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Similar to Advance Directives for Beginners (20)
Advance Directives for Beginners
- 2. © 2015 The BreathingSpecialist
When Am I Going To Talk
About This ?
- 3. © 2015 The BreathingSpecialist
“I have a Living Will, do I need
an Advance Directive also” ?
DPAHC- Appoints someone straightaway to make the
decisions
AD- Outlines their wishes
Living Will- Outlines what you do or do not want, and
appoints someone to make those decisions if the patient
cannot
- 4. © 2015 The BreathingSpecialist
DECLARATION
I, (Name) , being of sound mind, willfully and voluntarily make this
declaration to be followed if I become incompetent. This declaration reflects my
firm and settled commitment to refuse life-sustaining treatment under the
circumstances indicated below.
I direct my attending physician to withhold or withdraw life-sustaining treatment that
serves only to prolong the process of my dying, if I should be in a terminal condition
or in a state of permanent unconsciousness. I direct that treatment be limited to
measures to keep me comfortable and to relieve pain, including any pain that might
occur by withholding or withdrawing life-sustaining treatment.
In addition, if I am in the condition described above,
Living Will example
Excerpted from LegalTemplates.net
- 5. © 2015 The BreathingSpecialist
How Do You Feel About Each
of These Treatments?
Receiving blood or blood products Yes No
Having to have Surgery Yes No
Invasive Testing Yes No
Cardiac Resuscitation (CPR) Yes No
Mechanical Ventilation Yes
No
BiPap Ventilation Yes No
Tube Feeding Yes No
Dialysis Yes No
IV’s Yes No
Antibiotics Yes No
- 6. © 2015 The BreathingSpecialist
Directive to Physicians
Directive made this __ day of ____ in the year ____.
I,_____, being of sound mind, willfully and voluntarily make known my desire that
my life shall not be artificially prolonged under the circumstances set forth in this
directive.
If at any time I should have an incurable or irreversible condition caused by injury,
disease, or illness certified to be a terminal condition by two physicians, and if the
application of life-sustaining procedures would serve only to artificially postpone the
moment of my death, and if my attending physician determines that my death is
imminent or will result within a relatively short time without the application of life-
sustaining procedures. I direct that those procedures be withheld or withdrawn, and
that I be permitted to die naturally.
In the absence of my ability to give directions regarding the use of those life-
sustaining procedures, it is my intention that this directive be honored by my family
and physicians as the final expression of my legal right to refuse medical or surgical
treatment and accept the consequences form that refusal.
.
Advance Directive Sample
- 7. © 2015 The BreathingSpecialist
This directive is in effect until it is revoked.
I understand the full import of this directive and I am
emotionally and mentally competent to make this
directive I understand that I may revoke this directive
as any time.
I request that only comfort care be provided to me, no
antibiotics, no artificial nutrition, no mechanical
ventilation, and no hydration. It is my strong preference
to be allowed to die outside of a care facility if possible,
even if that preference is determined by my physician
to shorten my period of dying. The only condition under
which I desire these preferences for end of life care to
be altered is in the case of possible organ and tissue
donation. I request that any and all organs and tissue
that may be salvaged be provided for transplant. My
remains may then be cremated.
Signed ______________ in the City of
____________etc.
- 8. © 2015 The BreathingSpecialist
What Does all of this Mean?
What am I signing?
Revocable: If you can say it, we will do it
But, saying yes to one thing often means saying yes to
many things that are connected
- 9. © 2015 The BreathingSpecialist
BiPap- The new cover-all
solution (NOT!)
Bipap is ventilation without the endotracheal tube
=ventilator=life support
Often done for the family
Photo courtesy of Respironics
- 10. © 2015 The BreathingSpecialist
Photo courtesy of Respironics Inc.
- 11. © 2015 The BreathingSpecialist
What in the world is “The
Peri-operative Period?”
Pre-hospital DNR or Advance Directive in place
Procedures, surgeries, etc.
- 12. © 2015 The BreathingSpecialist
Surgery = -pre, -peri, and –
post op
DNR or any limitations gets rescinded during any
‘procedure’ in many hospitals
Immediate post-operative time is considered “the
extended peri-operative period”
Aggressive treatment to ensure success of the
procedure
Once treatment is started, very difficult to stop
After a ‘procedure’, when will the full Advance
Directive kick in?
