Total Hip Replacement

Patient Guide

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Patient Guide

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Total Joint Replacement Class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

What Is Total Joint Replacement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Rationale for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

The Total Joint Team: Who Are They? What Do They Do? . . . . . . . . . . . . . . .6The Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Orthopedic Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Nursing Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Nursing Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Physical Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Occupational Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Social Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Pharmacist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Getting Ready for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Visit to the Orthopedic Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Total Joint Replacement Class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Blood Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Pre-admission Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Insurance and Financial Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Advance Directive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Spiritual Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Preparing Your Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Checking into the Hospital—Admission Reminders . . . . . . . . . . . . . . . . . . . . .10Getting Ready to Go to the Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11In the Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

The Artificial Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12The Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12-13Blood Transfusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Thrombophlebitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-15Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Loosening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

After Surgery—Your Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Post-Anesthesia Care Unit (PACU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

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Patient Guide

On the Orthopedic Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Getting Back on Your Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Recuperation After Your Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Your Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18St. Patrick Hospital and Health Sciences Center

Outpatient Physical Therapy (Providence Center) . . . . . . . . . . . . . . . .18St. Patrick Hospital and Health Sciences Center

Transitional Care Unit (TCU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Nursing Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Follow-Up Doctor Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Weight Bearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Total Hip Replacement Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Risk of Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Hip Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21-22Posterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23-25

Inpatient Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Total Hip Replacement Excercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-27Using a Walker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28General Guidelines and Adaptive Equipment . . . . . . . . . . . . . . . . . . . . . . . .29

Bathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29-30Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Toileting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Household Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Furniture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Carrying Things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Car Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Dental Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Phone Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Preoperative Assessment Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35-36Total Hip Replacement Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37My Choices: Advance Directive for My Health Care . . . . . . . . . . . . . . . . . .38-41State of Montana Application for Special Parking Permit

or License Plates for a Physically Disabled Person . . . . . . . . . . . . . . . . . . .42-43Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

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IntroductionArthritis of the hip is a common condition causing pain and impaired lifestyle for manypeople after middle age. In the past, little was done for the condition. Fortunately, mod-ern surgical procedures can alleviate arthritis of the hip. A total hip replacement is theultimate solution for advanced hip arthritis. The procedure can help you feel better andmove more easily after your recovery.

The Total Joint Team at St. Patrick Hospital and Health Sciences Center provides jointreplacement services of the highest quality. We want you to be an active participant inour team. That's why we've provided you with this booklet. The chapters that followexplain how to prepare for surgery, what happens during the operation and during yourhospital stay, and what to expect as you recover.

We strongly recommend that in addition to reviewing the booklet you attend the free,preoperative total joint replacement class offered at the hospital. The class is designed toanswer many of your questions about joint replacement surgery. We believe that beingwell informed about your surgery can improve your recovery and outcome.

Total Joint Replacement ClassYou and your family members or others who may participate in your care are encour-aged to attend the total joint replacement class before surgery. You will be contacted byphone to register for the class. If you have not been called, please contact the admissionsdepartment at 329-5678 to register.

The class covers critical aspects of total joint replacement. Topics include

• instructions for the day of your surgery• operating room procedures• post-anesthesia care unit (PACU) procedures• nursing care, including equipment and your postoperative routine• pain management• physical therapy, including your daily activities, exercise program, and rehab choices• occupational therapy, including bathing, dressing, use of adaptive equipment, andhousehold activities• exercises started preoperatively and continued after surgery• planning for continued care after your hospitalization

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What Is Total Joint Replacement?A painful hip can severely affect your ability to lead a full, active life.Total joint replacement, also called arthroplasty, is surgery done toreconstruct a diseased joint. Hip replacement surgery is becomingmore and more common as the population of the world begins to age.Over the last twenty-five years, major advancements in hip replace-ment have improved the outcome of the surgerygreatly.

AnatomyThe hip joint is one of the true ball-and-socket joints of thebody. The hip socket is called the acetabulum. It forms adeep cup that surrounds the ball of the upper thighbone,known as the femoral head. The connection of the ball andsocket is held in place by the hip joint capsule, a soft tissuesheath that encloses the joint. The hip is surrounded by thethick muscles of the buttock in the back and the thickmuscles of the thigh in the front.

The surface of the femoral head and the inside of theacetabulum are covered with articular cartilage. This material is about one-quarter of aninch thick in most large joints. The articular cartilage surface is a tough, slick materialthat allows the surfaces to slide against one another without damage to either surface.

A healthy hip moves without pain. In an arthritic hip, the articular cartilage wears awayand leaves the bones unprotected, causing pain and stiffness.

Rationale for SurgeryThe main reason for replacing any arthritic joint with an artificial joint is to stop the bonesfrom rubbing against each other. Replacing the painful, arthritic joint with an artificial jointgives the joint a new surface that moves smoothly without causing pain. The goal is to helppeople return to many of their activities with less pain and with greater freedom of move-ment.

Artificial Hip Replacement

Hip Anatomy

The Total Joint Team: Who Are They? What Do They Do?Achieving the greatest benefit from total joint replacement surgery takes a team effort. TheTotal Joint Team works together to help you along the way, making sure you know what toexpect and assisting you toward your best recovery.

The PatientYou and your spouse, family, or significant other are the most essential members of the team.Taking the time to learn about your health and your surgery helps with your recovery.

Orthopedic SurgeonYour orthopedic surgeon is the leader of the team. In addition to planning and performingyour surgery, your surgeon will work with the other team members to assure your completeand rapid recovery. Feel free to discuss any aspect of your care with your surgeon. Yourcomplete satisfaction is the surgeon's concern.

Nursing StaffDuring your hospital stay, registered nurses and other skilled workers will care for you.Nurses attending you after surgery are specialists in orthopedic care. Each morning you andyour nurse will develop a plan for the day. The staff will assist you with personal care activi-ties, such as bathing and changing positions in bed. They will assist you with pain manage-ment, medication administration, care of your surgical site, bowel function, walking, andother aspects of your recovery.

Physical TherapistThe physical therapist focuses on developing your independence by increasing your abilityto move with ease. Your therapist will tailor an exercise plan to increase your strength andendurance. You will be shown special ways to walk and move to ensure your safety and pro-tect the new joint while it heals.

Occupational TherapistThe occupational therapist provides training and recommends equipment for independencein your daily activities. The therapist assesses your physical capabilities and limitations anddetermines your need for equipment such as a raised toilet seat, hand rails, a reacher, a sockaid, a tub bench, and so on.

