Advance Directives: Making Healthcare Decisions

Healthcare decision making has changed

It becomes clearer with each passing day that in the United States of America medical treatment is much more complicated than it was only a few decades ago. It is also a fact that the population involved in medical decisions is increasingly diverse. The number of premature infants and very old adults is growing. Expanding technologies are available and multiple specialists are involved in highly technical areas than ever before in our history. What all of this means are that many decisions about medical care and treatment have to be made. These are the new "facts of life."

Who makes these decisions about treatment? Years ago it was simple -- the physician did. Patients put their lives in the hands of the physician trusting that "the doctor knows best." That approach worked well for a long time. Now physicians work with a variety of other professionals to make up the healthcare team. They have numerous choices in regard to forms of treatment, therapies, medications and facilities for care. Patients, too, have changed. By and large they are more informed, or wish to be more informed, and desire to participate actively in decisions affecting their own care and treatment. Patients, physicians, nurses and others involved in making healthcare choices consider not only sound medical practice, but also culture, religion, law, economics and the availability of resources.

MAKING MEDICAL CHOICES

Patients and their families are often faced with serious decisions about treatment, artificial life support and quality of life. At Presbyterian Healthcare Services, we believe that each person's life is of great value, and that each person has the right to choose whether to receive or to refuse medical or surgical treatment. Our philosophy recognizes that it is not necessary to preserve life at all costs. There are times, such as in terminal or overwhelming illness, when patients and families may feel it is best not to use certain medical procedures to prolong life. At such times, patients may not wish to receive maintenance medical treatment such as ventilators, CPR, drugs to support blood pressure, antibiotics, or artificial nutrition and hydration.

What Are Advance Directives?

An advance healthcare directive is an individual instruction or a power of attorney for healthcare made, in either case, while the individual has capacity. It provides direction to healthcare providers, if you become unable to make choices for yourself, by making your wishes known.

What Does New Mexico Law Say?

• An adult or emancipated minor, while having capacity, has the right to make his or her own healthcare decisions and may give an individual instruction. The instruction may be oral or written; if oral, it must be made by personally informing a healthcare provider. The instruction may be limited to take effect only if a specified condition arises.
  
• An adult or emancipated minor, while having capacity, may execute a power of attorney for healthcare, which may authorize the agent to make any healthcare decision the person could have made while having capacity. The power of attorney must be in writing and signed by the individual. It remains in effect despite the individual's later incapacity. The power of attorney may include individual instructions.
  
• Unless otherwise specified in a power of attorney for healthcare, the authority of an agent becomes effective only upon a determination that the person lacks capacity, and ceases to be effective upon a determination that the person has recovered capacity.
  
• An agent shall make a healthcare decision in accordance with the person's individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the agent's determination of the person's best interest. In determining the person's best interest, the agent shall consider the person's personal values to the extent known to the agent.

REVOKING AN ADVANCE HEALTHCARE DIRECTIVE

• An individual, while having capacity, may revoke the designation of an agent only by a signed writing or by personally informing the supervising healthcare provider.
• An individual, while having capacity, may revoke all or part of an advance healthcare directive other than the designation of an agent at any time in any manner that communicates an intent to revoke.

[The linked form complies with the provision of the New Mexico Uniform Healthcare Decisions Act of 1995, NMSA 1978 Sections 24-7A-1 to 24-7A-18 (1996 Supp)]

How May I Let My Wishes Be Known

• You should talk about your preferences with your family, friends and your physician.
  
• You may complete and sign an Advance Healthcare Directive in which you give instructions about your healthcare and/or name someone else to make decisions for you.
  
• You may give oral instructions to a healthcare provider.

Upon admission to a Presbyterian Healthcare Services' hospital, you will be asked whether you have signed an Advance Healthcare Directive (this could be the optional New Mexico form or a Power of Attorney for Healthcare or a Living Will). If you have, these will be placed on your Medical Record, and we will honor your wishes.

Naturally, our physicians and hospital staff will always deliver the best possible care to you and your loved ones. As you consider the ethical dilemmas outlined here, please remember that we are not advocating any particular choice of treatment; we are simply outlining the issues so that patients and their families can take a good look at their wishes should this type of situation be encountered.

If you do not have advance directive documents, but would like to learn more about them, or if you have questions about making medical choices, please ask your doctor or nurse to contact the appropriate person.

END OF LIFE DECISIONS

Artificial nutrition (food), hydration (water) and ventilation (breathing) are technologies that are available to acutely ill patients. These technologies can sustain life while a person recovers from an overwhelming illness. It is also true that these technologies can prolong the dying process. In these instances, like other medical treatments, they may be refused or stopped. It is important that those involved in making decisions about a patient's care consider the difference between prolonging life and prolonging dying.

