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third level
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fifth level
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/div>
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le
E
C
Module 1:
Advance Care Planning
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
Page ‹#›
Permission to reproduce for educational purposes granted
Page ‹#›
Module 1:
Advance Care Planning
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E
P
E
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P
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Advance Care
Planning&= #13;
Planning&= #13;
Module=
4
![](3D"master24_background.gif")
![](3D"master24_image003.gif")
Learning Objectives . . .
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.33%'>•Define
advance care planning and explain its importance
•Describe the steps of
advance care planning
•Describe the role of patient, proxy, physician,
others
. . .
Objectives continued
•Distinguish
between statutory and advisory documents
•Identify pitfalls and
limitations in advance care planning
•Consider parallels with
other types of planning in which patients may =
engage
What =
is
advance care plann=
ing? .
. .
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.71%'>•Process
of planning for future medical care
•Values and goals are
explored, documented
<=
span
style=3D'font-weight:normal'>•Determine proxy decisi=
on
maker
• Professional, legal
responsibility
. . . What is advance care planning?
5 steps for successful advance
care planning
1. Introduce t=
he
topic
2. Engage in
structured discussions
3. Document pa=
tient
preferences
4. Review,
update
5. Apply direc=
tives
when need arises
Step 1: Introduce
the topic
the topic
Step 2: Engage is structured
discussions
<=
span
style=3D'font-weight:normal'>•Proxy decision maker(s)
present
Role of the proxy
<=
span
style=3D'font-weight:normal'>•Entrusted to speak for =
the
patient
Patient and proxy education
•D=
efine
key medical terms
•E=
xplain
benefits, burdens of treatments
Life support may only be short-term
Any intervention can be refused
Recovery cannot always be predicted
Elicit the patient’s va=
lues
and goals
Use a validated advisory document
<=
span
style=3D'font-weight:normal'>•Patients, proxy, family
can take home
Step 3: Document patient preferences
<=
span
style=3D'font-weight:normal'>•Recommend statutory
documents
Step 4: Review, update
Step 5: Apply directives
<=
span
style=3D'font-weight:normal'>•Ethics committee for
disagreements
Common pitfalls
<=
span
style=3D'font-weight:normal'>•Advance directives are=
not
read
Preparation for the
last hours of life . . .
last hours of life . . .
•A=
dvance
planning
personal choices
caregivers
setting
•L=
oss,
grief, coping strategies
. .
. Preparation for last hours
of life
•E=
ducating
/ training patients, families and caregivers
=
communication
tasks of caring
what to expect
physiologic changes, events
symptom management
Advance practical planning
. . .
•F=
inancial,
legal affairs
•F=
inal
gifts
bequests
organ donation
•A=
utopsy
. .
. Advance practical plann=
ing
Choice of caregivers
•Be
family first, caregivers only if comfortable
everyone comfortable in the role
seek permission
change roles if stressed
Choice of setting . . .
•B=
urdens,
benefits weighed
•P=
ermit
family presence
privacy
intimacy
. . .=
Choice
of setting
•M=
inimize
family burden
risk to career, personal economics, health
ghosts
•A=
lternate
setting as backup
End of Module 4:
Advanced Care Planning
Review Fast Facts: Advanced Care
Complete Module 4 Post Assessment
‹header›
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‹#›
Advance care planning is the proc=
ess of
planning for future medical care, particularly for the event when the pati=
ent
is unable to make his or her own decisions. It should be a routine part of
standard medical care and, when possible, conducted with the proxy decision
maker present. It is helpful to think of the process as a stepwise approac=
h.
The steps include the appropriate introduction of the topic, structured
discussions covering potential scenarios, documentation of preferences,
periodic review and update of the directives,
and application of the
wishes when needed. The steps can then be flexibly integrated into routine
clinical encounters by the physician and other members of the health care
team.
The process fosters personal resolution for the patient,
preparedness for the proxy, and effective teamwork for the professionals.&=
#13;
Advance care planning is a proces=
s, not
an event. It is the process of planning for future
medical care in the
event that the patient is unable to make his or her own decisions.
Dur=
ing
this process patients explore, discuss, articulate, and document their pre=
ferences.