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Social Worker/Case ManagerA social worker or case manager may assist with your discharge from the hospital. The social worker may help plan outpatient physical therapy, home health care, or a

short stay at a nursing home, if necessary. They can also assist in helpin you obtaindurable medical equipment if needed.

PharmacistThe pharmacist helps with pain management and provides information on medications.

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Getting Ready for SurgeryGetting ready for surgery is a process that involves a number of steps. Preparing willmake your experience easier.

Visit to the Orthopedic SurgeonThe decision to proceed with surgery should be made jointly by you and your doctor.The decision should only be made after you feel that you understand as much about theprocedure as possible. Talk to your doctor about what is expected of you, such as partic-ipation in a rehabilitation program, and which activities should be restricted after sur-gery. Your doctor will explain the benefits and risks of the procedure.

Total Joint Replacement ClassThe best way to plan for your surgery is to attend the free total joint replacement class atSt. Patrick Hospital and Health Sciences Center. The scheduler will contact you with theclass schedule. If you have not been contacted, please call the pre-admissions schedulerat 329-5678 to register.

Blood DonationYou may choose to donate your own blood prior to surgery in case a transfusion is need-ed while you are in the hospital. This reduces the risk of having an allergic reaction orgetting an infection, such as AIDS or hepatitis, from a blood transfusion. Blood can bedonated three to five weeks before the operation, giving your body time to make newblood cells before your scheduled surgery. A blood donation requires a physician's order,so discuss it with your doctor.

Pre-admission TestingBetween two and fourteen days before surgery, you must come to the hospital for pre-admission testing. Your doctor may order lab work, X-rays, and possibly an EKG (elec-trocardiogram). In some situations, your doctor may order the testing done at a facilitycloser to your home.

Insurance and Financial CounselingMost people review their insurance and financial situation before planning a total jointreplacement surgery. If you have insurance, the pre-admission nurses can check whetheryour surgery has been authorized. If you have questions or concerns, our pre-admissionnurses are available to assist you at 329-2684.

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Advance DirectiveAn advance directive is a legal document that some patients prepare before surgery. Itprovides guidance to the health care team about your wishes if you become incapable ofmaking or communicating decisions. An advance directive often appoints a representa-tive to make decisions for you and includes a living will. A sample advance directive islocated in the appendix of this booklet.

On admission to the hospital, you will be asked if you have an advance directive. Acopy of the advance directive will be added to your chart. Feel free to fill out the form atthe back of this booklet and bring a copy with you to the hospital when you check in.

Spiritual CareCaring for your spiritual needs during your hospitalization is very important. Hospitalchaplains are available, and your pastor or bishop is also welcome to visit. Chaplainsprovide spiritual care and support to patients, families, and staff, both in and out of thehospital. They are especially sensitive to the needs of anyone who is without spiritualcare in a congregational setting. Staff chaplains can help with advance directives, familymatters, grief and other emotions, faith, and ethical issues.

Preparing Your HomePreparing your home for your return after surgery is an important step in the planningprocess for any total joint replacement surgery. Most importantly, you will need some-one who can assist you at home for the first week after you leave the hospital. You andyour caregiver should attend the total joint replacement class at the hospital so you canlearn the best way to prepare your home for your safety and comfort after the operation.

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Checking into the Hospital—Admission Reminders• Avoid food and drink after midnight the night before your surgery. This includes med-ication, water, gum, and hard candy. An exception to this would be a sip of water withany medication your doctor has asked you to take. Before surgery, make sure your sur-geon is informed about any medications you take, especially aspirin, anti-inflammato-ries, and Coumadin® (warfarin sodium).

• On the day of your surgery, bring with you to the hospital a list of all the medicationsyou take. Include the name of the medication, the dose you take, when you are pre-scribed to take it, and who prescribes the medication for you. Include all vitamins andherbal supplements.

• Pack sleepwear for the hospital, including an open-front robe and low-heeled, comfort-able shoes with nonslip soles. Also bring loose-fitting clothing for your trip home.

• Bring your crutches or walker and other adaptive equipment to the hospital so you canpractice using these items with your physical or occupational therapist. The therapistwill check proper fit and safety. Please mark your full name clearly on any equipmentbrought from home.

• If you would like an advance directive added to your medical chart, bring a copy of itwith you to the hospital.

• Plan to report to St. Patrick Hospital and Health Sciences Center Day Surgery twohours before your scheduled surgery time. The family waiting area for orthopedic sur-geries is on the fourth floor by the elevators. The orthopedic-surgical unit is also on thefourth floor.

• The following items should be removed and left with a family member or nurse:

• all metal objects, such as hair clips or pins• partial dental plates and bridges• glasses and contact lenses• all jewelry

.

Getting Ready to Go to the Operating RoomBefore going into the operating room, you will change into a hospital gown. You will beasked to mark the hip you are having surgery on. The nurses will assist you with this.

The hip you are having surgery on will be scrubbed with special cleaners to remove bac-teria normally found on your skin.

You may be given a pre-anesthetic medication that helps reduce nausea.

An intravenous line (IV) will be placed in a vein, most likely in your arm. The IV isused to replace fluids and administer medications, antibiotics, or blood. It is importantnot to touch or tamper with the tubing or equipment and to report any pain or swellingto your nurse.

AnesthesiaJust before surgery, the anesthesiologist will review your medical history and brieflyexamine you. The anesthesiologist will talk to you about which anesthesia he or shefeels is best for you.

The technique most patients are familiar with is general anesthesia. With general anes-thesia, the patient is unconscious during the procedure. The anesthesiologist may admin-ister a variety of drugs and gases to keep you unconscious during the operation. Thistype of anesthesia requires a machine to breathe for you during the operation.

Another anesthetic technique is spinal anesthesia. With this technique, a small needle isused to inject an anesthetic solution into your lower back, near the spinal canal. Thisnumbs the body from the waist down, but you are still awake. You will also be givenother medications that make you groggy so you won't know the surgery is going on.

An additional option may be the epidural technique. This technique is similar to thespinal anesthesia and involves an injection into the lower spine. A small catheter isplaced through the epidural needle to add more analgesic-anesthetic solution during theoperation. After surgery, small amounts of medication may be infused through thecatheter for one or two days for pain relief.

Your anesthesiologist may suggest a modification or combination of any of these tech-niques and will be glad to explain the pros and cons of each type of anesthetic techniqueto you.