Mechanical Ventilation

Mechanical ventilation is provided through a tube inserted into the windpipe and connected to a breathing machine. It is frequently started during an emergency situation when a person has stopped breathing or breathing is inadequate to maintain life.

Artificial Nutrition and Hydration

Patients in the hospital are often not able to eat or drink. Under such circumstances they may be provided with artificial nutrition and hydration. There are three ways artificial nutrition may be given:

1. A tube placed into the stomach through the nose (an NG tube)
2. A tube surgically placed directly into the stomach (gastrostomy tube)
3. An intravenous (IV) line with a nutritional fluid called parenteral nutrition (TPN). Hydrating fluids are given intravenously.

ORGAN AND TISSUE DONATION

Many people wish to donate organs, tissues or corneas when they die. This is a choice that we try to respect whenever possible. Specific criteria must be met in order to donate organs such as heart, liver or kidneys, but most people can donate tissue and corneas. Donation can take place on individuals who are medically qualified to donate. A medical assessment for donation and transplant will take place at the time of death, and a representative from New Mexico Donor Services (NMDS) will meet with family members to discuss the potential donor's medical history. A donor's family will not have to pay any of the costs of donation or transplant.

New Mexico law was changed in 2002 to make the driver's license, an Advance Directive, or any other document about donation, the legal document for a person to consent to donate organs or tissue. This gives the individual the ability to choose to donate, and it is no longer up to family members to decide or go against an individual's wishes as stated on the driver's license or any other document.

About Organ and Tissue Donation

CARDIOPULMONARY RESUSCITATION (CPR)

When a patient's heart or breathing suddenly stops, doctors, nurses, and other healthcare providers immediately start CPR. CPR stands for cardio (heart), pulmonary (lung) resuscitation and includes a number of emergency procedures to prevent death. If a patient's heart has stopped, rhythmic pressure over the sternum (breastbone) will compress the heart and pump blood through the body. If the heart beats erratically and ineffectively, a quick electrical shock to the heart through the chest wall may restore regular beating. When a patient stops breathing, it may be necessary to insert a tube into the windpipe (intubate), and then use a breathing machine (ventilator) to assist breathing. In any of these situations, the use of a number of medications would also be required. Patients routinely receive CPR when it is needed, unless a competent patient has requested DNR, or the family and attending physician have agreed to a written "Do Not Resuscitate" (DNR) order.

Declining CPR

Patients, families and their physicians may feel that CPR should not be performed under special circumstances. It is the patient's right to decide that they do not want CPR. Refusing such resuscitation is a serious decision and patients should discuss it thoroughly with their physicians and family so that all understand the patient's illness and treatment alternatives. They should understand what cardiopulmonary resuscitation (CPR) can and cannot accomplish.

Patients with certain conditions are known to have a poor chance of survival after CPR, and their likelihood of hospital discharge is small. Patients should consider these matters and discuss them with their physicians. Families frequently are involved in this process and the patient should tell their physicians and families their wishes. This needs to be accomplished before a serious episode occurs requiring a decision for CPR. If a decision has been reached by the patient that CPR should not be performed, and the decision (request for DNR) has been communicated to the healthcare team (physician and/or nurse), this decision will be honored.

IF THE PATIENT CANNOT MAKE THE DECISION

If the patient has not identified an agent or left instructions for healthcare or is no longer able to do so, a surrogate

1. Spouse
2. Individual in a long-term relationship (significant other)
3. An adult child
4. A parent
5. An adult brother or sister
6. A grandparent, or
7. Other adult who exhibited special care and concern for the patient as well as familiarity with the patient's personal values, will be asked to participate in this decision.

WHEN THE DECISION IS "DO NOT RESUSCITATE"

As long as DNR is in effect, CPR will not be applied if the patient's heart or breathing stop. The decision for DNR can be changed at any time. In the operating room, DNR is usually temporarily canceled because of the type of care that is required. If you do go to surgery, you should discuss your wishes with your surgeon. "Do Not Resuscitate" does not mean the staff will stop any other treatment that the patient needs or wants. All necessary care and patient support will continue.

OUT-OF HOSPITAL DNR [EMERGENCY MEDICAL SERVICES (EMS) DO NOT RESUSCITATE]

You have the right to discuss with your physician the full meaning of an "EMS DNR Order", the available alternatives, how the order may be revoked, and receive answers to any questions you may have. If you wish to have an EMS DNR order, both you and your doctor must sign the document.