The
process helps patients identify and clarify their personal values and goal=
s about
health and medical treatment. They identify the care they would like, or n=
ot
like, to receive in various situations. Patients also determine whom they =
would
like to make health care decisions on their behalf in the event they cannot
make decisions for themselves.
Ideally, advanced care planning i=
s a
process of structured discussion and documentation woven into the regular
process of care that is reviewed and updated on a regular basis. It is
designed to ensure that a patient’s wishes will be respected in the
event that the patient is unable to participate in decision making. In the
case of a pediatric patient, it is designed to ensure that the patientR=
17;s
parents are provided with an understandable discussion of the child’=
s prognosis,
and of the treatment options, should the child’s condition deteriora=
te
to a terminal state. The sense of control and peace of mind that this proc=
ess
fosters in the patient and the reduction in anxiety of proxy decision make=
rs
are important benefits. Advance care planning is important for physicians =
for
many reasons. Patients have a right to participate in the planning of their
health care. Physicians have a legal and professional responsibility to as=
sure
this, even if the patient loses the capacity to make decisions.
The
process of determining those preferences for treatment builds trust and a =
sense
of teamwork
between the patient, the proxy, and the physician in sever=
al
ways. The invitation to discuss future care permits the patient (or the
parents if the patient is a child) to understand his or her own values, go=
als,
and preferences that govern his or her life. The physician and proxy learn
about those preferences and needs. The process helps to relieve anxieties =
and
fears on both sides because a spirit of frankness and openness is fostered.
Advance care planning is preventive medicine because it avoids future
confusion and
conflict.
The physician plays an important =
role in
initiating and guiding advance care planning. He or she needs to be involv=
ed
in some, but not all, stages of advance care planning in order to understa=
nd
the patient and establish a trustworthy shared decision-making process. Re=
cent
studies suggest that patients prefer discussing these issues with their fa=
mily
members. However, as the physician will be responsible for the actual medi=
cal
orders, sufficient involvement is necessary for the physician to feel
comfortable that he or she can pursue the goals and priorities for care th=
at
the patient wants.
Many physicians are concerned that advance care
planning is too idealistic or time-intensive
to include it in their bu=
sy
practice. The patient, proxy=
, and
family can do most of the work without the physician if they are given a
worksheet and background materials. For purposes of reimbursement, the time
that the physician takes to counsel and provide information about advance =
care
planning can be
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------=_NextPart_01C7D459.314A9DE0
Content-Location: file:///C:/C918B227/Module4AdvancedCarePlanning_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="us-ascii"
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var sld=3DGetObj("SlideObj")
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sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
=09
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
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document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
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if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
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else
document.body.start();
}
}
function MakeSldVis()=20
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var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )=09
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()=09
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()=20
{
if( !IsNts() ) return false=20
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {=20
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
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SlideObj.onfilterchange=3DAutoAdv
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AutoAdv()
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function AutoAdv()
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if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
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setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
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function GetObj(id)
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if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
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function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId() { return sId=3Dlocation.href.substring(location.href.la=
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function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
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function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
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function SupportsPPTHTML()
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var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
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ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
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if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
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var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
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}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
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if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
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(event && event.keyCode=3D=3D32) ) {
=09
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
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parent.GoToNextSld();
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}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
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g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
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var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
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r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
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var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
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window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0020.htm",1,-1,1),new hrefList(=
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htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
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function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
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// Clear any sounds playing before launching another browser window. Other=
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// in fullscreen mode, you'll continue to hear the sound in the frames mod=
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if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
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function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
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if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
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win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
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if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
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rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C7D459.314A9DE0
Content-Location: file:///C:/C918B227/Module4AdvancedCarePlanning_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 1
------=_NextPart_01C7D459.314A9DE0--
incorporated into the coding of complexity of the encounter.
There are legitimate cultural, ethnic, and age related differences in
approaches to medical decision making and advance care planning. However, =
generalizations
should not be used to ration=
alize
the omission of this topic for an individual patient. Pediatric patients a=
nd
their parents can benefit from the advance care planning process, too.
Determine how a patient and family want medical information to be shared a=
nd
medical decision making handled early in the therapeutic relationship.