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In the Operating RoomYou will probably talk with your doctor before surgery about the specifics of your jointreplacement operation. The overview below describes a typical hip replacement proce-dure. Ask your doctor if you have any questions about the procedure.

The Artificial JointThere are two major types of artificial hip replacements:

• cemented prosthesis• uncemented prosthesis

Both are widely used. In some cases, a combination of the two types is used. The ballportion of the prosthesis is cemented into place, and the socket is not cemented. Thedecision about whether to use a cemented or uncemented replacement hip is usuallymade by the surgeon based on your age and lifestyle and the surgeon's experience.

Each prosthesis is made of two main parts.

The acetabular component (socket) replaces the acetabulum. Theacetabular component is made of a metal shell with a plastic innerliner that provides the bearing surface. The plastic used is sotough and slick that you could ice skate on a sheet of it withoutdamaging the material much.

The femoral component (stem and ball) replaces the femoral head.The femoral component is made of metal. Sometimes, the metalstem is attached to a ceramic ball.

A cemented prosthesis is held in place by special epoxy cement that attaches the metalto the bone. An uncemented prosthesis has a fine mesh of holes on the surface. Overtime, bone grows into the mesh and attaches the prosthesis to the bone.

The OperationThe surgeon begins by making an incision on the side of thethigh to allow access to the hip joint. Several differentapproaches can be used to make the incision. The choice isusually based on the surgeon's training and preferences.

Once the hip joint is entered, the surgeon dislocates thefemoral head from the acetabulum. Then the femoral head isremoved by cutting through the femoral neck with a power saw.

Hip Components

Femoral Head Removal

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Attention is then turned toward the socket. The surgeon uses apower drill and a special reamer (a cutting tool used to enlarge orshape a hole) to remove cartilage from inside the acetabulum. Thesurgeon shapes the socket into the form of a half-sphere. This isdone to ensure that the metal shell of the acetabular componentwill fit perfectly inside.

After shaping the acetabulum, the surgeon tests the new component tomake sure it fits just right. In the uncemented variety of hip replace-ment, the metal shell is held in place by the tightness of the fit or byusing screws to hold the shell in place. In the cemented variety, epoxycement is used to anchor the acetabular component to the bone.

To begin replacing the femur, special rasps (filing tools) areused to shape the hollow femur to the exact shape of the metalstem of the femoral component. Once the size and shape aresatisfactory, the stem is inserted into the femoral canal. Again,in the uncemented variety of femoral component the stem isheld in place by the tightness of the fit into the bone. In thecemented variety, the femoral canal is enlarged to a size slightlylarger than the femoral stem, and the epoxy cement is used tobond the metal stem to the bone.

The metal ball that makes up the femoral head is then attached.

Once the surgeon is satisfied that everything fits properly,the incision is closed. Several layers of stitches are usedunder the skin, and either stitches or metal staples are usedto close the skin. A bandage is applied to the incision, andyou are moved to the recovery room.

Metal Shell Insertion

Stem Insertion

Ball Insertion

Hip Replacement Hip X-ray

Cartilage Removal

Blood TransfusionsTotal joint surgeries sometimes result in extra blood loss, making a blood transfusionnecessary during or shortly after surgery. If you have donated your own blood before theoperation, it will be available for you. The transfusion can also be done using bloodfrom a blood bank. Blood transfusions are an important part of modern medical therapy.They save many lives every year. Only a small percentage of patients end up needing ablood transfusion.

Medical safety procedures have made blood transfusions safer than ever. However,despite great improvements in blood testing, a low level of risk remains with each trans-fusion, including

• a very low risk of Hepatitis B, about 1 in 200,000 transfusions• a low risk of Hepatitis C, about 1 in 3,300 transfusions• a very low risk of acquiring AIDS (HIV), about 1 in 500,000 transfusions

To put this in perspective, the risk of being killed in a car accident in any given year is 1in 11,000. Please note that these risk estimates may have changed since this documentwas written.

Occasionally patients react to a blood transfusion. Symptoms are usually mild and mayinclude fever, chills, hives, or itching. In rare cases, a blood reaction will be severe. As aprecaution, your medical team will treat any reaction you may have as potentiallysevere. The transfusion will be stopped, and additional testing will be performed.

ComplicationsAs with all major surgical procedures, complications can occur. Some of the most com-mon complications following hip replacement surgery include

• thrombophlebitis• infection• loosening• dislocation

This is not intended to be a complete list of the possible complications, but these are themost common.

ThrombophlebitisThrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after anyoperation, but it is more likely to occur following surgery on the hip, pelvis, or knee.DVT occurs when blood clots form in the large veins of the leg. This may cause the legto swell and become warm to the touch and painful.

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If the blood clots in the veins break apart, they can travel to the lungs, where they lodgein the capillaries and cut off the blood supply to a portion of one lung. This is called apulmonary embolism. ("Pulmonary" means lung, and "embolism" refers to a fragment ofsomething traveling through the vascular system.)

Most surgeons are very serious about preventing DVT. There are many ways to reducethe risk of DVT, but probably the most effective way is getting you moving as soon aspossible after surgery.

Other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving• medications that thin the blood and prevent blood clots from forming

InfectionInfection can be a very serious complication following joint replacement surgery. Thechance of getting an infection following hip replacement is probably around 1 percent.Some infections may show up very early—even before you leave the hospital. Othersmay not become apparent for months or even years after the operation. Infection canspread into the artificial joint from other infected areas. Your surgeon may want you totake antibiotics when you have dental work or surgical procedures on your bladder andcolon to reduce the risk of spreading germs to the joint.

LooseningThe main reason that artificial joints eventually fail is loosening of the metal or cementfrom the bone. Great advances have been made in extending how long an artificial jointwill last, but most will eventually loosen and require a revision. You can generallyexpect twelve to fifteen years of service from an artificial hip, but in some cases the hipwill loosen earlier than that. A loose prosthesis is a problem because it causes pain.Once the pain becomes unbearable, another operation will probably be required to fix,or revise, the hip replacement.

DislocationJust like your real hip, an artificial hip can dislocate if the ball comes out of the socket.There is a greater risk just after surgery, before the tissues have healed around the newjoint. But there is always a risk of dislocation. Your physical therapist will instruct youvery carefully about how to avoid activities and positions that tend to cause hip disloca-tion. A hip that dislocates more than once may have to be revised to make it more sta-ble. This means another operation.

