Transcript Our Care, Our Decisions Native Values and Health Care

Our Care, Our Decisions:
Native Values and Health Care Decisions
Understanding Advance Directives
Sponsored by:
The Alaska Native Medical Center Medical Ethics Committee
Facilitators: Colleen Anagick, LCSW
Michelle Moran, RN MPH OCN CHPN
Overview
 Issues in health care decision making
 Definitions of terms used in health care
decision making
 Case studies and examples
 Tools and resources to help in the health care
decision making process
What are you hoping to get from this
workshop?
 Tell us what you would like to know to be able
to talk to patients about advance directives
 Specific questions?
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professional
personal
Why Bother with AD’s?
 Advances in medical technology
 People are living longer
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chronic illness
 Unexpected situations
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acute illness
accidents
military deployment
Advances In Medical Technology
 Advances in medical technology allow people
to survive illnesses and injuries that once
they would have died from
 Examples:
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cancer treatment
dialysis
children with complex medical conditions
head injuries due to accidents
Case #1:
 Robert, an 82 year old Yupik elder, was medi-vaced to ANMC
from the YK region with a massive stroke
 Robert was admitted to the intensive care unit and placed on
life support
 His prognosis was poor
 He did not have advanced directives but, according to his
eldest son, had previously expressed his desire not to be put
on life support and that he would never want to live in a
nursing home
 Robert’s condition got worse
 A care conference was held to discuss withdrawal of lifesupport
 Family members expressed that they knew Robert would not
want to be on a breathing machine, but the decision to take
him off the breathing machine was too hard to make
People Are Living Longer
 Proportion of US population > 65 years old
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~12% in 2000
~20% in 2030 (projected)
 Number of US population > 65 years old
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~35 million in 2000
~71 million in 2030 (projected)
US Census Bureau, International Data Base, Table 094
Unexpected Situations
 Families may have to make decisions about
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putting their loved one on a breathing machine
to keep them alive
the risks and benefits of major surgery
restarting their loved one’s heart if it were to
stop beating
feeding tubes
Case # 2
 Teri Shiavo, a 27 year old woman who suffered
severe brain damage from a heart attack in 1990
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Teri was in an irreversible persistent vegetative state
for 15 years
Teri’s spouse and parents disagreed on whether lifesustaining measures should be continued or not
Teri’s family fought in court about who had the right to
make medical decisions for Teri
Teri did not have written advance directives
Teri Shiavo died at the age of 41 on March 31, 2005.
What are Advance Directives?
 Advance Directives are a tool for:
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communication
advocacy
counseling
Advance Directives are:
 A communications tool
 for assisting people in clarifying their values
and preferences
 An advocacy tool
 for helping patients project their caring for
family into an uncertain future
 A counseling tool
 for supporting and guiding family members in
making decisions in stressful situations
National Healthcare Decisions Day 2008
Advance Directives Include:
 Instruction for Health Care
 Durable Power of Attorney
 Comfort One (in Alaska)
Instructions for Health Care
 An oral or written advance directive that
conveys the wishes of a person in the event
of terminal illness or life-threatening event
 It goes into effect when a person cannot
make or communicate their own health care
decisions
 Also known as a living will
Durable Power of Attorney
 A legal written document that allows a person
to name someone else to make health care
decisions for them and uphold their wishes if
they are not able to do so themselves
 It goes into effect when a person cannot
make or communicate their own health care
decisions
 It remains in effect as long as a person
cannot make or communicate their own
health care decisions and becomes null and
void when the person dies
Comfort One
 The Alaska Comfort One Program
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allows a person who is terminally ill to choose
not to have cardiopulmonary resuscitation
done when their heart stops
establishes a protocol for health care
providers to respect these wishes
remains in effect unless/until revoked
allows health care providers in Alaska to
respect Do Not Resuscitate orders from other
states, territories or possessions of the US
Why Make Health Care Decisions
in Advance?
 Increases the likelihood that a person’s
wishes will be honored
 Reduces personal worry
 Reduces feelings of helplessness and guilt
for families
 Reduces legal disputes
 Provides direction to the health care team
 It is a gift to your loved ones
Why Make Health Care Decisions
in Advance?
 Protect your rights
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To make informed decisions
To accept or refuse certain types of care or
treatments
 To have some control during illness
 To have your wishes be respected at the
end of your life
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Beginning “The Conversation”
 Having the tough conversation with patients,
families, friends, health care providers
 We can’t make decisions for patients and
families, but we can provide information to
help individuals make decisions that are right
for them and their families
How to Begin
The Tough Conversation
 AD’s can be uncomfortable to talk about
 Everyday life events can provide an opportunity to
talk about advance directives
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death of a loved one, friend, acquaintance
change in health status
family events such as holidays, anniversaries,
memorial potlatches
the “6 D’s”
 It is usually more difficult to talk about advance
directives under stress or during a crisis
Making it Personal
 “Normalizing” the process
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“we do this with everyone”
 Have you completed your Advance Directives?
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have you helped a friend or someone in your
own family complete theirs?
how did you/they feel about the process?
Three Big Decisions
 The three most common decisions people
struggle with:
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3.
CPR
Artificial hydration and nutrition
Cure vs. comfort
Decision #1
1. Should we attempt resuscitation (CPR)
(restart the heart when it has stopped
beating)?
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most successful for people who were healthy
prior to an accident or injury
people with the least chance of survival
include:
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terminally Ill
multiple medical problems
those who are dependent on others for care
Decision #2
2.
Should we consider artificial hydration and nutrition
(feeding tubes)?
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Beneficial to those needing short term artificial
feeding or patients who have lost the ability to
swallow and who can live with a feeding tube and still
enjoy life (visiting with family, reading, etc.).
Risks of artificial feeding may include aspiration
pneumonia, ulcers and infections. If need to be
restrained to prevent removing the tube, immobility
means they are at additional risk for bedsores or
atrophy and stiffening of their limbs.
Decision #3
3. When is it time to shift the goal from cure to
comfort care?
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most people will die of chronic diseases but
may live many years before dying
patients and families need to weigh the
benefits and burdens of any specific
treatment; quality of life is the goal
health condition and functional changes
often come gradually over time
patients and families have difficulty when a
diagnosis becomes terminal
“Final Gifts”
 Any other
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stories?
examples?
questions?
Take Home Pearl #1
 Advance healthcare planning helps people:
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by developing guidelines that determine and
document a person’s goals and wishes
by ensuring that care is provided according to
that person’s choices
by decreasing crisis decision making by
anticipating potential emergencies
by promoting understanding, reflection and
communication about values and preferences
National Healthcare Decisions Day 2008
Take Home Pearl #2
 Advance healthcare planning is important
because:
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it can avoid some of the crises that occur
when someone becomes incapacitated and
others are left to make decisions about their
healthcare
it can be a gift to loved ones in times of crisis
by documenting the wishes of the person who
can no longer speak for themselves.
National Healthcare Decisions Day 2008
Resources
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ANMC’s advance directives packet
Regional primary care providers and hospitals
Alaska Legal Services Corporation:
www.alsc-law.org
Alaska State Advance Directives:
www.hss.state.ak.us/dph/director/living_will
Alaska Law Help: www.alaskalawhelp.org
Aging with Dignity: www.agingwithdignity.org
American Bar Association:
www.abanet.org/aging/toolkit
Caring Connections: www.caringinfo.org