- 13. © 2015 The BreathingSpecialist
Have We Met?
Electronic Medical Records- blessing and nightmare
- 14. © 2015 The BreathingSpecialist
A Personal Choice
To Live, or to Die
Definition of Living
-Cultural
-Religious
-Personal Beliefs about the Afterlife
-Fear in the Moment
-Understanding of what is available
-Understanding your own physiology
- 15. © 2015 The BreathingSpecialist
How Do You Feel About Each
of These Treatments?
Receiving blood or blood products Yes No
Having to have Surgery Yes No
Invasive Testing Yes No
Cardiac Resuscitation (CPR) Yes No
Mechanical Ventilation Yes
No
BiPap Ventilation Yes No
Tube Feeding Yes No
Dialysis Yes No
IV’s Yes No
Antibiotics Yes No
- 16. © 2015 The BreathingSpecialist
Quality of Life
What does ‘quality of Life’ mean to you?
Would you want to live on a ventilator?
Would you want to live at home as long as possible?
Would you want to live in a Care Facility?
If you had solid answers to these questions, who could
you trust to carry out your wishes for you?
- 17. © 2015 The BreathingSpecialist
DNR variations and choices
“Intubation only, no CPR”
- Often chosen by those with Asthma or COPD
“Chemical Code only”
Use of BiPap
DNR: Do Not Resuscitate orders
- 18. © 2015 The BreathingSpecialist
What is a “Code Blue” ?
Not like on TV
MD comes running to put breathing tube in the throat
RT ventilates with a bag and assists with intubation and
secures the breathing tube
Pharmacy team comes running
RN comes running with crash cart, starts IV’s and gives
initial meds
Someone does chest compressions
Defibrillator attached - Ouch!
- 19. © 2015 The BreathingSpecialist
What if family is present
during a code?
Violent images that are hard to forget
Shock at how violent and/or chaotic it seems
Anger – may try to remember all the details
Guilt- Things unsaid
- 20. © 2015 The BreathingSpecialist
The Nightmare
No Advance Directive on file
“No specific directions = full code
Patient crashes, gets intubated, and sent to ICU
Family called
Conflicting opinions between family members
- 21. © 2015 The BreathingSpecialist
A different nightmare
Patient has Advance Directive on file at the Nursing
Home or RCF, but becomes unresponsive and gets
transferred to ED for ‘further evaluation”
Patient in SNF gets an infection requiring transfer to ER
for Antibiotics.
Subsequent decline of the patient requires a full code,
because no one can find the original Directive
- 22. © 2015 The BreathingSpecialist
Worse Nightmare
Patient’s AD is at her primary care MD’s office, or in a
safe deposit box or attorney’s office somewhere
Patient’s caregiver get scared, calls 911 despite being
told not to.
- 23. © 2015 The BreathingSpecialist
Worst Nightmare Ever
Patient is stating his/her wishes, family is deciding
otherwise
Family’s choices to prolong include tracheostomy and
home ventilation, or SNF sentence
Photo courtesy of Allegro Medical
- 24. © 2015 The BreathingSpecialist
The solutions
Make sure to add a line for Non-Invasive
Positive Pressure Ventilation to AD
Be sure there are provisions for feeding tubes
Include a well-defined peri-operative period
(i.e., 24 hours)
Include TPN as a choice
Educate the public on the amount and extent
of choices they have, and the complications
of each
If bedridden, make provisions for bedsore
care
- 25. © 2015 The BreathingSpecialist
Doctors are trained to save
lives, not end them.
DNR for end-stage COPD
On floor, she gets very short of breath
Gets to ICU, and is in progress with MI
Cardiologist talks her into a cath
Intubated for cath
Unable to extubate after procedure
Family furious
- 26. © 2015 The BreathingSpecialist
What Can You Do?
Search for Advance Directive Forms for your State
Discuss with family members your wishes
Appoint carefully
Make sure everyone knows where to find your
document.
For more information, visit us at:
http://www.TheBreathingSpecialist.com
- 27. © 2015 The BreathingSpecialist
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