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After Surgery—Your Hospital Stay

Post-Anesthesia Care Unit (PACU)You will be moved to the PACU immediately after sur-gery. There, a nurse specialized in post-anesthesia carewill assist you while monitoring your vital signs. Youwill wake up with your IV line still attached and wear-ing a bulky dressing on your hip. A drain may havebeen inserted into your hip to prevent fluid buildup.

Pain ManagementPain management is an important part of your recoveryand starts in the PACU. You play a major role in help-ing to manage your pain. The PACU nurse will ask youto rate your pain using the "pain assessment scale." Onthe scale, zero represents no pain, and ten represents theworst pain you can imagine. The nurse will work withyou on pain control.

Your doctor may order a device called a PCA (patientcontrolled analgesia) pump. This pump lets you delivera dose of pain medication by pushing a button. Safetylimits are programmed into the pump to prevent youfrom taking too much medication.

Patients usually begin taking pain pills the day aftersurgery. At first, you will probably need to take themregularly. The nursing staff and pharmacists will helpyou with pain management.

Pain Assessment Scale

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On the Orthopedic UnitOnce you have recovered sufficiently from the anesthesia, you will be moved to theorthopedic nursing unit for the rest of your hospital stay. A typical hospital stay aftertotal joint replacement lasts four days or less.

• The IV line started before surgery will remain in place after surgery. It won't beremoved until you can take fluids and pain medication orally and until you've completedany antibiotics or blood transfusions (if needed).

• The nurses will keep track of your fluid intake (both IV and oral) and also your fluidoutput (how much you urinate). You may need a catheter placed in your bladder if youcan't urinate on your own.

• A nurse will explain the proper way to cough and take deep breaths. This helps pre-vent pneumonia by keeping your lungs well expanded and clear.

• With your doctor's order, the nurse may administer blood-thinning medications (antico-agulants) to help prevent blood clots.

• A nurse will reposition you approximately every two hours after surgery to stimulatecirculation, prevent pressure sores (bed sores), and keep your lungs clear.

• The large dressing on your hip will be checked frequently and changed according toyour doctor's orders.

• You will be served well-balanced meals so that your body will have the nutrients itneeds for proper healing. Maintaining adequate fluid intake is very important for gooddigestion. Even with good nutrition and fluid intake, constipation is a common sideeffect of inactivity and pain medication. Please let the nurse know if you have any spe-cial routine or medication for your bowels. The nurse will be glad to assist you.

• An occupational therapist and a physical therapist will visit you on the orthopedic unit.You will be taught safe methods of transfer (getting in and out of bed, standing up andsitting down, and so on) and how to shower and dress safely.

• You will begin walking with your physical therapist the day after surgery unless yourdoctor orders otherwise. (See the "Rehabilitation" section of this booklet for more infor-mation.)

Getting Back on Your Feet

Recuperation After Your Hospital StayAfter your stay in the hospital, you will probably complete your recovery in one of fourplaces, depending on how much care you need. Your physician, therapists, social worker,and nursing team will help you and your family decide on the best choice for you.

• Your HomeWe hope you are among those patients who can return directly home. Some peoplerequire no further assistance at all, while others may need additional physical or occupa-tional therapy, nursing care, or home maintenance. All of these are available throughhome health care agencies. We feel the best place for you to recover is in your ownhome, and we will make every effort to get you there.

• St. Patrick Hospital and Health Sciences Center Outpatient Physical Therapy(Broadway Building)You may benefit from additional therapy at an outpatient rehab program. The Total JointTeam will make this recommendation if it seems appropriate for you. You will still gohome but will return to the physical therapy center two to three times per week.

• St. Patrick Hospital and Health Sciences Center Transitional Care Unit (TCU)This unit is located on the fifth floor of St. Patrick Hospital and Health Sciences Center.It is designed for patients who need additional rehabilitation before returning home. TheTotal Joint Team may recommend that you stay a few extra days until you are ready to gohome. A stay on the TCU can range from three to twenty-one days.

• Nursing HomeIf you require a rehabilitation stay of longer than twenty-one days, a nursing home maybe the best choice for you. There are a variety of nursing homes in and around Missoula.If you don't live in Missoula, you may want to choose a nursing home in your own com-munity. The Total Joint Team can help arrange your transfer to one of thesefacilities. • SPH Inpatient Rehab (Providence Center)

Follow-Up Doctor VisitsIn any of the above settings, your doctor will continue to monitor your progress. Onceyou return home you should continue to practice all the precautions you have beentaught for another six to eight weeks. • any openings in your incision• questions about medications such as Coumadin® (warfarin sodium), Lovenox®(enoxaparin sodium), or aspirin

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Your doctor should be notified of any of the following:• temperature above one hundred degrees Fahrenheit• infection anywhere in your body• redness, swelling, or drainage from the surgical site• any openings in your incision• questions about medication such as Coumadin (warfarin sodium), Lovenox (enaxaparin sodium), or aspirin • chest pains or shortness of breath• increased pain in the operated hip• pain, swelling, or tenderness in either calf

Ask your surgeon when you can resume driving, bathing, swimming, and otherphysical activities.

Patient Guide

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RehabilitationA well-planned rehabilitation program is essential for optimum recovery. You will learnas you go, and the goal will be getting you back to your normal activities.

It is very important for you to discuss your individual goals with your physician and therest of the Total Joint Team. Recovery can be demanding and sometimes painful.Therefore, we feel it is essential that you are a part of the team and that you feel goodabout your progress.

Getting safely back in motion will involve

• walking with crutches or a walker• going up and down stairs• maintaining healthy posture and body alignment• avoiding certain positions if necessary, especially while bathing, dressing, andworking• learning the best way to move while walking and sitting• learning how to change positions while sitting, standing, and lying down• learning to use adaptive equipment• performing regular exercises for strength and endurance

The Total Joint Team will teach you about the things you can do, things to avoid, andapproaches to daily activities. Always ask before doing something you are unsure about.

Weight BearingThe amount of weight you can put on the foot of your operated leg after surgery willdepend on your doctor and the procedure used. If a cemented procedure was used, yourdoctor may recommend placing a comfortable amount of weight through your operatedleg after surgery using your walking aid. If the surgery was done without cement, youmay be directed to place only the toes of the operated leg on the ground for four to sixweeks after surgery.

Total Hip Replacement PrecautionsHip surgeries such as total joint replacement require the surgeon to open the hip joint capsuleand cut some of the ligaments around the hip joint. Until these ligaments heal, the hip is atrisk of dislocating. You need to follow special precautions about hip positions and move-ments to avoid after surgery in order to keep the hip safe.

