Advanced Directives

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What is a code?

When a patient’s heart or breathing stops, a code is started. During a code, many different emergency procedures may be needed to restore life, including cardiopulmonary resuscitation, electric shock and breathing assistance.

Category: Advanced Directives

Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is the most frequently used form of emergency life support. During CPR, the patient’s chest is compressed to help the heart pump blood. Oxygen is given to the patient through a breathing mask or by mouth-to-mouth.

Administering CPR and other emergency measures can cause complications including:

• Broken ribs or a sore chest
• Brain damage from lack of oxygen or blood flow to the brain while the heart was stopped.
• Skin burns from the defibrillator used to restart the heart.
• Puncture of the lungs from broken ribs or procedures.
• Vocal cord soreness or damage.
• Broken teeth.
• Increased risk of infection.

Questions to ponder:

• Would you want CPR?

Category: Advanced Directives

Intubation

If the patient does not quickly begin to breathe on his or her own, a tube is used to get oxygen into the lungs. An endotracheal (en-doe-tray-key-el) tube is passed through the mouth or nose and into the trachea (windpipe). The tube is connected to a ventilator (respirator), which helps the patient receive oxygen. The person cannot eat or talk with the tube in place. There may be feelings of anxiety associated with the inability to breathe and being placed on a ventilator. Medications such as sedatives can reduce these symptoms.

Questions to ponder:

• How long would the ventilator be needed?
• Under what circumstances and for how long would you be willing to be on a ventilator?

Category: Advanced Directives

Emergency Medications

A number of medications may be given during an emergency procedure. Antiarrhythmic (anti-a-rith-mic) medications help to control the heart rate and rhythm. Vasopressor medications can help increase the blood pressure and circulation. Medications are adjusted as the patient’s condition changes.

Category: Advanced Directives

IVs

An IV is a catheter placed in a vein to give the patient medications, fluids or nutrition. IV is short for “intravenous” or “within the vein”. Some types of IV catheters are for short-term use and other types are for longer-term needs.

When only one IV is needed for a short time, it usually can be placed in the arm. If an IV is needed for a longer time, it may be placed in a larger vein found in the neck, chest or groin. This type of IV may be referred to as a “central line”. Central lines are used when the IV is needed for a long period of time, the IV can’t be placed in the arm or if more then one site is needed.

Intravenous fluids, sometimes referred to as “IV fluids,” are a way to hydrate a patient while they are in the hospital. Intravenous fluids would be delivered with an IV line. IV fluids are not the same as tube feeding. IV fluids provide hydration. Tube feedings provide nutrition.

Intravenous fluids are helpful to many hospitalized patients if they are not drinking enough fluids, or if they are receiving IV medications with additional IV fluids. However, when IV fluids are given to a dying patient, fluids may not be helpful, and could make the patient uncomfortable.

When a patient is dying, it is important for clinicians to frequently reevaluate if IV hydration is still helpful. Patients and families often reconsider IV hydration, especially as death approaches.

Questions to ponder:

• What is the purpose of IV fluids?
• What are the side effects you can expect from the IV fluids?
• What are the short and long term effects of the IV fluids?
• If the patient is dying, how long should IV fluids is used?

Category: Advanced Directives

Defibrillation and Cardioversion (Electric Shocks)

Defibrillation is a procedure that attempts to correct life-threatening abnormal heartbeats.

Cardioversion is a procedure that attempts to correct heartbeats that are abnormal, but not necessarily life threatening.

During both of these procedures, electric paddles or pads are placed against the chest and a shock is given to the heart.

Category: Advanced Directives

Temporary Pacemakers

Pacemakers send an electric signal to the heart to make it beat. A temporary pacemaker uses pads placed on the chest or a wire passed through the vein from a generator or battery. The signal is different from the shock given for defibrillation or cardioversion.

Questions to ponder:

• Would you want these treatments?

Category: Advanced Directives

Tube Feeding

A feeding tube is a common medical treatment to provide nutrition when the patient cannot swallow. There are two main kinds:

A nasal gastric (NG) tube, which is passed through the nose or mouth and into the stomach.

A gasterostromy or jejunostromy (G or J) tube, which goes directly into the stomach or small intestine.

These treatments can be short term, long term or permanent.

Questions to ponder:

• Is it important to you that tube feeding is temporary, and you eventually would be able to eat normally?
• If it was long-term, perhaps for the rest of your life, would you still be willing to be tube fed?
• What side effects can you expect from a feeding tube?
• Would you want to be kept alive with a feeding tube?

Category: Advanced Directives

Do-Not-Resuscitate Orders

If the end of life is near, some patients and their families may not want emergency measures such as CPR or to be put on a ventilator. This is an important decision that should be discussed thoroughly with family members and the patient’s physician. It is vital for everyone involved to know the patient’s wishes.

After this discussion, if the patient does not want emergency measures, a Do-Not-Resuscitate order (DNR) must be written by a physician so that those wishes can be followed. Without this order, everything will be done to prolong life.

Some patients limit the kinds of treatments they wish to receive. Again, this should be discussed with the physician.

Patients also can make their wishes known through an advance directive such as a Living Will, Power of Attorney for Health Care, or Physicians Order for Life Sustaining Treatment (POLST).

Questions to ponder:

• Under what circumstances would you want emergency measures such as CPR or ventilator support?
• Have you clearly stated your wishes to your physician and your loved ones?
• Do you have advanced directives?

