Many adults are re-luctant to even talk about it.

Conversations about end-of-lifeissues are not easy to start. Manypeople think that they do not needto worry about these issues.However, there are countlesstragic situations in which familymembers are fearful of making

Communicating End-of-LifeChoices to Family and LovedOnes: Isn’t It Time We Talk About It?

Kathy Brandt, M.S., and Karen Lo, M.S., R.N.

We are all parents, adults,children, spouses or

partners, siblings, nieces, neph-ews, grandchildren or grandpar-ents. No matter what our role,we have responsibilities to family.One of the most difficult obliga-tions is the role of health care sur-rogate. In Florida, if a person be-comes incapacitated and cannotcommunicate health care wishesor decisions, a health care surro-gate can make those decisions.What happens if someone has notselected a surrogate? The re-sponsibility for medical decision-making would fall to family mem-bers. This means that you couldautomatically become a relative’sproxy should something happento them. Would you know theirwishes?

Likewise, one of your relativescould become your proxy if


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decisions about the care of some-one who did not communicatetheir own wishes clearly. The fol-lowing are tips to start a conver-sation about end-of-life prefer-ences.

Explore PersonalBeliefsEase into the discussion by talk-ing about personal values. If youknow someone’s values, it will beeasier to make decisions for themif you are ever appointed theirsurrogate. This might also help toclarify their feelings prior to talk-ing specifically about medical careoptions. You might consider someof the following questions:

! What would help you livewell at the end-of-life?

! What do you want toaccomplish before you die?

! How will you prepare foryour own death?

! What would you want saidfor your eulogy?

! What legacy from your lifedo you hope to leave toothers?

! What would help you copewith facing your death orthe death of a loved one?

! Do you have anyrelationships that needattention, care and/orreconciliation?

Ask yourself: “How can I ensure that my wishes arehonored if something happens to me?”

You should talk with family members and let themknow your wishes regarding how much emergencyor life-preserving care you want, should youbecome incapacitated. Those wishes should beformalized in advance directives. You should alsoconsult with an attorney for assistance in developinga will (last will and testament) or a trust agreementto protect and distribute your assets in accordancewith your wishes upon death.

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Explore PreferencesSome people know what they donot want, rather than what theydo want. If you do not know theanswer to a medical question, youcan always ask your physician orcall your local hospice. You mightconsider some of the followingquestions:

! Who would be most ableto provide comfort to you?

! Where do you want tospend the last days of yourlife?

! What kind(s) of medicalcare do you want as theend-of-life approaches?

! Are there specific medicalprocedures that you wantto learn more about beforemaking care decisions?

! Are there some proceduresyou definitely do not want?

! Have you discussed theseissues with anyone?

! Have you completed anyadvance directives such asa living will? If so, where isit?

! Are there any issues relatedto dignity or quality of life at

the end-of-life that youwant to explore with yourfamily or physician?

After having these conversations,it is important to decide whetheror not you feel comfortable put-ting your wishes in writing. Manypeople find the idea of writingdown their preferences in a livingwill confusing and intimidating.Although options exist that do notrequire your wishes in writing,written statements more effectivelyformalize your decisions. Livingwills are written statements inwhich an individual expresses hisor her desires for end-of-life care.They preserve the individual’sright to accept or decline care —even when he or she may be in-capacitated. Legal counsel is notrequired to complete and executean advance directive.

ConclusionWe cannot plan when or how wewill die. However, we can takesteps now to ensure that ourwishes are honored at the end-of-life. Let it be a time of peace,where the greatest burden to yourloved ones is saying goodbye —


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and not determining how you willdie. Now is the time to talk aboutend-of-life planning with your

“You, your family andloved ones, your physician,your lawyer and/or yourclergy should have copies ofyour advance directives.”

friends, family, and health careproviders.

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Strategies for Advance CarePlanning

Gail Austin Cooney, M.D., and William L. Allen, J. D.

Deciding to have an ad-vance directive is only the

first of several key decisions aboutend-of-life care. Once a personmakes this decision, a number ofquestions arise about the bestapproach to take. However, thebest approach may vary from oneindividual to another. This articleidentifies the benefits as well asthe potential problems withvarious approaches. Thisinformation is intended to help youdetermine which avenue is bestsuited to your situation.

1. Having only a livingwill.Advantage:

Some people have felt that if theycould be sufficiently clear abouttheir choices of treatment limita-tions in a living will, they wouldnot need a surrogate decision-maker. In one case a man reported

that he deliberately chose thisstrategy, so that his wife wouldnot have the emotional burden ofmaking decisions or the respon-sibility for carrying out his choicesabout limitations or refusals oftreatment.

