Transcript Advance Directives - West Virginia Center for End-of

Cindy Jamison
Program Coordinator
WV Center for End-of-Life Care
Goals
At the completion of this program, the participant will be
better able to:
 properly complete and implement Medical Powers of
Attorney and Living Will forms
 perform the process of surrogate selection
 understand when and how to complete a DNR and POST
form
Troubling Case
Mrs. Jones, an 85-year old woman, is admitted to the hospital from home with
her 4th bout of acute pneumonia in a year. She immediately goes into
respiratory arrest in the ED and is placed on a ventilator. Her entire family her 90-year old husband, six adult children and spouses, and twelve
grandchildren - arrive at the hospital and are in the waiting room. One of her
daughters is a nurse at the hospital. The family thinks she has an advance
directive but can’t find it at home. No conversation between Mrs. Jones and
her family has ever taken place about her treatment wishes. Mrs. Jones has a
loving family that only wants the best for her – including making her medical
decisions.
Now What?
WV Health Care Decisions Act
• Protects patients’ right to make own health care decisions
• Promotes advance directives
• Reduces court involvement
• Defines legal protection for those who uphold provisions
of Act
Types of Advance Directives
• Medical Power of Attorney (MPOA)
• Living Will
• DNR Card
• POST Form
NOT MEDICAL ADVANCE DIRECTIVES:
• Health Care Surrogate (HCS)
• Durable Financial Power of Attorney - However, always
read them. They may contain medical decision-making
language! If so, it can be used
Medical Power of Attorney
Representative (MPOA)
Definition:
A person 18 years or older, who is appointed by
another individual to make health care decisions for
the individual.
MPOA
Who Can Complete a MPOA?
• Any competent adult
What Does it Take?
• Must complete a form which is in substantial compliance
with the law
• Must have form witnessed by 2 adults
• Must have form notarized by a notary public
MPOA Witnesses
A Witness May Not Be….
• Person being appointed MPOA
• Person who signed the MPOA or LW on behalf of or
at direction of principal
• Related by blood/marriage
• Entitled to any portion of estate
• Financially responsible for principal’s medical care
• Attending physician
Who Can Not Serve as MPOA?
• Principal’s treating health care provider
• Employee of a treating health care provider
• Operator of health care facility serving the principal
• Employee of the operator of health care facility serving
the principal unrelated to the patient
Authority of MPOA
• Make health care decisions
• Access medical records
• Authorize release of medical records to third parties
• Make decisions regarding autopsy and organ/tissue donation
Living Will
Who can do one?
• Any competent adult
What does it Take?
• Must complete a form which is in substantial compliance
with the law
• Must be witnessed by 2 adults
• Must be notarized by a notary public
Living Will Witnesses
May Not Be:
• Person who signed the MPOA or LW on behalf of or
at direction of principal
• Related by blood/marriage
• Entitled to any portion of estate
• Financial responsible for principal’s medical care
• Attending physician
Reciprocity
• Living Will or MPOA executed in another state is valid as
long as executed in compliance with laws of WV or with
laws of state where executed
DNR Card
Notes DNR status of the person
Requires:
• Patient’s (or Rep’s) name, Address, DOB, Gender,
Signature
• Physician Name, Address, and Signature
• Top part must be mailed to the Office of Emergency
Medical Services
• Bottom part is kept with patient
Health Care Surrogate
Person who is >18:
• Reasonably available
• Willing to make health care decisions on behalf of the
patient
• Possesses capacity to make health care decisions
• Identified or selected by attending as best qualified to
make those decisions
Before Choosing a Surrogate
Must make reasonable attempt to determine if
incapacitated person has appointed MPOA or has a courtappointed guardian.
What constitutes a reasonable attempt?