While you are in the hospital, your health care team will remind you often about the need tofollow these hip precautions. They may place a sign by your hospital bed as a reminder.Once you get home, you will have to remember to follow these rules until your surgeonapproves motion beyond these limits. This usually happens six to twelve weeks after surgery.

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Posterior ApproachThe main positions and movements to avoid after a posterior approach include crossingyour legs, turning your hip and leg inward, or bending the hip more than ninety degrees.

• Don't cross your legs. When sitting, do not crossyour operated leg. When lying on your back, don'troll your operated leg toward the other leg as youmight do when rolling over. A pillow or triangular-shaped wedge may be used to block the legs fromcrossing.

• Don't roll your leg and foot in. Use a pillow orwedge between your legs when lying in bed tokeep your leg from rolling inward.

• Don't allow the knee of your operated leg tocross the midline of your body. Your kneeshouldn't move across your body past your bellybutton. When lying in bed, place pillowsbetween your legs to keep your hip in the correctposition.

• Don't turn your upper body toward your sorehip. When sitting, swivel your whole body ratherthan just your upper body.

Use a Pillow to Avoid Rolling Leg Inward

Proper Pivoting While Sitting

Use a Pillow to Keep from Crossing Legs

• Don't twist your body toward your operated hip. Thismeans you can't stand pigeon-toed. Keep the toes of youraffected leg pointed forward when you stand, sit, or walk.If you turn your body in the direction of your operated hipwithout pivoting your foot, your hip will be placed in anunsafe position. Remember to lift and turn your foot as youturn in the same direction as your surgical hip.

• Don't bend the hip past ninety degrees. This means do notlean too far forward when sitting up in bed.

Also, raising your knee as you lie in bed can cause the hipangle to go past ninety degrees.

To avoid bending past ninety degrees when sitting ina chair, lean back slightly.

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Sitting Up in Bed

Do Not Twist Your Body

Raising Leg in Bed

Avoid Bending Past Ninety Degrees

• Don't bend over past ninety degrees at the waist.Your hip may go past ninety degrees if you bendover at the waist to tie your shoes or pick upitems off the floor. Instead, use elastic shoelacesand a reacher. (See "General Guidelines andAdaptive Equipment" for more information.)

Inpatient Physical TherapyThe first inpatient physical therapy visit gives your physical therapist an idea of howwell you can move in bed and how safe you are getting up and sitting on the edge of thebed. Your therapist will also see whether you can begin to walk using a walking aid,putting the right amount of weight through your foot.

You may do a few exercises in your hospital room on the first visit. Your therapist willdemonstrate exercises to begin toning and strengthening the thigh and hip muscles.Ankle and knee movements may be used to help pump swelling out of the leg and pre-vent blood clots from forming. A

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Avoid Bending Past Ninety Degrees

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Total Hip Replacement ExercisesAfter surgery, you should do only those exercises recommended by your doctor or phys-ical therapist. The type of procedure used will determine the exercises.

The exercises are designed to achieve a variety of goals. Some exercises help controlpain and improve movement in the hip. Other exercises strengthen the thigh muscles.Extra pain felt after these or other exercises is a signal that you are overdoing it. Youmay need to change the number of repetitions, the amount of pressure, or how often youdo the exercises.

Caution: Do only the exercises approved by your therapist.Patients who have had a posterior approachshould avoid exercise number seven.

1. Ankle Pumps: Slowly paddle your feet bybending your ankles up and down.

2. Quad Sets: With your knee straight, tighten themuscles on top of your thigh by pressing the backof your knee down toward the bed. Hold the con-traction for five seconds.

3. Gluteal Sets: While lying on your back, tightenyour buttock muscles. Hold tightly for five sec-onds.

4. External Rotation: While lying on your back, roll your footand thigh out away from the other foot, as shown below.Return to the starting position. (Do not do this exercise if yoursurgeon used an anterior approach.)

Ankle Pumps

Quad Sets

Gluteal Sets

External Rotation

5. Heel Slides: Lying flat on your back, bend yourknee by sliding your heel back toward your but-tocks. Try to increase the bend in your knee a lit-tle more with each repetition, but avoid bendingyour hip further than ninety degrees.

6. Short Arc Quads: With your knee bent over atowel roll, straighten your knee by tightening themuscles in the front of your thigh. Hold for fiveseconds, and then lower your foot back down.

7. Hip Abduction: Lying flat, tighten the muscles in the front ofyour thigh. Lock your knee, and move the operated leg out andthen back to midline.

8. Straight Leg Raises: With one knee bent to takethe strain off your lower back, tighten the muscles inthe front of your other thigh. Lock your knee, andraise the leg twelve inches off the bed. Hold for fiveseconds, and then lower your leg back down.

9. Hip Bridges: Lie on your back with yourknees bent, feet flat on the bed, and your arms atyour sides. Tighten your abdominal and buttockmuscles as you lift your buttocks off the bed.Hold for five seconds. Relax, returning to thestarting position.

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Heel Slides

Short Arc Quads

Hip Abduction

Straight Leg Raises

Hip Bridges

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Using a WalkerUsing a Walker on Level Surfaces

Do1. Advance the walker.2. Step up to the walker with your operated leg.3. Step forward with your nonoperated leg, using your arms to bearmost of your weight.

Do NotDon't step until all four legs of the walker are firmly placed on thefloor.

Using a Walker on StairsTo go up or down stairs with a walker, you will either need to use a handrail or havesomeone support you on one side. Be sure to bear only the correct amount of weight onyour foot.1. Place your walker sideways with the opening toward you.2. Firmly grasp the rail with one hand and the walker with the other.

Stepping UpStep with your nonoperat-ed leg, and then followwith your operated leg tothe same step.

You will progress to crutches or a cane within fourto six weeks, with the approval of your physician and physical therapist.

Correct Use

Incorrect Use

Upstairs Downstairs

Stepping DownStep down withyour operated leg,and then followwith your nonop-erated leg to thesame step.

General Guidelines and Adaptive EquipmentDuring your recovery, follow these general guidelines.

• Use crutches or a walker with appropriate weight bearing until your doctor tells youotherwise.• Keep walking distances within your tolerance.• Use caution around pets when using crutches or a walker.• Enjoy sexual relations, being careful that you and your partner avoidcertain body positions.

Your therapist and physician will be able to answer specific questions for you, and infor-mation will be available at the total joint replacement class.

