© EPEC Project, 2003
Permission to reproduce for educational purposes granted
Page ‹#›
Permission to reproduce for educational purposes granted
Page ‹#›
Module 4:=
Pain
Management
------=_NextPart_01C7D459.8E844740
Content-Location: file:///C:/4E921AF3/Module4AdvancedCarePlanning_FastFacts_files/pres.xml
Content-Transfer-Encoding: quoted-printable
Content-Type: text/xml; charset="utf-8"
![](3D"master09_image001.gif")
![](3D"master09_image002.gif")
E
P
E
C
P
E
C
Advanced Care Planning
<=
b>FAST
FACTS
<=
b>Module
4
![](3D"master08_image003.gif")
![](3D"slide0169_image004.gif")
ACGME Competencies: Medical Knowledge, Patient Care,
System-based Practice
Keyword(s): Caring for families, family conferences,
communication skills, discussing prognosis=
ADVANCE CARE PLANNING=
Adv=
ance
care planning is the process by which an individual considers his or her personal values about the end of
life, discusses those val=
ues
with family or others close to them and health care providers, and completes the documents that record t=
hose
decisions for the
future.
While this process is important for all =
age
groups, some of the most dif=
ficult
end-of-life decisions involve young people.
Between the ages of one and 44, the most common caus=
e of
death is trauma (m=
otor
vehicle accidents, homicide, suicide, drowning).
Such causes of death or profound, severe,
permanent damage cannot be
predicted. For this reason, EVERYONE needs advance car=
e planning,
not just older or chronically ill people.
The second
part of advance care planning is to communicate with others.
Tell
your family, others close to you, and your health care
providers what kind of care you would want in different
situations.
Write
your wishes down so that they are available if in =
the
future you are not able to make your choices known.
Consider
who might best know your wishes and make decisions
for you if you are unable to do so.
------=_NextPart_01C7D459.8E844740
Content-Location: file:///C:/4E921AF3/Module4AdvancedCarePlanning_FastFacts_files/slide0194.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
![](3D"slide0194_image005.gif")
Advance Directives
are the documents used to help a person express =
his
or her wishes and values about medical care in ca=
se
the person cannot, at some future time, speak
for him or herself.
There
are three documents available in Texas to record
this information. They are:
Texas Directive to Physicians, Families or =
Surrogates (formerly known as a “living
will”),
Medical Power of Attorney, and
Out of Hospital DNR (Do Not Resuscitate).
![](3D"slide0173_image006.gif")
TEXAS HEALTH & SAFETY
CODE
CHAPTER 166. ADVANCE
DIRECTIVES
SUBCHAPTER A. GENERAL
PROVISIONS
![](3D"slide0173_image008.jpg")
Po=
licies
& Procedures
Advance
directives are free.
Advance
directives are reversible.
![](3D"slide0192_image009.gif")
![](3D"slide0192_image010.gif")
The Texas Directive to Physicians, Famil=
ies
or Surrogates (“Texas Directive”)
Allows a person to indicate
choices about treatment in the event of a terminal or irreversible disease or
condition.
This document records for y=
our
physicians, family, and others what your wishes are if you are unable to speak for you=
rself.
![](3D"slide0192_image012.gif")
For examp=
le:
Mr. L has suffered a severe stroke. He is paralyzed and unable to take care of himself or communicate in any way.
Additionally, he has pne=
umonia
and will probably die if he does not receive intravenous antibiotics. =
He may also need a breathing machine.
The doctor thinks he has little chance of returning =
to
normal, but he has a fair chance of
getting over the pneumonia.
Mr. L’s family members disagree about what they
should do. His son believes his
father was never a quitter. He thinks his father would have chosen to righ=
t as long as there was the slightest hope.
Mr. L’s daughter disagrees and thinks that
although her father wasn’t a quitter, he wanted to die naturally. She thinks he would be
horrifed to be kept alive this way.
Mr. L had completed a directive stating =
his
wish that if he were in a condition where he was totally dependent and had little chance=
of
recovery, he would not cho=
ose
life-sustaining measures such as the use breathing machines, feeding <=
/span>tubes, or medications other than those than would ma=
ke
him comfortable. His family and
health care providers, therefore, are able to make the decision not to give antibiotics or use a breathing machine, and =
they
can be comfortable in the knowl=
edge
that this is what he wants.
Mr.
L’s directive made it possible for him to:
clarify
the treatments he did and did not want;
resolve
a disagreement among family members; and
=
relieve
some of the stress, guilt, and emotional burden for his =
family.