Reasonable Attempt
•
•
•
•
Current medical record
Appropriate persons to ascertain possible existence of
MPOA or Guardianship: spouse, adult children,
parents, adult siblings, adult grandchildren, patient’s
close friend, DHHR or courthouse to see if legal
guardian been appointed and is on file
Old chart
Document attempts
Choosing a Surrogate
Appropriate appointing rank: Start at the top & work
down:
1. Is there a court appointed guardian? If not….
2. Is there a spouse? If not,
3. Any adult children appropriate? If not….
4. Parents? If not….
5. Adult siblings? If not….
6. Adult grandchildren? If not…
7. Patient close friends? If not..
8. Any other person or entity?
These People Cannot Be the Patient’s
Surrogate Unless Related to the Patient
•
•
•
•
Patient’s treating health care provider
Employee of the treating health care provider
Owner, operator, CEO of health care facility serving the
pt
Any employee of the above
Relying on the Surrogate’s Decision
May do so when, after reasonable inquiry, believes:
• No other MPOA or guardian available, capable, willing to serve
• No other applicable advance directive
• No reason to believe that such health care decisions are
contrary to the incapacitated person’s religious beliefs; and
• Physician has not received actual notice of opposition to any
health care decision made.
What if Multiple HCS at same
priority level?
Physician should choose person who reasonably appears to be
best qualified…..
Physician may select a proposed surrogate who is ranked lower
in priority if, in his/her judgment, that person is best qualified
to serve. The Physician must document in the person’s medical
record his reason for selecting a surrogate in exception of the
priority order.
Criteria for Choosing Best Qualified
Surrogate
•
•
•
•
•
Reasonably appears to be better able to make decisions in
accordance with the known wishes or person’s best interests
Has had regular contact with the person prior to & during the
incapacitating illness
Demonstrates care & concern
Is available to visit the incapacitated person during his/her illness?
and
Is available to engage face-face contact with the health care
providers for the purpose of fully participating in the decisionmaking process?
Choosing Surrogate
 If HCS becomes unavailable for any reason, the physician may
appoint another HCS
 If a person who ranks higher in priority than the HCS becomes
available and willing to serve, the physician may appoint this
person unless the physician feels the lower ranked person is
better qualified
 With each new admission, physician must evaluate is the
previous HCS still best qualified? If so, must document that.
If Opposition of Appointed HCS,
advise . . . .
 Challenger has burden of proof of invalidity of selection
 File petition for review of selection of HCS
 Challenging party responsible for all court costs and his own
attorney’s fees unless . . .
 Court finds facility selected inappropriate HCS, facility
becomes responsible for court costs except . . .
 Challenging party still responsible for his own attorney fees
If Opposition of Appointed HCS,
advise….
 Physician documents objection
 Informs challenger decision shall be implemented in 72
hrs unless receipt of a court order prohibiting
implementation of decision
 24 hrs if patient is brain dead & HCS authorized
organ/tissue donation
Physician Orders
for Scope of Treatment
POST
A standardized “hot pink” form containing orders by a
physician who has personally examined a patient
regarding that patient’s preferences for end-of-life care.
• Complements, but does not replace, MPOA and/or Living
Will advance directives
• Effective immediately as soon as order written and all
requirements met
Requirements for Valid POST
Must have:
• Patient’s name and date of birth
• Basis for orders
• Physician’s signature
• No conflicting orders
• Signature of person, parent if minor, guardian/MPOA/HCS
Rationale for doing a POST
• Advance directive may not be available when needed
• Advance directive may not be specific enough
• No provision for treatment in NH/home
• May not cover topics of most immediate need
• Advance directive does not immediately translate into
physician order
• Completions of advance directive may NOT have
prompted needed discussion
POST: Physician orders for…
• CPR code status
• Level of intervention (i.e. comfort care only, intermediate
care, or full treatment?)
• Use or withholding of antibiotics & feeding tubes
Who Should Have a POST form
completed?
• Any individual with a chronic or serious illness who may
need a life-sustaining treatment in the future to attempt
to survive
• NO answer to the surprise question (Would I be surprised
if this patient died in the next year?)