Disadvantages:

Most living wills cannot ad-equately foresee all of the clinicalcircumstances that may arise;therefore, some decisions mayneed to be made that the patientcould not have foreseen or directlyaddressed in prior instructions.Therefore, what is expressed in aliving will often needs to be aug-mented by a decision-maker cho-sen by the patient who will be ableto interpret what is in the living willor explain what the patient wouldhave wanted under the circum-stances.


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someone who says, “How canyou demonstrate that what youhave chosen is what the patientwould have wanted?” Writtendocumentation of your choicescan be used to show consistency.

3. Having a combi-nation of living will andhealth care surrogatedecision-maker.Advantages:

The key to making this optionwork for you is to make sure yoursurrogate has read your living willand asked you questions to clarifyany remaining questions. If youhave both a living will and a sur-rogate, a challenger will find thatit is his word against yours andyour surrogate’s, instead of hisword against your surrogate’sword alone.

Disadvantage:

If your surrogate hesitates to fol-low your choices as expressed inthe living will, it makes it very dif-ficult for the physician to withdrawtreatment that you refused in writ-ing.

2. Having only a healthcare surrogate decision-maker.Advantages:

Some groups advise that the bestway to prevent a living will frombeing interpreted in a way thatresults in an outcome contrary toyour intention is to not write oneat all. This strategy tries to pre-vent that misinterpretation by sim-ply naming someone who knowswhat you want and who will ex-press those decisions for you,without having a document thatmay be ambiguous and thereforeused by others to challenge whatyour surrogate says you wouldwant.

Disadvantage:

Although the risk of the abovescenario cannot be ruled out, awritten living will can also be animportant source of formal sup-port for what your surrogate saysyou would want when someonechallenges his or her account ofwhat you would have chosen. Ifyour surrogate is challenged by

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4. Adding a “valueshistory.”A “values history” is an idea de-rived from the term “medical his-tory.” Just as your medicalrecord, augmented by yourphysician’s elicitation of new in-formation during each encounterwith you, provides a history ofyour health status that guidesmedical diagnosis and recommen-dations for testing and treatment,so a values history is an attemptto elicit your values, feelings,choices, and biographical detailsthat may shed light on what deci-sion you would make if you everlost the capacity to decide foryourself. A values history, eitheras part of or separate from anadvance directive, can help yoursurrogate and your care provid-ers determine what you would belikely to decide, based on a broadexpression of what has been andis important to you. A key com-ponent of a values history is yourown expression of what consti-tutes an acceptable quality of lifefor you. This can help your phy-sicians and surrogate know that if

proposed treatments cannot re-store you to a quality of life youfind acceptable, you would refusesuch treatment.

5. Relying on the proxydecision-maker insteadof naming a surrogatedecision-maker.Advantages:

If choosing one member of yourfamily to be your surrogate willhurt the feelings of others, it maybe tempting to simply avoidchoosing, especially if the list ofproxy decision-makers specifiedin statute will turn out to be thesame person you would have cho-sen, anyway.

Health care decisions may bemade for the patient — if the pa-tient has no advance directive ordesignated surrogate — by anyof the following individuals, in thefollowing order of priority:

! Judicially appointedguardian

! Patient’s spouse

! Adult child of the patient

! Adult sibling of the patient


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! Adult relative of the patient

! Close friend of the patientSee section 765.401, FloridaStatutes.

Disadvantages:

The problem with this is that aproxy’s decision may be moreeasily challenged than a specifiedsurrogate’s. By naming a surro-gate, you are giving that personthe legal presumption (in Florida)that his/her determination of whatyou would want is correct. Any-one challenging what your surro-gate says will have the burden of

showing that person is wrong. Bynaming a surrogate, you place yourdecision-maker in a much stron-ger position to prevail against any-one who might decide to challengehim or her.

6. Including “choice ofsettings” language.One strategy that may help youimprove the probability that youwill have your choices honored isto specify in your advance direc-tive (living will and/or surrogate)your choice of the setting in whichyou want to spend your last days.You may want to rank order sev-eral options to allow for trials of

To help you develop a values historyconsider the following:

! Overall attitude toward life and health

! Personal relationships

! Thoughts about independence and self-sufficiency

! Living environment

! Religious background and beliefs

! Relationships with doctors and other health caregivers

! Thoughts about illness, dying and death

! Finances

! Funeral plans

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certain types of treatment that re-quire hospitalization, but specify-ing that if there is not sufficient im-provement, you choose to bemoved to your home, or if that isnot possible, to a residential hos-pice or a nursing facility near yourhome and family or friends.

