Advanced Care Planning

=Objectives=

To understand the ethical and legal principles underlying advance care planning.

 * Allow patients to retain control over life saving treatments.
 * Barriers to understanding:
 * lack of skills to have conversation
 * uncertainty of mortality/morbidity
 * fear of taking away hope; uncomfortable conversation

POLST

 * POLST stands for "Physicians Orders for Life Saving Treatment"
 * [[media:polst_form.pdf|POLST form]] is filled out by clinicians and can be signed by NP, PAs, or physicians
 * POLST should reflect the patient's advance directive, if it exists
 * Addresses the problem that 25% of advance directives aren't followed correctly
 * Puts patients wishes into executable medical orders. Typically used for seriously ill people.
 * Electronic registry, specific boxes are checked, so it's a finite document.

Advanced Care Directive
In the state of Oregon an Advanced care directive names a representative to serve as a surrogate if a patient loose the ability to make decisions. It serves two main purposes: 1) To appoint a health care representative and 2) To provide end of life instructions, if an end of life scenario would arise. advance directive. That witness must also not be entitled to any portion of the person’s estate upon death. That witness must also not own, operate or be employed at a health care facility where the person is a patient or resident.
 * The form goes through 4 scenarios and asked whether full life support and feeding tubes should be provided. The scenarios include:
 * close to death
 * extraordinary suffering
 * permanent unconsciousness
 * Includes space for open ended instructions
 * Could be filled out with a health care representative, like a nursing home director
 * One witness must not be a relative (by blood, marriage or adoption) of the person signing this

Make your own conclusions and Read the form on the Oregon.gov website
 * Does not translate into medical orders
 * It may not be specific enough, and may not apply if one's conditions change.
 * The doctor needs to have a copy; they might not know this document exists unless they are told.

To learn and practice communication skills relevant to advance directives conversations.
=Historical Perspective=
 * Technology has had a huge impact on end of life issues
 * Defibrilator invented in 1960s
 * dialysis, fairly new
 * 50 years ago we couldn't keep [wikipedia:Terri_Schiavo|Terri Schiavo] alive for 12 years, for example. We are concerned about the potential for these lingering deaths.
 * Patient doctor relationship has changed significantly in 50 years; we've seen a rise of patient autonomy
 * only 10% of doctors would tell a patient that they have a life threatening illness in 1960
 * 97% of doctors would tell patient they have cancer 15 years later (1975)

=Links=
 * Oregon Health Decisions
 * Resources for Healthcare Professionals (POLST)