• Hospitalized patients being discharged to nursing home
or home with hospice or home health
• Nursing home residents
Who Should NOT have a POST
form completed?
• Patient who wants to be full code or full
treatment and is not willing to initial box in
Section F
• Patient who requests contradictory orders
What if Patient already has Advance
Directive?
• POST reinforces wishes expressed in advance directive
• Original hot pink POST form remains with the patient
• POST is a physician’s order that should be immediately
used to direct the care of the patient
• Recommend that very ill patients have both, POST &
advance directive
Need POST if has DNR
Order/Card?
Recommended because:
• POST addresses more than just DNR. Addresses….
 Comfort level
 IVs / Nutrition
 Antibiotics
Need DNR order if has POST?
• Some hospital policies require transferring DNR order
from the POST onto facility physician order form
• Community: POST serves as the DNR order, however…
• Orange DNR card also recommended for mobile patients keep in wallet
Where Does Physician Sign?
• Section E by a physician who has examined the patient
• Section F after each review of form upon change in care
setting or substantial change in patient’s condition
Who Can Fill Out POST Form?
• Physician
• Social Worker
• Nurse
• Other health care professionals
• This person signs Section F of form
• Physician signs regardless who completes
Before completing form…
• New Form: Converse with patient or, if the patient lacks
capacity, representative/surrogate
• Revising: Physician, MPOA, HCS cannot change a POST done by
the patient unless patient initials Section F granting authority
for all decisions to MPOA/HCS.
• That’s why….
 Best not to do a POST until patient is seriously or chronically ill…
 Importance of detailed discussion with patient up front…
Changing the POST
POST should be reviewed:
• Patient is transferred from one care setting or
care level to another, or
• There is substantial change in patient’s health
status, or
• The patient’s treatment preferences change
What if Patient/Surrogate Changes Mind?
• Void the form; complete a new one
• Leave in permanent record
How to Void the POST
• Draw a line though the Physician Orders
• Write the word VOID in large letters, then
• Sign and date the form under VOID
• After voiding the form, a new form may be completed
• If no new form is completed, full treatment &
resuscitation may be provided
Must Health Care Comply with
POST?
YES
• Providers can be disciplined by their licensing board for
failure to honor advance directives or decisions of
surrogate, provided provider had actual knowledge of
directive
• Law protects good faith compliance with honoring
advance directives
When Patients are Transferred…
• Facility initiating transfer must communicate the
existence of POST form to receiving facility PRIOR to
transfer
• POST orders remain in effect in receiving facility
• After admission, attending physician required to review
POST & continue w/o change, void and do new one, or
void, do not do new one (Section G)
• If POST done by patient & patient now incapacitated,
form can only be changed if box in Section F is initialed
Photocopying the POST Form
• Photocopy may accompany patient in transfer between
facilities
• Copy is legally valid if copied onto “hot pink” paper
• Sending copy ensures that original is not lost in transfer
Where is original POST kept?
• With the patient
• If patient resides at home: instruct patient to keep it
posted on the refrigerator for EMS personnel
• In hospital: required to keep as first sheet on chart unless
otherwise specified by hospital policy
Handling Conflicts
Patient’s self-implemented advance directive says one thing
---- MPOA representative or HCS says another…
Patient’s own advance directive rules
Most recently executed one rules to extent
needed to resolve inconsistency
Handling Conflicts
MPOA or HCS disagrees with what the physician thinks is in
the best interest of patient, physician should….
Consult another qualified physician or ethics
committee
Transfer care to physician who will carry out the
MPOA requests
Legal Protection
• Good-faith compliance with or reliance upon the
directions of the MPOA, HCS, POST, LW
• Can’t comply? Transfer to another physician who will
honor such.
• Transfer under these circumstances does not constitute
abandonment.
Troubling Case Resolved
 Make reasonable attempt to locate advance directive
 If one can't be found go through the surrogate selection
process
 Consider a DNR card
 Consider a POST form
WV Center for
End-of-Life Care
www.wvendoflife.org
1-877-209-8086