Sometimes the most difficult par=
t of the
advance care planning process is the introduction of the topic. Physicians
often have a number of concerns that make them reluctant to do so. Some ma=
y be
concerned that the subject of advance care planning will frighten the pati=
ent
or send the “wrong message.” Others may be uncertain about the
most effective approach to use. In fact, most patients welcome the opportu=
nity
to discuss their preferences with their physician, and physicians who
routinely engage in the process find it
helpful and not too time-consuming.
While some patients will be more likely to need advance care planning than=
others,
healthy people who experience an unexpected illness, such as major trauma,=
can
suddenly be the patients most in need of advance directives. Whenever
possible, routinely initiate the advance care planning process with every
adult patient in your practice, regardless of age or current state of heal=
th. An
outpatient office or other non-threatening setting is ideal.
For pedia=
tric
patients with a chronic illness, the optimal timing of advance care planni=
ng
will vary. At a minimum, the discussion should take place at the time of
relapse of disease, or at the time of significant complications, before the
child is in a state of crisis.
Before beginning the process, be prepar=
ed
to explain the goals and the process that you recommend using. You may have
literature that you would like the patient to read. If you are using a
validated worksheet, give it to the patient to look over before the next
discussion. Explain the roles of other family members, or a proxy. If
appropriate, introduce other members of the health care team who will be
involved in the process.
While most patients will welcome the opportun=
ity
to discuss these matters, be aware of the patient’s comfort level du=
ring
the introduction of the topic. If a patient (or parent if the patient is a
child) does not seem comfortable talking with you, be supportive and provi=
de
information, but do not force the conversation. It may happen later when t=
he
patient is ready.
A critical success factor for ad=
vance
care planning is the ability to structure discussions with the patient that
both convey the information patients need and elicit relevant preferences =
to
determine their advance directives. It may help you to think about ways to
conduct the discussion.
To prevent any misunderstanding, remind the
patient that it is the goal of advance care planning to plan the potential
loss of his or her capacity to make decisions, either temporarily or
permanently. Convey the physician’s and health care team’s
commitment to follow the patient’s wishes, desire to protect the pat=
ient
from unwanted treatment or under-treatment, and desire to help plan for any
caretaking needs of the patient’s family or significant others.
Involve the potential proxy deci=
sion
maker in the discussions and planning so that he or she can have a thorough
and explicit understanding of the patient’s wishes. Usually, the
appropriate role for the proxy during the initial discussions is to listen,
perhaps to take notes, and to ask questions for clarification. A joint mee=
ting
between the patient, physician, and proxy to ensure common understanding c=
an
be invaluable if the proxy and physician are later called on to collaborat=
e in
decision making.
As part of the advance care planning process, the pat=
ient
should specify the role he or she would like the proxy to assume if the
patient is incapacitated. Proxies may try to implement specific treatment
choices, or they may try to decide according to the patient’s best
interests, or they may decide by taking into consideration the interests of
all parties that the patient cares about in a form of substituted judgment.
While these possibilities often coincide, they may not, and it can be very
helpful for the patient to decide which standard is most important to him =
or
her.
In all cases, the proxy will need to work with the physician and,=
in
general, should have the same participation in decisions that the patient
would have had. Most commonly, the proxy uses a blend of standards —
his/her own best judgment based on the situation and what he/she knows abo=
ut
the patient’s wishes. This allows for unexpected factors that could =
not
be anticipated during the advance care planning process.
At the core of advance care plan=
ning is
the empowerment and preparedness of the patient and proxy. Both usually
require some education, time for reflection, and discussion. In order to m=
ake
informed choices, the patient must understand the meaning of the various
clinical scenarios under discussion, as well as the benefits and drawbacks=
of
the various treatment options. The discussion should provide insight into =
the
types of clinical scenarios that might arise and the types of decisions th=
at
proxies most commonly face.