You may also want to add a state-ment that once the conditions ofyour living will are met, you wishto be moved to your home orchoice of facilities, even if such a

move could increase the risk toyour health status.

Decisions on which of these ap-proaches to advance care plan-ning best suits you requires care-ful reflection. But don’t stop withreflection. Follow up by imple-menting the approach youchoose, and talk with yourphysician(s) and your loved onesabout what you have chosen. Thisprocess can minimize a host ofproblems later.

“Deciding to have an advance directive isonly the first of several key decisions aboutend-of-life care.”


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Emergency Medical Services &The Do Not Resuscitate Order

Freida Travis and Jessica Swanson

The emergency medicalservices (EMS) system

delivers rapid out-of-hospitalmedical care for victims sufferingfrom sudden illness or injury. Overthe last 30 years, new develop-ments in medical technology andnew treatments have improved theability of EMS providers to mo-bilize care and sustain life in emer-gency situations. Emergencymedical technicians (EMT) andparamedics complete compre-hensive coursework and aretrained to perform highly techni-cal life-saving measures using so-phisticated equipment. Standardlevels of care have evolved fromclosed chest cardiac compres-sions to definitive techniques us-ing equipment such as automatedexternal defibrillators, in many in-stances reversing sudden deathoutside the hospital.

Until very recently, there were fewprovisions in emergency medicinefor withholding care from patientswho would not benefit from ad-vances in medical technology andtraining — specifically, those whosuffer from an end-stage condi-tion, terminal illness or persistentvegetative state, where advancedlife-saving measures can be pain-ful, intrusive and futile. As earlyas 1990, the growing awarenessover end-of-life issues and thedesire to honor a patient’s wishnot to be resuscitated, promptedthe Florida Department of Health,Bureau of Emergency MedicalServices to examine ways to vali-date a document that would al-low EMS providers to honor apatient’s last wishes.

In 1992, the first legislation ad-dressing pre-hospital Do Not Re-suscitate Orders (DNRO) was

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The development of the DNROwas critical to EMT’s and para-medics. When an EMT or para-medic arrived on scene theyneeded to respond immediatelyby providing care to the patient incardiac or respiratory arrest, un-less presented with clear proof ofthe patient’s wish not to be resus-citated. This situation could be-come volatile and occasionally ledto conflict when family membersdisagreed with the EMT’s deci-sion to attempt resuscitation.Many health care facilities woulduse their own forms, and doctorswould write, “Do Not Resusci-tate” in a patient’s chart. However,if a patient was transferred ortransported to another facility,their wishes may or may not havebeen honored.

EMS needed a readily accessible,standardized document thatwould meet the needs of the pa-tient, but that would also be rec-ognized statewide by EMS pro-viders as legal and binding, pro-tecting them from potential civiland criminal liability for honoringthe DNRO document.

enacted. The 2000 Do Not Re-suscitate Order legislation autho-rized changes to the form, and alsoprovided protection from civil li-ability for criminal prosecution tovirtually every licensed health carefacility honoring the DNRO. Sincethat time, the Bureau has con-sulted with health care providers,consumers and other state agen-cies. In February 2000, a revised,yellow DNRO form was rede-signed for simplicity and portabil-ity.

The Do Not ResuscitateOrderA Do Not Resuscitate Order is aspecific, physician-directed docu-ment that says that the individualdoes not wish to be resuscitatedin the event of cardiac or pulmo-nary arrest. It is usually written forsomeone who is terminally ill, suf-fering from an end-stage condi-tion or in a persistent, vegetativestate. According to the DNRO,Form 1896, cardiopulmonary re-suscitation includes artificial ven-tilation, cardiac compression, en-dotracheal intubation and defibril-lation.


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The revisions in 2000 were madeto the DNRO in an attempt to al-leviate public and professionalconcerns that do-not-resuscitateorders were confusing, hard toaccess and could not be usedwhen transporting a patient be-tween health-care settings. Toassess the extent of these prob-lems and to identify possible so-lutions, the state held workshopsto collect input on how theDNRO should look and how it

could be incorporated throughoutthe continuum of care. The out-come of these workshops resultedin a form that was easy to iden-tify, met the needs of the patient,and was portable between healthcare settings. Consequently, theDNRO is intended to be used asa tool to record the patient’swishes, reduce conflict on sceneand allow EMS personnel to pro-vide compassionate and appro-priate care.

The DNRO is different from aliving will or other type ofadvance directive.

