Patient Autonomy and Advance Directive

1. Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
Patient
Autonomy and
Advance
Directive

2. Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
Patient
Autonomy and
Advance
Directive
I have a Patient
Empowerment
Program in which I
like to empower the
lay people or
patients to take
control in the
management of
their health.

3. I launched this PEP
TALK on May 15,
2021 with MODULE
on COVID19.
2nd Module: PATIENT
EMPOWERMENT
3rd Module: PATIENT
MANAGEMENT
PROCESS
4th Module
RIGHTS IN PATIENT
EMPOWERMENT
Patient
Autonomy and
Advance
Directive
Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.

4. Patient
Autonomy and
Advance
Directive
Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
What I have in mind
in my PEP TALK
which may run for 3
years is to empower
at least 30 persons,
with my family
members and my
patients as a
priority. This is my
key performance
indicator.
I hope you will be in
my group of 30.

5. Patient
Autonomy and
Advance
Directive
Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
4th Module
RIGHTS IN PATIENT
EMPOWERMENT
2 Parts
• Basic Rights
• Patient
Autonomy and
Advance Directive

6. Patient
Autonomy and
Advance
Directive
Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
My PEP TALK today
is entitled: Patient
Autonomy and
Advance Directive.

7. Patient
Autonomy and
Advance
Directive
The foremost right in patient
empowerment is
PATIENT AUTONOMY.

8. Patient
Autonomy and
Advance
Directive
Patient autonomy is defined as the
right of all competent adults to
make informed decisions about their
health and medical care.

9. Patient
Autonomy and
Advance
Directive
Patient autonomy is one of the
principal ethical principles
established in the medical world and
being respected by all physicians.
Patient autonomy is also embodied
in the bill of human rights,
specifically on the right to health.

10. Patient
Autonomy and
Advance
Directive
Right to health means the states or countries
have the legal obligation to promote the health
of their citizens.
And under the right to health, there are 2
components: freedom and entitlement.
The freedom component has emphatically
stressed the rights of every citizen to control
one’s health and body.
Thus, patient autonomy is embodied in
this freedom component of right to
health.

11. Patient
Autonomy and
Advance
Directive
So,
everybody, physicians or health care
providers and even relatives
included,
should respect patient autonomy
with regards to decisions on
health.

12. Patient
Autonomy and
Advance
Directive
In medical practice, the principle of
PATIENT AUTONOMY underlies the
requirement to seek the consent or
informed agreement of the patient before
any investigation or treatment takes
place.

13. Patient
Autonomy and
Advance
Directive
However, this principle comes into
prominence when hard decisions
involving patient autonomy have to be
made in the care of the terminally-ill
patients.
The advance health care directive
will demonstrate the application of
patient autonomy.

14. Patient
Autonomy and
Advance
Directive
There are 2 keywords or phrases in the definition
of patient autonomy: “competent adults” and
“informed decisions.”
“Competent adults” means conscious, coherent
and discerning adults.
“Informed decisions” means a permission or no
permission is granted by the competent adults
after proper understanding of the purpose;
options with benefit, risk, cost and availability
data analysis; and consequences of procedures
to be undertaken.
These 2
components or
requirements
must be fulfilled
for patient
autonomy to be
ethically and
legally binding.

15. Patient
Autonomy and
Advance
Directive
So, after being advised properly and
adequately, after studying more data and
information by himself if needed and
after introspection,
a patient can end up with a decision of
either informed consent or informed
refusal.

16. Patient
Autonomy and
Advance
Directive
Whatever be his decision,
because of his right to patient autonomy,
this should be respected
as long as there is nothing illegal in the
court of law of the land where he is
residing.

17. Patient
Autonomy and
Advance
Directive
Patient autonomy should be
respected in whatever settings such
as
when being managed by a physician;
when being managed by relatives;
and when doing self-management.

18. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive

19. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
An advance health care
directive is patient autonomy
in action or in operation.

20. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
An advance health care directive or
living will is an advance health care
planning in which the author or
person who makes this explains how
he wants medical decisions to be
made in case he cannot make
decisions already.

21. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
By setting the contents of an advance
health care directive,
the author is exercising his right of
patient autonomy as what are usually
placed in the directive are
what medical measures he will allow to
done and
what he does not want to be done to his
body.

22. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
By the way,
a last will as differentiated from a living
will
is a document in which the author or
person who makes this determines what
and how he wants done with his property
and other material things after he passes
away.

23. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
Advance health care planning is not just
about old age.
At any age, a medical crisis could leave a
person too ill to make his own health care
decisions.
Advance health care planning can be and
should be done in any adult age.

24. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
Advance health care planning is not yet
very popular yet in the Philippines
compared to other countries.
If there are people making it, they are
usually done by terminally-ill patients
who have accepted their status and who
want to prepare well for the eventuality,
not only for themselves but also for the
family.

25. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
It is advisable, though,
for all competent adults to have an
advance health care directive as part of
the patient empowerment program (to
gain greater control over decision and
actions on their health).

26. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
ADVISABLE!
As mentioned, at any adult age. It does
not have to be old age or at the time
when one is suffering from an incurable
disease.
An advance health care directive is also
included in an intentional living plan of a
person who plans out his life properly.

27. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
To repeat,
an advance health care directive is a
document that spells out some medical
decisions and actions that the author
wants done and not to be done to his
body in case he cannot make decisions
anymore.

28. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
The document can be notarized or not.
What is most important is there is a
concrete document that is known to be
made, dated and regularly updated by
the competent-adult author and its
contents are known to and accepted by
immediate relatives and significant
others.

29. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
This document serves as a guide to the
immediate relatives and significant others
when the time comes to implement the
contents as well as to the health care
professionals who may eventually be
called to manage him.

30. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive

31. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
ADVANCE HEALTHCARE DIRECTIVE on
How I Want To Be Treated MEDICALLY,
When I am Near End-of-life, When I have
a Terminal Illness, and When I Am
Bedridden
I, Reynaldo O. Joson, residing at
XXXXXXXXXX Makati City, being of sound
mind, willfully and voluntarily make this
ADVANCE HEALTHCARE DIRECTIVE:

32. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(1) If the situation occurs that I am in a VEGETATIVE STATE
or COMA from an INCURABLE disease process or injury (as
determined by two physicians approved by my wife
[AAAAAAAAAA] or in her absence, either my son
[BBBBBBBBBBBB] or my daughter [CCCCCCCCCC]), I desire
and direct that ALL LIFE-SUSTAINING PROCEDURES AND
MEANS BE WITHHELD OR WITHDRAWN, including assisted
respiratory ventilation, artificially administered fluids or
nutrition (intravenous, gastric, jejunal, or other tube
feedings), and blood transfusion and that I be permitted to
die naturally.

33. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(2) If I should develop severe mental impairment to the
degree that I am TOTALLY UNABLE TO PERFORM ACTIVITIES
OF DAILY LIVING OR AT LEAST TO RECOGNIZE AND
MEANINGFULLY COMMUNICATE WITH MY FAMILY AND
OTHERS (as determined by two physicians approved by my
wife [AAAAAAAAAA] or in her absence, either my son
[BBBBBBBBBBBB] or my daughter [CCCCCCCCCC]), I DO
NOT WANT INTENSIVE OR PROLONGED HOSPITALIZATIONS,
MAJOR SURGERY, ARTIFICIALLY ADMINISTERED FLUIDS OR
NUTRITION (INTRAVENOUS, GASTRIC, JEJUNAL, OR OTHER
TUBE FEEDINGS), BLOOD TRANSFUSIONS, OR ASSISTED
VENTILATION.

34. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(3) If the circumstance occurs that I am in a state
of near-death, but a good possibility exists (more
than 50% probability) of recovery to a purposeful
situation (such as my being able to write or
otherwise communicate helpful thoughts and
information to my family and others), then I do
not restrict my physicians from exercising their
skills with prudence, wisdom, and restraint.

35. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
However, I do not desire extreme measures such
as a transplant, extensive and complicated
surgery, chemotherapy, radiotherapy, dialysis,
etc. And, if the state of near-death is part of a
terminal cancer or other progressively incurable
disease process or injury, then I desire
that MEASURES BE DIRECTED AT COMFORT,
RATHER THAN TO DELAY THE MOMENT OF
DEATH.

36. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(4) Furthermore, if I am in a vegetative state or coma from
an incurable disease process or injury, or in a state of near-
death with a progressively incurable disease or injury, or if
I have developed severe mental impairment to the degree
that I am totally unable to perform activities of daily living
or at least to recognize and meaningfully communicate
with my family and others (as determined by two
physicians approved by my wife [AAAAAAAAAA] or in her
absence, either my son [BBBBBBBBBBBB] or my daughter
[CCCCCCCCCC]), and IF MY HEART OR LUNGS CEASE TO
FUNCTION, I DO NOT WANT TO BE BROUGHT BACK TO LIFE
WITH MEDICATIONS OR WITH ELECTRICAL OR
MECHANICAL RESUSCITATION OR VENTILATION, OR EVEN
WITH ORDINARY CARDIOPULMONARY RESUSCITATION.

37. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(5) In any of the above circumstances, it is
MY DESIRE TO BE MADE COMFORTABLE
WITH MEDICATIONS THAT ARE USED TO
CONTROL PAIN, knowing that such
medications may unintentionally hasten
death. However, medications should not
be used with the intention of causing
death.

38. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
(6) It is my desire that the COSTS OF MY
TERMINAL CARE BE KEPT TO A MINIMUM,
inclusive of diagnostics and treatment and also
place of care (MINIMALIST MANAGEMENT).
Diagnosis shall be mainly CLINICAL, based on
symptoms and signs. Unless there are
compelling reasons to the contrary, I would
PREFER TO SPEND MY LAST DAYS AT HOME
RATHER THAN IN A HOSPITAL OR OTHER
EXPENSIVE MEDICAL FACILITY – unless being at
home would be an unreasonable burden on my
family.

39. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
This ADVANCE HEALTHCARE DIRECTIVE
shall be accompanied by implementing
guidelines and instructions which I shall
be read and followed by all concerned.

40. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
I am legally competent to make this ADVANCE
HEALTHCARE DIRECTIVE, and I understand its full
import.
My wife [AAAAAAAAAA] or in her absence,
either my son [BBBBBBBBBBBB] or my daughter
[CCCCCCCCCC] shall enforce this ADVANCE
HEALTHCARE DIRECTIVE.
Witness my hand, this 20th day of January 2021.
Signature

41. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
Implementing Guidelines and Instructions
I, Reynaldo O. Joson, am a mortal human being
who may get sick anytime of whatever cause.
In the event that I became unconscious and
cannot make any decision regarding treatment to
be instituted on my body, here are the guidelines
that I am leaving for my immediate family
members, my brothers and sisters, and my
attending physicians to follow:

42. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
Implementing Guidelines and Instructions
1.For diagnosis of my health problem, rely
heavily on clinical parameters and include
observation.
2.Do paraclinical diagnostic procedures only
when the results will significantly affect the plan
of treatment.
3.Try to save me only when my chances of
recovery without disability, note without
disability, are more than 50%.

43. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
Implementing Guidelines and Instructions
4.No heroic measures when my chances of recovery from
my disease are less than 50%.
• No respirator.
• No nasogastric tube.
• No tracheostomy.
• No gastrostomy.
• No urinary catheter
• No intravenous fluid.
• No blood transfusion.
Keep me in a private room until I expire.

44. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
Implementing Guidelines and Instructions
5.No heroic measures if I have the following
diseases or conditions:
Cancer
Cerebrovascular accident

45. Patient
Autonomy and
Advance
Directive
An example of advance
health care directive -
ROJoson Advance Health
Care Directive - which I
formulated in 2006
(when I was 57 years old)
and have been reviewing
and updating up to now
(2021 - 72 years old) -
which I have made
known to my wife and 2
children.
ROJoson Advance Health Care Directive
Implementing Guidelines and Instructions
6.Do not hurt me unnecessarily when my
chances of complete recovery are small. Let me
die as peacefully as you can afford me.
7.Keep costs of my terminal care to a minimum
possible inclusive of diagnostics and treatment
and also place of care.