Category: Advanced Directives

Advanced Directives

Advance directives are legal documents stating the patient’s decisions about future health care. They allow people to say exactly what they do and do not want if they should become incapacitated or are unable to communicate. There are a number of types, including a Durable Power of Attorney for Health Care, a Health Care Directive (more commonly called a Living Will), a Physician Order for Life Sustaining Treatment, and the Advance Mental Health Directive.

Hospitals and doctors support patients’ rights to make decisions about their medical care.  

People who have advance directives should make sure their family members know where it is kept, and also give copies to their doctor and attorney.  Patients being admitted to the hospital should take a copy to the health care facility.  At Providence St. Mary Medical Center, an individual’s advance directive can be copied and kept available for future admissions. It is also a good idea for people to take copies with them when they travel.

Advance directives can be changed as a patient’s condition or situation changes. Changes can be made by destroying the original and the copies, and making new ones.

Category: Advanced Directives

Living Will (Health Care Directive)

A Living Will, also known as a Health Care Directive, allows people to state what they would want if they were terminally ill  (expected to die within six months) or permanently unconscious.

It is important to note that a Living Will does not apply to any other health care situation except for a terminal illness or irreversible coma. It would not go into effect, for example, if the patient was temporarily incapacitated but expected to recover. The Living Will also does not allow patients to appoint a spokesperson to speak on their behalf.

A standard form for a Living Will is available at Providence St. Mary Medical Center. The Living Will must be signed and dated in the presence of two witnesses, who must also sign it. The witnesses cannot be family members.

Category: Advanced Directives

Durable Power of Attorney for Health Care

The Durable Power of Attorney for Health Care is a more wide-ranging document than the Living Will. It covers more medical situations where people may need someone to speak on their behalf. Some people have both a Living Will and a Durable Power of Attorney for Health Care.

The Durable Power of Attorney for Health Care allows patients to state their wishes and appoint someone to act as a spokesperson to ensure those wishes are followed. If patients cannot speak for themselves, the spokesperson works with the physician to make care choices. (Please note that a Power of Attorney for Health Care is different than a Power of Attorney for financial matters, although it can be included in it.)

Unlike the Living Will, the Durable Power of Attorney for Health Care also can be used whenever there is a need, such as if a person developed dementia or was temporarily incapacitated, but expected to recover.

The patient can state specifically when the Durable Power of Attorney for Health Care should go into effect.

Choosing who will act as a spokesperson is a very important decision. It should be someone the patient trusts completely. It cannot be the patient’s doctor, an employee in the doctor’s office, or someone from a facility where the patient lives or is under treatment.

A standard form for a Durable Power of Attorney for Health Care is available at Providence  St. Mary Medical Center. It’s a good idea to have a Durable Power of Attorney for Health Care witnessed and notarized. Washington does not currently require this, but many other states do, and it could be important if the patient travels, moves or goes to a facility in another state.

Category: Advanced Directives

Advance Directive for Mental Health Decisions

People who are concerned they may be subject to involuntary psychiatric commitment or treatment in the future can prepare an Advance Directive for Mental Health. When they have the capacity to make good choices for themselves they may, with the help of a doctor or a lawyer, make out a directive which states their choices about mental health treatment. They can use the directive to tell a doctor, institution or judge the types of confinement and treatment that they do or do not want. They can write in detail what approaches or medicines work best for them, and those that do not.

They also can appoint a person to make health care decisions for them if they become unable to make the decisions for themselves.

Category: Advanced Directives

Physicians Order for Life Sustaining Treatment

The Physicians Order for Life Sustaining Treatment (POLST) is a “portable” physician order form that gives directions regarding emergency life-sustaining treatment. It is called portable because it is intended to go with patients from one care setting to another. If a patient has an emergency at home, the form serves as the physician’s orders to the emergency response team for his or her care.

Category: Advanced Directives

Assistance with advance directives and POLST forms

Assistance, referrals and forms to help you in preparing advance directives are available through the Providence St. Mary Medical Center Chaplaincy Department at extension 2207, or 522-5807.

Questions to ponder:

• Do you want an advance directive?
• What type would be most useful in your situation?
• Would you like help preparing one while you are at Providence St. Mary Medical Center?
• If you have created one or more in the past, do they reflect your most current wishes?  
• Have you given a copy of them to your physicians and family members?
• Have you (or your family) brought a copy of your directives  to the hospital so that the directives can be honored if the need arises during your stay?

Category: Advanced Directives

Our Commitment To Pain Management

Providence St. Mary Medical Center’s Patient/Client Rights and Responsibilities state the patient’s right to expect and receive appropriate assessment and management of pain. We are committed to excellence in all areas of service. Our patients can expect:

• State-of-the-art pain management
• Information about pain and pain relief measures
• A concerned staff committed to pain prevention and management
• Health professionals who will believe and respond quickly to reports of pain

Category: Advanced Directives

Hospice Care

Hospice works with patients who are expected to live six months or less. The focus of care is on providing comfort rather than a cure. Hospice will help patients and families in their homes manage symptoms throughout the terminal process. A hospice referral can be made by a patient, the patient’s family, or a physician.

Questions to ponder:

• If you were dying, would you prefer comfort care to more aggressive measures?
• Would hospice be the right approach for you?
• Are your pain and symptoms well managed?

Category: Advanced Directives