Life
sustaining treatment is
any treatment, procedure, or medic=
ine
that doctors
believe is maintaining the patient's life. Without it, doctors b=
elieve
the patient will die.
Examples
include use of
life support
equipment such as breathing machines and kidney dialysi=
s,
medications, heart pacemakers, feeding tubes, fluids provided through a vein
(artificial nutrition and hydration), and blood
transfusions. A terminal condition is an
=
incurable disease, illness, or inj=
ury
that doctors expect will cause death within about six
months even with life-An irreversible condition is
a disease, illness, or injury that
cannot be cured although it may be treated. Many irreve=
rsible
conditions will reach an advanced stage when they wi=
ll
also be considered terminal. Many illnesses or injuries,=
such
as cancer; kidney, heart, liver, or lung failure; and
serious brain damage or dysfunction caused by strok=
e,
injury, or Alzheimer’s dementia, are irreversible,=
but
patients may be kept alive for prolonged periods of time w=
ith
life-sustaining treatments. Many people worry
that if they complete an advance directive, they w=
ill
not receive treatment that they want.
It
is important to remember that your directive only =
takes
effect if two criteria are met:
first, that you are unable to make=
your
wishes known
and,
second, that a doctor has stated in writing that you are in a terminal or
irreversible condition.
It
is also good to remember that you can change your directive
at any time.
For examp=
le:
A man with severe emphysema had been in the Intensive Care Unit (ICU) at the hospital many times, but is now home, a=
nd
needs oxygen just to stay comfortab=
le
while sitting.
His doctor told him that it was likely his breathing
would get worse again at some time in t=
he
near future, and that it was very likely he would be in the ICU on a <=
/span>breathing machine again, unless he chose not to be, =
and
that this might be where he dies.
The man was no longer enjoying his life. He was very
limited in his activities because of
severe shortness of breath even while sitting still. In addition, he <=
/span>=
wanted to be at home in his final moments.
=
For all these reasons, he signed a living will. It
directed his doctors and family to give him anything necessary to keep him comfortable,=
but
not to take him back to the ICU i=
f he
were to get sick again.
Now his youngest child is getting marrie=
d in
two weeks. Even though his condition has not changed, the patient states, “Well,
I’ve made it this far, I want to do =
everything I can to be here for the wedding.” =
This
statement may represent a reversal =
of
the advance directive. After clarification of his wishes, this verbal =
reversal takes priority over the written document th=
at
he signed before. In other words, on=
ce a
living will is filled out, it can be changed, just by saying so.
The second advance
directive document in Texas, <=
b>the
Medical Power of Attorney (MPA):
<=
b> allows a person to name someone to=
make decisions in the event that=
the
person is unable to do so.
This
is important when there is a problem you did not
predict and explain in your living will. This document
is especially helpful if the person you would
choose to make choices for you is not your legal
next of kin.
This document is differ=
ent
from a general power of attorney and does=
not
allow the person to make decisions about y=
our
money or property.
For examp=
le:
A man with severe emphysema after many years of heavy smoking is on a breathing machine in the ICU f=
or
the sixth time.
=
;=
After 10 days, he is not getting better. He is divor=
ced
and has three
children, one of whom is a nurse.
In his MPA, he chose the daughter who is a nurse to =
make
decisions for him when =
he
was unable to communicate for himself.
Assuming that he had not specified in a
Texas Directive what he wanted do=
ne
in this situation, she would be responsible for deciding.
This would relieve the burden of making
decisions from his other chi=
ldren,
who might be less familiar with this kind of situation. His family would suffer less uncertainty, and this might
help them adjust to=
his
eventual death more peacefully.
The MPA
allows the person you appoint to make specific treatment decisions in accordance with your wishes.
In complex and rapidly changing medical situations t=
his
can be very important. Many
people fear spending extended per=
iods
of time on life-support equipment in intensive care units at the end of their lives.
But some would be willing to be put on a breathing
machine (for example) for a sho=
rt
period of time (several days to sev=
eral
weeks, perhaps) if there were a good possibility that they could recover to their previous state of health=
and
independence.
=
Your MPA would allow the person you appo=
int
to evaluate the situation=
and
make decisions that you would make in that specific situation if you could.
------=_NextPart_01C7D459.8E844740
Content-Location: file:///C:/4E921AF3/Module4AdvancedCarePlanning_FastFacts_files/slide0189.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
![](3D"slide0189_image013.gif")
Two important poi=
nts
about the person appointed to be your MPA:
1. The person you choose m=
ust
know your wishes.