46. Patient
Autonomy and
Advance
Directive As mentioned, advance health care planning is
not yet very popular in the Philippines. However,
what is becoming more and more popular now
is something akin to the advance health care
directives in persons who are seriously or
terminally ill. The issue of withholding and
withdrawing life-sustaining orders in these
seriously or terminally-ill patients often crop up
in the last minute.
Advance Directive and DNR

47. Patient
Autonomy and
Advance
Directive In this day and age, most, if not all hospitals in
the Philippines already have a readied proforma
form commonly called DNR Order or Form with
DNR denoting Do Not Resuscitate.
Advance Directive and DNR
In this day and age,
most, if not all
hospitals in the
Philippines already
have a readied
proforma form
commonly called
DNR Order or Form
with DNR denoting
Do Not
Resuscitate.

48. Patient
Autonomy and
Advance
Directive The DNR orders should originate from the
patients and significant others.
They may arise after discussion with the
physicians.
Advance Directive and DNR

49. Patient
Autonomy and
Advance
Directive The attending physicians of these seriously or
terminally-ill patients can make the formal
medical orders only upon instructions from the
patients and significant others.
Advance Directive and DNR

50. Patient
Autonomy and
Advance
Directive
Patients and significant others should tell their
attending physicians way before how they want
to be treated when they are seriously or
terminally ill in terms of withholding and
withdrawing life-sustaining treatment which
may be futile and which may affect their quality
and dignity of life.
If they don’t tell their attending physicians
beforehand, the latter will order all possible life-
sustaining treatment despite the odds.
Advance Directive and DNR

51. Patient
Autonomy and
Advance
Directive
The following have to be decided by the
patients and significant others (through
an advance directive or DNR order):
withhold – not to be done;
withdraw – to remove after being done
Advance Directive and DNR

52. Patient
Autonomy and
Advance
Directive
•Whether to do resuscitation or not.
•whether to do defibrillation or not.
•Whether to do intubation or not.
•Whether to do mechanical ventilation or
not.
•Whether to do dialysis or not.
Advance Directive and DNR

53. Patient
Autonomy and
Advance
Directive
•Whether to do nasogastric tube
insertion or not.
•Whether to do gastrostomy or
enterostomy or not.
•Whether to have artificial hydration or
not.
•Whether to have artificial nutrition or
not.
•Whether to have medications or not.
Advance Directive and DNR

54. Patient
Autonomy and
Advance
Directive
•Whether to have diagnostic procedures
or not.
•Whether to have operative procedures
or not.
• Others
Advance Directive and DNR

55. Patient
Autonomy and
Advance
Directive
The patients and significant others
can specify what to withhold and
what and when to withdraw.
Advance Directive and DNR

56. Patient
Autonomy and
Advance
Directive
All of the above instructions from
the patients and significant others
should be written and signed (and
witnessed) in a document or form.
Advance Directive and DNR

57. Patient
Autonomy and
Advance
Directive
After giving the initial instructions,
the patients and significant orders
can change or revoke them anytime
they wish.
However, these new instructions
should also be written and signed
(and witnessed) in a document or
form.
Advance Directive and DNR

58. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
This document serves as a guide to the
immediate relatives and significant others
when the time comes to implement the
contents as well as to the health care
professionals who may eventually be
called to manage him.

59. Patient
Autonomy and
Advance
Directive
Advance Health Care Directive
or Advance Directive
This document serves as a guide to the
immediate relatives and significant others
when the time comes to implement the
contents as well as to the health care
professionals who may eventually be
called to manage him.
I am ______, a cancer
patient. Should I be
brought to the hospital
during emergency or my
last breath, please do no
intubate and do not
resuscitate. Thank you.
Signed
Date:
PS. I just need the oxygen.

60. Patient
Autonomy and
Advance
Directive
So, there you are – the PATIENT AUTONOMY
AND ADVANCE HEALTH CARE DIRECTIVE as rights
in patient empowerment.
• Maximize your knowledge (KAALAMAN) on
these rights.
• Maximize your capability (KAKAYANAN) in
seeking for and implementing these rights.
• Lastly, maximize your self-determination
(KAPANGYARIHAN) in using the rights in
gaining greater control over decisions and
actions affecting your health.
Conclusion
Take Away

61. Empowerment
objective - for
laypeople to have
an understanding
of PATIENT
AUTONOMY AND
ADVANCE HEALTH
CARE DIRECTIVE
as Rights in
Patient
Empowerment.
Patient
Autonomy and
Advance
Directive