Define key medical terms using words the
patient and proxy can understand. Explain the benefits and burdens of vari=
ous
treatment options (eg, life support on a ventilator may only need to be us=
ed
for a short time if the underlying problem is reversible). Remind them that
any intervention can be refused or stopped if it is not meeting overall
treatment goals (see Module : Withholding, Withdrawing Therapy). Because
recovery cannot always be predicted, help patients to consider situations
involving uncertainty, incomplete
recovery, or even death
Develop an understanding of the
patient’s values and goals related to health and illness (see Module=
:
Goals of Care). For pediatric patients, involve them to the level they are
comfortable with and work with the parents/guardian. There are a number of
ways to facilitate this part of the discussion. Ask about past experiences,
either the patient’s own or those of other people the patient knows.
Describe possible scenarios and ask the patient what he or she would want =
in
such a situation.
As a range of clinical situations is reviewed with t=
he
patient, it will be possible to get a sense of where thresholds exist for
withdrawal or withholding of care. Help the patient to articulate his/her =
own
general principles, values, and goals for care in given situations and
specific treatment wishes. Consider asking the patient if he or she wants =
to
write down in a letter to the physician how such things should be
handled.
Some patients and proxies will have an emotional response to =
the
material. Respond to the emotional reactions. Responding to emotions in the
context of an interview is discussed in Module : Communicating Bad News.&#=
13;
To guide the discussion and capt=
ure
patient preferences, consider using a worksheet or other carefully develop=
ed
and studied tool, such as a linear or interactive videotape or a software
program. Many people find that, by using a worksheet, the discussion with =
the
patient readily identifies the patient’s values and attitudes regard=
ing
health and medical care across a range of medical situations, possible goa=
ls,
and treatment choices. By going through various scenarios and options, the
patient’s personal threshold for use/nonuse of interventions can bec=
ome
clearer. Proxy decision makers can be identified and their roles
defined.
Ensure that the worksheet includes a range of potential scenarios that
patients should consider. It should elicit the patient’s values and
goals related to health and medical care in general terms and should inclu=
de
the most common life-saving interventions. If a patient already has a
life-threatening condition, the conversation may be more focused on specif=
ic
scenarios and treatment issues. For example, a patient with end-stage
cardiomyopathy really needs to consider the issues of cardiopulmonary
resuscitation (CPR) and the role of intensive care units. The patient with
end-stage renal disease must consider dialysis.
The patient with advan=
ced
AIDS needs to consider dementia and respiratory failure.
Once the patient has come to some
decisions, it is crucial for the physician to review the advance directives
with the patient and proxy. Check for, and help to correct, any
inconsistencies and misunderstandings. Make sure that the directives provi=
de
the type of information needed to make clinical decisions.
After a fin=
al
review is complete, ask the patient to confirm his or her wishes by signing
the directives. Although any statement of a patient’s wishes, writte=
n or
verbal, can be considered an advance directive and should be respected by =
physicians,
a formal written document signed by the patient can avoid ambiguity.
O=
nce
the directives have been reviewed and accepted, the physician must formally
document them in the patient’s medical record. When a validated work=
sheet
has been used to structure the planning discussion, the completed, finaliz=
ed,
and signed worksheet can itself be used as the entry in the medical record=
.
In
the absence of a validated worksheet, the physician should describe the pa=
tient’s
wishes in a written document and ask the patient to review and amend it as
appropriate.
Once everyone is satisfied, have the patient sign the
document and enter it into his or her medical record. It is also useful for
the physician and proxy to sign the advance directive and provide their
location information. This offers reassurance to the patient and helps to
ensure the physician’s and proxy’s involvement in eventual
decision making.
For added protection, patients should be encouraged to
complete one or more statutory documents (eg, living will or durable power=
of
attorney for health care) that comply with state statutes. Physicians shou=
ld
familiarize themselves with the specific advance directive statutory
requirements of their state. They can do this by checking with their
hospital’s legal counsel, their state attorney general’s offic=
e,
or their local medical society.
Once preferences have been documented,=
the
physician may need to change the plan of care and put certain things in pl=
ace
to ensure that the patient’s wishes can be followed. For patients who
may wish to remain at home and never be taken to an emergency department o=
r be
hospitalized again, appropriate alternative arrangements, including referr=
al
to a home hospice agency, provision of appropriate medications, and
instructions detailing how to handle symptoms and crises may possibly be
needed. Practical suggestions may be helpful. Consider posting telephone
numbers by the home telephone to call
in an emergency (eg, the hospice
nurse on call), or numbers not to call (eg, 911).