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The DNRO “YellowForm”The DNRO is often referred toas the “yellow form” because itmust be either the original on ca-nary-yellow paper, or a copymade onto similar colored-yellowpaper. It must be signed by theindividual or the individual’s healthcare representative and by aFlorida licensed physician. Ac-cording to Chapter 64E-2.031,Florida Administrative Code, anyprevious version of the Depart-ment of Health Do Not Resusci-tate Order will be honored, andthere is no need to sign a newform. The Florida DNRO is onlyvalid in Florida, and it can be re-voked, either orally or in writing,at any time by the patient or thepatient’s health care representa-tive.

Patient Identification Device

At the bottom of the DNRO thereis a patient identification devicethat was included and may be re-moved from the form by cuttingon the perforated lines, completed

and may be laminated. To use thePatient Identification Device, theperson or the person’s health carerepresentative and a Florida li-censed physician must sign thedevice. If laminated, the devicecan be worn around the neck, onthe wrist, or attached to bedding,clothing or somewhere else whereit can be easily seen. The PatientIdentification Device was de-signed for portability between set-tings.

The device is a card, and doesnot have to be completed with theDNRO, Form 1896, for the formto be valid. Once completed andremoved from the form, the Pa-tient Identification Device isequally valid to the DNRO, Form1896. The Patient IdentificationDevice should not be carried as awallet card. Emergency medicaltechnicians and paramedics areunlikely to have the time beforethey attempt resuscitation tosearch a wallet of someone in car-diac or pulmonary arrest. If usingthe device, it is best to keep it dis-played or easily accessible at alltimes.


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Portability

The yellow DNRO form was re-designed also with portability inmind, allowing one document towalk through many different

health care settings. According toFlorida Statutes, the DNRO maynow be honored in most healthcare settings, including hospices,adult family care homes, assistedliving facilities, emergency depart-

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ments, nursing homes, homehealth agencies and hospitals. Italso protects the health care pro-fessional, from criminal prosecu-tion or civil liability for the with-drawal or withholding of cardio-pulmonary resuscitation. The sig-nificance of portability means thathaving one form signed, whetherit is the original or a copy, andkeeping a copy with you will pro-tect your wishes if you are trans-ferred between health care set-tings.

Calling 9-1-1

When a person signs a DNRO itis a critical time in his or her life.He or she has made a personalchoice, hopefully with the supportof family, caregivers and healthcare workers, including hospiceprofessionals and volunteers.Even if prepared, managing deathis difficult and may not occur in-stantly. The person may experi-ence a wide range of symptoms,including shortness of breath,pain, seizure or other problems.When this happens, those caringfor the patient may be unsure ofwhat to do, scared, or just want

the support of a health care pro-fessional. This is the time at whichmany decide to call 9-1-1, theemergency services telephonenumber.

Any family member, caregiver orhealth care provider can call 9-1-1 at any time to attend to the pa-tient with a DNRO. The DNROonly means that in the event ofcardiac or pulmonary arrest, EMSwill not attempt resuscitation. Aperson will still be treated for painand provided “comfort care.” Itis clear that a DNRO does notmean “do not treat for pain,” “donot offer comfort care measureslike oxygen” or if there is a re-versible medical problem, “do nottreat or transport to another facil-ity.” The State of Florida is un-dertaking an educational effort toprepare emergency medical tech-nicians and paramedics to betterrespond to calls involving aDNRO so that they are preparedto treat and comfort patients andfamilies at the end-of-life.

Emergency Medical Services per-sonnel are there for the family andact as a resource in a difficult time,


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providing comfort care or trans-port to another facility if the needarises. If 9-1-1 is called, it is im-portant to communicate a briefdescription to the dispatch opera-tor and explain the situation. Forexample, “My family member hasa DNRO form, but is convulsingand I don’t know what to do.”When the emergency medicaltechnician or paramedic arrives,as much information as possibleshould be shared with them sothey will be able to provide themost effective and efficient care.

It is important to have the DNROavailable immediately, so that theywill not delay treatment whilesomeone searches through files ordrawers for the proper docu-ments. Make clear the wishes ofthe patient, specifically that theydo not want to be in pain or whattype of comfort or care they needor request. The emergency re-sponding EMS professional isthere to answer any questions orconcerns about treatment andcare.

ResourcesWhen deciding to complete a DoNot Resuscitate Order, it may bebest to speak with your physician,local clergy, or a social workerabout your wishes. You shouldalso inform your family membersor caregivers about your wish notto be resuscitated. It is importantto reiterate that a Do Not Resus-citate Order does not mean donot treat, and the provision of com-fort care measures, such as oxy-gen or medicines are availablethrough emergency medical ser-vices.