Following are specific guidelines for different activities and areas of your home. Someactivities, such as bathing, may require special equipment during your recovery. Thisadaptive equipment is available at medical supply stores. Certain items, such as tubtransfer benches, may be rented.

BathingYou can stand in the shower with the aid of your walker, or you may find it easier to sit ona chair. You may rent a shower chair from a medical supply store, but any sturdy, above-the-knee, waterproof chair will do.

Consider using safety friction strips or a rubber mat on the floor of the shower or bathtub,a portable grab bar on the wall, and a long-handled sponge. You may also find a hand-heldshowerhead very helpful. Soap on a rope prevents you from having to reach down andpick up the soap if you drop it.

• Shower Transfers:For a shower that you need to step up into, place your walker in the shower first. Followwith the nonoperated leg, then the operated leg.

In the bathtub, use a stool or a tub transfer bench. When you first try the bench, be sureyour knees are positioned slightly lower than your hips. This way, you'll be sure to keepyour hip from bending more than ninety degrees while sitting down. Because one pair ofthe bench's legs sit in the tub while the other pair is outside the tub, you can slide acrossthe seat and avoid the potentially hazardous situation of stepping over the tub wall.

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• Tub Transfers:Caution: DO NOT SIT IN THE BOTTOM OF THE TUB!1. Using your walker, back up to the tub.2. Reach back for the chair or bench while the other handremains on the walker.3. After you sit, lean back, and lift your legs into the tub.4. Dry off before leaving the shower or tub, or use a cottonbathrobe to soak up water.5. To get out of the tub, lean back, lift your legs over theside, and stand up with the aid of your walker.

Leave your crutches or walker outside of the tub on a nonslip surfacesuch as a rubber-backed mat.

DressingBefore your surgery, store comfortable, loose-fitting clothingin a convenient place that is easy to reach. When dressing, donot bend over or raise or cross your legs. Also, do not stand onone foot to put on your pants. Get help with putting on pants,skirts, shoes, or socks, or use adaptive equipment such as ashoehorn, sock aid, or reacher.

To use a sock aid, pull the sock over the form, insert your foot, andpull the two straps to bring the sock over the foot.

A reacher can be used to pick up items from the floor.

Wear stretchy socks and flat-heeled, slip-on shoes. Avoid twisting yourfoot as you place it in the shoe. If you have only tie shoes, elasticshoelaces can eliminate the task of tying laces.

ToiletingA toilet can be elevated with a raised, locking seat to prevent your hipfrom bending too far when you sit down. Getting on and off the toiletseat may be easier with the help of securely fastened handrails (a toiletsafety frame) or grab bars.

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Elevated Toilet

Sock Aid

Using a Reacher

Tub Transfer

Household SafetyTake care to avoid potential hazards. Put throw rugs away. Keep clothes off the floor.Keep electrical cords out of your path. Be aware of telephone wires and bedspread cor-ners. Be wary of spills on the floor and snow and ice on steps. (Spread sand or rock saltoutside.) Leave heavy housework to someone else. Do not stand on a stool, chair, orstepladder. Make your bed accessible from both sides.

FurnitureTo prevent your hip from bending beyond ninety degrees, you may need to elevate yourcouch or chair. Reclining chairs and rocking chairs are often difficult to get out of, and youshould avoid them. Instead, sit in a tall, high-backed chair with armrests.

A good rule of thumb is to have a seat height that is at least twenty inches above the floor.If you find that your furniture is too low, consider using a platform under your chair orcouch to raise it to the desired height. Using four-by-four blocks may be helpful, but besure that the chair or couch is safe and steady before you sit down. You may also use pil-lows or firm cushions to elevate the seat height of chairs.

Similarly, you may want to raise your bed by placing bricks or wooden blocks under thelegs of the bed or by adding an extra mattress. Ensure that your bed is stable after you makethese adjustments.

KitchenTo avoid excessive bending and lifting, arrange your kitchen shelves and cupboards withfrequently used items at waist to shoulder height. For lighter items on lower shelves, besure to have your reacher handy to keep from bending over too far at the hip.

You may want to freeze meals and store groceries before your surgery to make things easierfor the first week or two after you return home from the hospital.

Carrying ThingsA great variety of packs and pouches are available to help you carry things. They comewith handles, straps, and assorted compartments. They are available at sporting goodsstores. If you carry a thermos, get one with a handle. Around the house, an apron or jacketwith several large pockets will prove helpful. A front wheel walker tray clips onto a walkerand allows you to carry items as you walk.

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Patient Guide

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Car TransfersFor your trip home from the hospital and other trips you make rightafter your surgery, use a vehicle that is easy to get in and out of. Thevehicle should have large doors and high, comfortable seats. Add firmcushions or pillows to raise the seat, if needed. Avoid pickup trucksand sport-utility vehicles with elevated running boards that make thevehicle difficult to get into. Plan in advance the closest and clearestpath between the passenger side of the vehicle and the door you'll useto enter your home. Wear slick clothing or sit on a plastic bag to assistwith sliding.

While getting into the car, don't attempt to swing your operated leg into thecar in one motion, and don't attempt to put equipment into the car by yourself.1. Have the car parked several feet away from the curb.2. Step off the curb, and back up to the car. Give your walker or crutches to the personhelping you.3. Reach for the seat with one hand, and hold onto the dashboard with the other. Loweryourself slowly onto the seat. Lean back while sliding yourself back and across the seat.4. Bring your legs into the car by alternately moving each leg a few inches at a timewith your hands.5. Continue this until you are facing forward.6. Reverse this procedure to get out of the car.

Dental WorkArtificial joint replacement patients may need to take antibiotics whenever they havecertain dental procedures. This helps prevent an infection from occurring in the artificialjoint. Bacteria that live in the mouth can be released into the blood stream during dentalwork and may spread to the joint. Discuss this with your orthopedic surgeon, and notifyyour dentist and primary care provider.