It is important to revisit the s=
ubject
of advance care planning on a periodic basis to review the patient’s
preferences and update the documents. Major life events such as illness,
marriage, the birth of a child, or the death of a loved one may affect a
person’s attitude toward their health care and/or end-of-life care&#=
13;Any
changes in preferences warrant discussion to allow the patient to reassess=
and
to ensure that the physician and proxy decision maker fully understand the=
new
wishes. Changes in preferences should be documented and existing documents
should be updated and shared appropriately.
When patients become incapacitat=
ed, the
application of prior wishes to real circumstances can be challenging. The
following guidelines may be helpful to ensure that a patient’s advan=
ce
directives are followed as closely as possible.
Most advance directive=
s go
into effect when the patient is no longer able to direct his or her own
medical care. Learn to recognize when a patient becomes incapable of making
decisions. While situations where the patient is unresponsive are obvious,=
if
the patient has some ability to respond, the physician must first determine
his or her capacity to make decisions (see Module: Goals of Care).
Nev=
er
assume an advance directive’s content without actually reading the d=
ocument.
Do not take for granted that patients who have living wills want treatment
withheld. Some people indicate within their living will that they want all
full measures taken to prolong their life.
Advance directives should =
be
interpreted in view of the clinical facts of the case. Validated
docum=
ents
are likely to be more useful than short statements or statutory documents.=
No
matter how thorough they are, advance directives cannot anticipate all
possible circumstances. The proxy and the physician may need to extrapolate
from the scenarios described in the advance directive to the current situa=
tion,
and make an educated guess as to what the patient would want if he or she =
were
able to speak for himself or herself.
Whenever significant interpretat=
ion
is necessary, the physician should consult the patient’s
proxy.
Sometimes the physician and/or proxy may believe that a patient would have
indeed wanted something other than what is reflected by a strict reading of
the advance directive. In this case, they should work together to reach co=
nsensus.
Certain
patterns of decisions have high predictability and follow logically. For i=
nstance,
a declination of less invasive interventions has been shown to predict dec=
linations
of more invasive interventions. Acceptance of more invasive interventions
predicts acceptance of less invasive interventions. If a patient has indic=
ated
that he or she would like intervention in a poor-prognosis scenario, there=
is
a high probability that the patient would also accept intervention in a be=
tter-prognosis
situation. Likewise, if the patient has indicated
he or she would decl=
ine
intervention in a better-prognosis scenario, there is a high probability h=
e or
she would also decline if the prognosis were poor.
If disagreements ca=
nnot
be resolved, assistance should be sought from an ethics consultant
or committee.
Anticipating and avoiding the co=
mmon
pitfalls is essential to a successful advance care planning process. There=
are
several.
Failure to plan: Do not avoid advance care planning. Too often,
situations occur and decisions are made without the benefit of advance care
planning. Be proactive. It is easy to forget the central role of the patie=
nt,
and easy to forget the importance of the proxy.
Involve both early and often.
Proxy not present for discussions: Do not leave the proxy decision
maker(s) out of the
initial discussions with the patient.
Unclear patient preferences: Vague statements can be dangerously mi=
sleading.
Be sure
to clarify patient preferences if they do not seem clear to yo=
u or
to the proxy. For instance,
patients who make statements such as ̶=
0;I
never want to be kept alive on a machine” should be asked to clarify
whether their wishes would change if their condition were readily reversib=
le,
or if their prognosis were unclear.
Discussion focused too narrowly=
: Avoid
isolated do-not-resuscitate (DNR) discussions; they often create chaotic
emotions and thoughts in patients who have to imagine imminent death to ma=
ke
the decision. A DNR discussion is usually an indication that other palliat=
ive
goals and measures should be considered in the context of a range of
scenarios.
Communicative patients are ignored: Sometimes people
assume that what a patient wants in the present is what he or she indicated
for future possible scenarios. As long as the patient is competent, talk to
him or her. An impaired patient may still be able to express wishes at some
level. In such cases, both the advance directive and tangible evidence of =
the
patient’s current wishes should be taken into account.