2. The person you choose must be willing to follow your wishes. If your wife,= son, or friend tells you he or she couldn’t make the decision to withhold life= -sustaining treatment even = if that were your wish, that person should not be your MPA. <= /span>
2. The person you choose must be willing to follow your wishes. If your wife,= son, or friend tells you he or she couldn’t make the decision to withhold life= -sustaining treatment even = if that were your wish, that person should not be your MPA. <= /span>
For examp=
le: Mr. R. is a widower with no children who is <=
/b>=
undergoing treatment for lung cancer.
His closest friend, Mrs. J., visits him daily, and
they have talked extens=
ively
about his wishes as he comes to the end of his life.
<=
/span>
Mr. R. develops an infection and a hi=
gh
fever that has made him deliri=
ous,
and as a result he is unable to make his own decisions.
Mr.
R.’s next of kin is a brother who lives in another state, and =
Mr. R. has never discussed these issues with him.
By naming Mrs. J. as his medical power of attorne=
y,
Mr. R. can make s=
ure
she will be the one to decide on his behalf.
Otherwise, Mrs. J. has no legal standing, and the
patient's brother
would be responsible for making these decisions.
------=_NextPart_01C7D459.8E844740
Content-Location: file:///C:/4E921AF3/Module4AdvancedCarePlanning_FastFacts_files/slide0187.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
The third type of Texas
advance directive is called the <=
b>Out
of Hospital DNR .
It
is used most commonly when
a person has a life-threatening or
terminal illness and does NOT want a 9-1-1 emergency response team to be activat=
ed in
the event that he or she is dying.
This
applies not only in
the inpatient hospital sett=
ing,
but also at home, in a nursing home, at a grocery store, <=
/span> in the emergency room, in an
outpatient clinic, or in an ambulance leaving =
the
hospital to go home.For examp=
le:
A woman with advanced ovarian cancer has enrolled in a hospice program.
She is still able to get around a bit and
enjoys grocery shopping. She
would like not to die an agonizing and painful death, with blockage of her intestines, spending her final momen=
ts
in the hospital.
Like most of us, she would prefer to go
suddenly. She filled out an Out of
hospital DNR and wears the wristband.
While grocery shopping one day, she stops breathing =
and
is found on the floor. A k=
ind
person calls 9-1-1. When the EMTs arrive, they find the bracelet and allow her to go in
peace, just as she wante=
d.
They notify her family.
Two witne=
sses
are required to sign all of your Texas advance =
directive documents.
One of these witnesses must be
someone
who is NOT related to you;
a
person having a claim to your estate;
the
person appointed to be your spokesperson in the document;
your
attending physician or one of the physician’s employees; or &#=
13;<=
span
style=3D'font-family:Arial;font-size:83%;text-shadow:auto;color:white;
mso-color-index:0'> a
person providing direct care to you or employed in =
the business off=
ice of
a health care facility where =
you are a
patient.
REMEMBER THESE IMPORTANT POINTS
<= /span>= 2. Advance directives are free.
<= /span>= 3. Advance directives are reversible.
<= /span>4. Advance directives work best when accompanied by family discussions of values.
5. Advance directives prevent arguments and bad feelings at the end of life and help create a more peaceful bereavem= ent for the survivors.
Citati=
on
for reference material is Office of the Attorney General; PO Box 12548
Austin, TX 78711-2548
Austin, TX 78711-2548
![](3D"slide0170_image014.gif")
The
Out-of-Hospital
Do-Not-Resuscitate program:
Allows people to decide that they do not want to =
be
resuscitated if they stop breathing and their hearts stop beating.
defibrillation,
artificial ventilations and
transcutaneous cardiac pacing.
![](3D"slide0171_image015.gif")
Texas
Partnership for End-of-Life Care
TxPEC Mission<=
/b>
TxPEC members will
achieve the mission by:
![](3D"slide0171_image016.gif")
Promoting best practices and dissemin=
ating
information to extend implementation at the patient, community, and state level.<=
/span>
Encouraging dialogue among individual=
s and
families, health professionals, communities, clergy, experts in legal and ethical
issues, insurers, policy makers on end-of-life issues.
Enhancing professional knowledge and
practice in end-of-life preparation and care.
Raising public awareness and expectat=
ions
for individually directed end-of-life care.
‹header›
‹date/time&=
#8250;
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
‹footer›
‹#›
' + ENDSHOW_MESG + '
![](3D"notes_flag.gif")
No=
tes![](3D"buttons.gif")
![](3D"slide0173_image007.jpg"){kind=link}
![](3D"slide0192_image011.png"){kind=link}