Car Transfer

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Appendix

Phone DirectoryPreoperative Assessment WorksheetTotal Hip Replacement ChecklistMy Choices: Advance Directive for My Health CareState of Montana Application for Special Parking PermitMap

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Phone Directory

St. Patrick Hospital and Health Sciences CenterMain Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .543-7271Admissions Office and Scheduling . . . . . . . . . . . . . . . . . . . . . .329-5678Financial/Authorization Nurse . . . . . . . . . . . . . . . . . . . . . . . . .329-2684Physical Therapy/Occupational Therapy . . . . . . . . . . . . . . . . . .329-5779Orthopedic Unit (4 South) . . . . . . . . . . . . . . . . . . . . . . . . . . . .329-5778Nursing Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329-5805Outpatient Rehab Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .329-5895Pastoral Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329-5784

SPH Inpatient Rehab Gym. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329-3256

Home Health Care AgenciesPartners in Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .728-8848 Missoula

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363-1083 HamiltonInterim Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549-7000 Missoula

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363-7200 HamiltonWest Mont Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . .443-4140 Missoula

Blood BankAmerican Red Cross (Missoula)Lorraine Martin, Special Services Coordinator . . . . . . . . . . . . .543-6695American Red Cross (outside Missoula,call for the nearest location) . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-695-7258

My ChoicesAdvance Directive for My Health Care

Print your full name, Date of birth, and Social Security Number.

These directions apply only in situations when I am not able to make orcommunicate my health care choices directly. [Put an X through any sections you arenot completing at this time.]

I. Health Care Representative (Power of Attorney for Health Care)

My Representative may make ALL health care decisions for me as authorized in thisdocument and shall be given access to all my medical records. This appointment applieswhether I am expected to recover or not.

I wish to appoint a Representative: ‘ Yes ‘ No [Go to Part II.]

A. I appoint as my Representative.Print Representative’s Full Name

Representative’s Address

City State Zip

Home Phone Work Phone

My Representative’s authority is effective when I cannot make health care decisions orcommunicate my wishes. I may revoke this authority at any time I regain these abilities(unless my attending physician and any necessary experts determine I am not capable ofmaking decisions in my own best interest).

If, for any reason, I should need a guardian of my person designated by a court, Inominate my Representative, or Alternate Representative(s), named below.

B. Alternate RepresentativesIf 1) I revoke my Representative’s authority; or 2) My Representative becomes unwilling or unable to act for me; or 3) My Representative is my spouse and I become legally separated or divorced,

I name the following person(s) as alternates to my Representative in the order listed.

1. 2.

Address Address

City ST Zip City ST Zip

Home Ph Work Home Ph Work

Version 2.0 7/98 Witness and Notary on Page 3

II. Terminal Conditions (Living Will)I provide these directions in accordance with the Montana Rights of the Terminally Ill Act.These are my wishes for the kind of treatment I want if I cannot communicate or makemy own decisions. These directions are only valid if BOTH of the following twoconditions exist. IF:

1) I have a terminal condition;

AND

2) In the opinion of my attending physician, I will die in a relatively short time without life sustaining treatment which only prolongs the dying process.

I authorize my Representative, if I have appointed one, to make the decision to provide,withhold, or withdraw any health care treatment.General Treatment Directions [Check the boxes that express your wishes.]

‘ I provide no directions at this time.

‘ I direct my attending physician to withdraw or withhold treatment that merely prolongs the dying process.

I further direct that: [Check all boxes that apply.]

‘ Treatment be given to maintain my dignity, keep me comfortable, and relieve pain even if it shortens my life.

‘ If I cannot drink, I do not want to receive fluids through a needle or catheter placed in my body unless for comfort.

‘ If I cannot eat, I do not want a tube inserted in my nose, mouth or surgically placed in my stomach to give me food.

‘ If I have a serious infection, I do not want antibiotics to prolong my life. Antibiotics may be used to treat a painful infection.

‘ I have attached additional directions regarding medical treatment to this form.

‘ I have not attached additional directions to this form at this time.

III. I have a Chronic Illness or Serious Disability (Optional) My chronic illness or disability can complicate an acute illness, but should not bemisinterpreted as a terminal condition.A. Diagnosis:

B. Consult my physician. [Name, phone]

C. Special directions. [Use additional pages if necessary.]

Witness and Notary on Page 3

IV. Signing, Witnessing this Advance DirectiveA. Your signature [Ask two people to watch you sign and have them sign below. Sign this document in front of a Notary Public if you can.]

1. I revoke any prior health care advance directive or directions. 2. This document is intended to be valid in any jurisdiction in which it is presented.3. A copy of this document is intended to have the same effect as the original.4. Those who act as I have directed in this document shall be free from legal liability

for having followed my directions.5. If my attending physician is unwilling or unable to comply with my wishes as

stated in this document, I direct my care be transferred to a physician who will.I sign this document on the day of 19

Signature Print Full Name

Address City ST Zip Home Ph Work

B. Ask Your Witnesses to Read and Sign

I declare that the person who signed this document is personally known to me, and hassigned these health care advance directions in my presence, and appears to be of soundmind and under no duress, fraud, or undue influence.As a witness, I am NOT:

- The person appointed as Representative by this document;- Financially responsible for this person’s health care;- Related to this person by blood, marriage, or adoption; andS To the best of my knowledge, entitled to inherit any part of this person’s estate

under a will now existing or by operation of law.

1. 2.Signature Date Signature Date

Name Name Address Address City ST Zip City ST Zip

C. Notarizing this Document (Optional)STATE OF )

:ss.

COUNTY OF )

On this day of , 19 the said known to me (or satisfactorilyproven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the State and Countyaforesaid, and acknowledged that he or she freely and voluntarily executed the same for the purposes stated therein.

Notary Public for the State of Montana

Residing at , MT

My commission expires:

(See Page 4 for Special Directions)

V. Special DirectionsA. Spiritual PreferencesMy religion: My faith community:

Contact person: I would like spiritual support. ‘ Yes ‘ No

B. Where I would like to be when I die:‘My home ‘Hospital ‘Nursing home

‘Other

C. Donation of Organs at My Death

‘ I do not wish to donate any of my body, organs or tissue.

‘ I wish to donate my entire body.