If you have questions about theDNRO, Form 1896, contact yourlocal EMS provider, your physi-cian, local attorney or senior cen-ter program. You can also call(850) 245-4440, ext. 2735 orwrite to:

Bureau of EmergencyMedical Services4052 Bald Cypress Way Bin C 18Tallahassee, Florida32399-1738

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or visit

Bureau of EMS’s web page athttp://www.doh.state.fl.us/demo/EMS/default.htm

Florida is a very diverse state,and many people have requestedtranslations of the DNRO in theirnative language. Unfortunately, theBureau of EMS does not providetranslations of the form. There aresome health care agencies inFlorida that do translate, but todate only into Spanish. Emergencymedical services providers can-not honor this translation, and itshould be used only for informa-tional purposes. If the patient orpatient’s health care surrogatesigns a Spanish version theyshould also sign the Departmentof Health English version 1896and keep the forms together. Thisensures that a responding EMTor paramedic can read and honorthe English, Department of Healthversion, while also assuring thatthe patient fully comprehends thedocument.

DNRO ConclusionEmergency medical services pro-viders throughout the state areworking in their communities toprovide leadership and resourcesfor people at the end-of-life. TheDNRO is one tool people can useto help ensure that their wishesnot to be resuscitated will be hon-ored. The DNRO was redesignedto be easy to understand, locateand transfer between health caresettings. EMS will work in part-nership with the community andhealth care facilities to providemedically appropriate and com-passionate care, improving thequality of end-of-life care.


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End-of-Life Preparations andHospice Care

Hospice care is a specialway in which family

members and others providecomfort and support to terminallyill loved ones during the finalmonths of their lives. Rather thanengage in painful struggles to keeppatients alive, this time is used asa period of social, emotional, andspiritual healing. The objective ofhospice care is to improve pa-tients’ quality of life by makingthem as comfortable as possible.

Hospice care strives to manage apatient’s pain while keeping themcoherent and alert. It also empha-sizes care and counseling of boththe patient and his or her family.Although consent and certificationfrom a doctor is necessary for ad-mittance to hospice care, it is of-ten a more cost effective choicethan traditional hospital care.

Should your loved one reach apoint where death appears to beinevitable, it is important to dis-

cuss their wishes with them. Withadvances in today’s medical care,a person’s life can be extendedthrough the use of life support sys-tems; however, the remaining qual-ity of life may be unacceptable.Often patients with terminal ill-nesses would rather spend theirremaining time in the comfort oftheir home, close to family andfriends.

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Bereavement and FinalArrangements

Sadly, your period of bereave-ment can be an opportunity fordishonest persons to try to takeadvantage of you. During thistime, dishonesty can take manyforms including attempts to denybenefits or claims due, overcharg-ing for services rendered, or with-holding important information thatcould affect the decisions andchoices you make. Pay carefulattention when making arrange-ments and consult with loved oneswhen you have concerns.

Listen carefully to those individu-als who have no vested interestor potential gain in the outcomesof your decisions. While griev-ing, remember that your loved onecared about you and would beconcerned about your financialand physical well being long afterhe or she is gone.

Try to take comfort in the timesand memories you shared. It is

The loss of a loved one,whether they lived to be

over 100 years old or died muchsooner, is a sad, painful, anddeeply personal experience.While bereavement is a time ofreflection and healing, it is also atime when many critical decisionsmust be made. These decisionsrange from the choice of funeraland burial arrangements, to assetsprotection and accounting, as wellas securing your own future careneeds. Unless life care and end-of-life issues have been plannedwell in advance, a decision madeout of highly charged emotionsmay prove to be problematic.

Be careful. Do not be pressuredto make decisions on the spot ortoo quickly. Do not be afraid toget second and third opinions,compare prices and services, andalways seek information from in-dependent sources.


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Confused about funeral and burial services?

“Funerals: A Consumer Guide” is a publicationproduced by the Federal Trade Commission. Itwill assist you in asking the right questions andhelp you understand your rights as a consumerwhen making final arrangements. To request acopy, write to:Funerals: A Consumer GuidePublic ReferenceFederal Trade CommissionWashington, DC 20580.

okay to laugh, cry, and talk aboutyour loved one as though he orshe were still with you and remem-ber all of these reactions are anormal part of grieving.

Now that you know more about why advance directives are important, it's time to get started. Here are two re-sources to help you as you begin to make these decisions:

Aging with Dignitywww.agingwithdignity.org

1-888-5-WISHES (1-888-594-7437)

National Hospice & Palliative Care Organization

www.nhpco.org1-800-658-8898

For questions regarding this publication, contact:Florida Department of Elder Affairshttp://elderaffairs.state.fl.us(850) 414-2000

strategies for advance care planningelderaffairs.state.fl.us/doea/pubs/pubs/eol.pdf · your wishes....

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