Always
read advance directives: Sometimes physicians assume that they know wh=
at
is stated in an advance directive. This is a mistake. Advance directives c=
an
be for aggressive intervention, comfort care, or a wide range of specific
views and must be read and understood.
Preparation for the last hours of life
Planning other issues that face patients at the end of their lives is crit=
ical
if their needs and expectations are to be respected by health care
professionals and family members who will survive them. While it would be
ideal if all patients and families prepared for death well in advance of t=
he
final hours of their lives, most patients with advanced illnesses and their
families have neither discussed nor prepared for their death.
As patie=
nts
approach the last hours of their lives, they have a last chance to finish
their business, create final memories, give final gifts, and say their goo=
d-byes.
If appropriately assisted, considerable planning can be accomplished around
many of these issues.
The 5-step model for eliciting, documenting, and
following advance directives can be used to guide these decision-making
processes and document patient choices. As these important tasks are gener=
ally
more than individual physicians can handle, other members of the
interdisciplinary team can help patients and families complete their busin=
ess
and get their affairs in order.
In preparing for death, it is im=
portant
to understand the perspective and wishes of all who are present: the patie=
nt,
the family, and the caregivers. Personal expectations, agendas, fears,
phobias, and acceptable setting(s) for care need to be clear, since any one
person may alter the course of care unexpectedly and may interfere with the
patient’s wishes if such are not clearly known. Personal, cultural, =
and
religious values, beliefs, and practices need to be anticipated and respec=
ted,
as missed rites/rituals or errors made by unknowing caregivers may have
grievous consequences in the eyes of the patient or family members.
Id=
entification
and acknowledgment that some family members have a need to give care and
others don’t will help to allow each to participate as closely as ma=
kes
him/her comfortable.
Many patients will choose to get=
their
financial and legal affairs in order, give gifts and plan for bequests, or=
gan
donation, autopsy, burial/cremation, their funeral/memorial services, and
guardianship of their children as they finish their business. Some patients
will even want to give family members permission to build new lives after =
they
die.
The choice of caregivers for each
patient is crucial as vulnerability increases. Patients may or may not want
family members to care for them. Family members may or may not be able to
assume responsibilities for caring and should ideally have the opportunity=
to
be family first and caregivers only if both they and the patient agree to =
the
role. All caregivers need to have the opportunity to change their role if =
they
feel the stress is too much, or they are not getting enough chance to fini=
sh
their personal business with the patient.
The choice of the care setting f=
or the
last hours of a person’s life should be as acceptable as possible to=
the
patient, the family, and all caregivers. Each setting will carry benefits =
and
burdens. Whatever the choice, the setting should permit family members to
remain with the patient as much as they want, and provide them with
opportunities for privacy and intimacy. While dying at home may be the wis=
h of
many patients, such a choice may expose family members to undue burden or
compromise their careers, their personal economic resources, or their heal=
th.
If the number of able caregivers and personal resources
is limited or =
if
family members are afraid of ghosts and would not be able to live on in th=
eir
home afterward, care and death in the home may not be the best choice. An
alternate inpatient setting may be a hospice or palliative care facility, a
skilled nursing facility, or even an acute care facility. Depending on the
resources that are locally available and whether the staff is skilled in t=
his kind
of care, these alternative settings may lead to a far better outcome.
Advance care planning should be a
routine part of standard medical care that is integrated into clinical
encounters by the physician and other members of the health care team.
Formally, it can be thought of as a stepwise approach, to include the
appropriate introduction of the topic, structured discussions covering
potential scenarios, documentation of preferences, periodic review and upd=
ate
of the directives, and application of the patient’s wishes when need=
ed.
Less formally, the process fosters personal resolution for the patient, pr=
eparedness
for the proxy, and effective teamwork for the professionals.
A number =
of
critical factors contribute to a successful process and outcome: physician
guidance and participation, family/proxy participation, and use of a works=
heet
or structured materials to foster discussion and documentation.
The
process also has pitfalls to be aware of. Vague or misleading statements o=
f wishes
can be hazardous; failure to involve the proxy risks discord around decisi=
ons;
premature activation of the directive when the patient is still competent
fails to honor the patient’s real-time autonomy; and assumptions abo=
ut
wishes in advance directives being for nonintervention may not be accurate=
.
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