‘ I wish to donate only the following: [Check all that apply]

‘ Any organs, tissues or body parts ‘ Heart ‘ Kidneys‘ Lungs‘ Bone marrow ‘ Eyes ‘ Skin ‘ Liver‘ Other(s)

D. After Death Care:[Care of my body, burial, cremation, funeral home preference]

E. Additional Directions:[Use additional pages if necessary.]

Signature _________________________________ Date __________________________

F. Distributing this Document

I plan to send copies of this document to the following people or locations:Representative: Family Member: Relationship Name Name Address Address City St Zip City St Zip Home Ph Work Home Ph Work

Physician: Hospital:Name Name Address Address City St Zip City St Zip Phone Phone

Clergy: Other: Name Name Address: Address City St Zip City St Zip Phone Phone

“My Choices” was created by the Advance Care Planning Task Force of the Missoula Demonstration Project (406/728-1613). Members of this task force representMissoula hospitals, home care agencies, hospice, long term care facilities, Missoula Aging Services, Coalition of Montanans Concerned with Disabilities, AARP, publichealth, physicians, nurses, physician assistants, social workers, emergency medical technicians, attorneys and clergy. Version 2.0

STATE OF MONTANA DEPARTMENT USE ONLYAPPLICATION FOR SPECIAL PARKING PERMIT or Expiration Date:

LICENSE PLATES FOR A PHYSICALLY DISABLED PERSON Permit Number(s):

THIS PART MUST BE COMPLETED BY THE APPLICANT (please print):

Name of Applicant:(one applicant per form)

Address: City or Town:Mailing Address: Zip Code:I understand that I am eligible for one special parking permit and/or one set of license plates for each non-commercial motorvehicle that I own and that if I do not own a motor vehicle, I may only receive a single special parking permit. I am applyingfor the following type and quantity of permit(s) and/or sets of license plates (please specify number required if more than onepermit and/or set of plates is sought): THERE IS NO FEE FOR THIS PERMIT(S).

Replacement Permits Special License PlatesDate: Applicant's signature:

NOTICE CONCERNING RELEASE OF PERSONAL INFORMATIONMotor vehicle records are released to individuals and businesses for a variety of uses, BUT you may have your name and address withheld from releasefor certain uses by INITIALING (void if any other mark is used) the appropriate box(es) below. Your selection(s) will not affect release for motor vehiclerecall, warranty, anti-theft, safety or emission purposes. Selection applies to personal information of any co-owner for this vehicle record. To cover othervehicle records, you must obtain a separate form at your county treasurer's office.

initials No release for DIRECT initials No release for OTHER USES, EXCLUDING governmental, businessonly --> MAIL/PRODUCT only --> or employment verification, legal proceedings, licensed investigations,

MARKETING uses insurance, towing or other statistical reporting purposes.

THIS PART MUST BE COMPLETED BY A LICENSED PHYSICIAN, CHIROPRACTOR OR NURSE PRACTITIONER:

PLEASE NOTE: Under Montana law, a special parking permit or license plate may only be issued to a person whosemobility is limited or impaired by a disability and whose condition, as determined by a licensed physician or licensedchiropractor, meets specified criteria.Please check which conditions, if any, apply to the above-named applicant:

cannot walk 200 feet without stopping to rest; is severely limited in ability to walk because of an arthritic, neurological, or orthopedic condition; is so severely disabled that the person cannot walk without the use of or assistance from a brace, cane, another person, prosthetic device, wheelchair, or other assistive device; uses portable oxygen; is restricted by lung disease to the extent that forced expiratory respiratory volume, when measured by spirometry, is less than 1 liter per second or the arterial oxygen tension is less than 60 mm/hg on room air at rest; has impairment because of cardiovascular disease or a cardiac condition to the extent that the person's functional limitations are classified as class III or IV under standards accepted by the American Heart Association; or has a disability resulting from an acute sensitivity to automobile emissions or from another disease or physical condition that limits or impairs the person's mobility and that is documented by the licensed physician or licensed chiropractor as being comparable in severity to the other conditions listed above.

Please check which term best describes the expected duration of the condition: Permanent (limited or no improvement expected) Temporary (improvement expected within six months) Extended Temporary (improvement not achieved within initial six month period, but expected within an additional period of ______ months [please specify], not exceeding 24).

PHYSICIAN, CHIROPRACTOR OR NURSE PRACTITIONER INFORMATION: (please type or print clearly) PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER PRINTED NAME TYPE OF PHYSICIAN PROFESSIONAL LICENSE NUMBER

PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER ADDRESS CITY STATE ZIP CODE

PHYSICIAN/CHIROPRACTOR/NURSE PRACTITIONER SIGNATURE DATE TELEPHONE NUMBER -> X

MV5 (09/00) Upon request, this form can be made available in an alternative format.

Mail this application to the Title and Registration Bureau, 1032 Buckskin Drive, Deer Lodge,Montana, 59722. If a permit is lost or mutilated, a replacement may be obtained upon written request.

Section 49-4-301, M.C.A. Special Parking Permits

The Title and Registration Bureau, Department of Justice, shall issue a special parking permit to aperson who meets one of the criteria listed on the reverse side.

A disabled person [who does not own a motor vehicle] may obtain one (1) permit only.

The permit may be used in any vehicle in which the permit holder is riding.

The permit shall be prominently displayed in the windshield of the vehicle when the parking privi-lege is being used by the disabled person in a vehicle other than the one to which special licenseplates are affixed.

Permanent permits become void upon the recovery or death of a permittee or three (3) years from thedate of issuance. A permittee may renew a permit for an additional three (3) years if a physician orchiropractor certifies that the permittee's disability impairing mobility still exists.

Temporary permits become void upon the recovery or death of a permittee or six months from theoriginal date of issuance. A permittee may renew a temporary permit for up to 24 months if a physi-cian or chiropractor certifies that the permittee's disability impairing mobility still exists.

Blue permanent and red temporary permits are to be displayed by hanging them on the rear viewmirror (or placing them on the dashboard in the absence of a mirror) when parked in a disabled per-sons parking location. REMOVE PERMIT FROM MIRROR WHILE THE VEHICIE IS INMOTION.

Section 61-3-332 (10) (g), M.C.A Special License Plates

A Montana resident who is eligible to receive a special parking permit under 49-4-301 may, uponwritten application on a form prescribed by the department, be issued a special license plate with adesign or decal bearing a representation of a wheelchair as the symbol of the disabled person.

The special license plates shall be affixed to the vehicle.

Special license plates must be applied for at the county treasurer's office of the county of residence.

If the applicant is applying for special plates and permit, the applicant must first obtain the platesfrom the county treasurer and then forward this application to the Title and Registration Bureau toobtain the permit.

If the applicant is applying for only the special plates, the county treasurer shall forward this applica-tion to the Title and Registration Bureau.

License plates become void upon the recovery or death of a permittee or three (3) years from the dateof issuance. A permittee may renew a license plate for an additional three (3) years if a physician orchiropractor certifies that the permittee's disability impairing mobility still exists.

A LICENSED PHYSICIAN OR CHIROPRACTOR MUST COMPLETE THE CERTIFICATIONON THE REVERSE SIDE DESCRIBING THE EXTENT OF THE DISABILITY

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