For information about EMS-DNR (Emergency Medical Services - Do Not Resuscitate) Orders, contact the New Mexico Department of Health's EMS Bureau at (505) 476-7701.

RESOLVING ETHICAL DILEMMAS

Ethics is the study of how good decisions can be made. Ethically speaking, there are usually several choices, not just one, which could be "good" for all concerned parties, the patient, physician, healthcare team and hospital/facility. Ethics shows the values necessary for living within the guidelines of what is right or moral for all people concerned in healthcare--not the least of which is the patient. Some ethical choices call for action, while others allow for inaction.

Our hospital, like other hospitals in the country, has specific policies and methods for resolving ethical dilemmas, and making the types of decisions discussed here.

The purpose of these policies and the involvement of an ethics committee which may be formed in a hospital, are to support physicians, patients and families during difficult decision-making times.

Physicians, nurses, social workers, chaplains, attorneys and administrators may be involved in reviewing cases and consulting with those involved. Medical, emotional and social issues are explored during the consultation process. The family and physician may be offered alternatives and recommendations. These suggestions are advisory in nature. It is not the intention of a policy or the committee to make or enforce decisions on behalf of patients, families or physicians.

Throughout the ethics review process, confidentiality is very important. If you need more information about ethics procedures, please ask your nurse or admitting representative to contact the appropriate individual(s) in this hospital.

DEFINITIONS

Adult – In New Mexico, any individual who is 18 years of age or older.

Advance Healthcare Directives – Individual instructions or a power of attorney for healthcare made, in either case, while the individual has capacity.

Agent – An individual designated in a power of attorney for healthcare to make a healthcare decision for the individual granting the power.

Brain Death – Irreversible cessation of all function of the entire brain and brainstem.

Capacity – An individual's ability to understand and appreciate the nature and consequences of proposed healthcare, including significant benefits, risks and alternatives to proposed healthcare and to make and communicate an informed healthcare decision.

Cardiac Arrest – Cessation of the mechanical function of the heart, resulting in the loss of arterial blood pressure and irreversible brain damage and death if circulation of the blood is not restored within minutes.

Cardiopulmonary Resuscitation (CPR) – Technologies used to restore and maintain blood circulation and breathing in a person who has experienced cardiac or respiratory arrest.

Do Not Resuscitate (DNR) – An oral or written, witnessed advance directive made by a hospitalized adult patient who has capacity, or an order written and signed by a physician to withhold cardiopulmonary resuscitation (CPR) in the event that a patient experiences cardiac or pulmonary arrest.

Emancipated Minor – A person between the ages of sixteen and eighteen who has been married, who is on active duty in the armed forces or who has been declared by court order to be emancipated.

Guardian – A court appointed individual, "guardian" or "conservator", who has been given the authority to make a healthcare decision for another individual.

Healthcare – Any care, treatment, services or procedure to maintain, diagnose or otherwise affect an individual's physical or mental condition.

Healthcare Decision – Includes selection and discharge of healthcare providers and institutions; approval or disapproval of diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; directions relating to life-sustaining treatment, including withholding or withdrawing life-sustaining treatment and the termination of life support; and directions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of healthcare.

Informed Consent – A legal term that refers to a person's consent to a proposed medical intervention after being provided information about the nature of the intervention, alternatives to it, and its significant risks and benefits.

Irreversible Coma – That state in which brainstem functions remain but the major components of the cerebrum are irreversibly destroyed.

Life Sustaining Treatment – Any medical treatment or procedure without which the individual is likely to die within a relatively short time, as determined to a reasonable degree of medical certainty by the primary physician.

Living Will – A document, in which a person capable of making healthcare decisions expresses in advance, his or her wishes regarding certain life-sustaining treatments in the event that he or she can no longer make such decisions.

Minor – In New Mexico, any individual less than 18 years of age.

Parenteral Nutrition (TPN) – Infusion of nutrients directly into the bloodstream

Power of Attorney for Healthcare – The designation of an agent to make healthcare decisions for the individual granting the power, made while the individual has capacity and effective, unless otherwise indicated, only after the individual has lost capacity.

Principal – An adult or emancipated minor who, while having capacity, has made a power of attorney for healthcare by which he delegates his right to make healthcare decisions for himself to an agent.

Prognosis – An informed judgment about the likely course and probable outcome of a disease process.

Respiratory Arrest – A life-threatening condition in which the breathing system does not provide oxygenation or ventilation adequate to sustain life processes.

Resuscitation – Procedures for the restoration of heart rhythm and maintenance of blood flow and breathing following cardiac or respiratory arrest.

Supervising Healthcare Provider – The primary physician or, if there is no primary physician or the primary physician is not reasonably available, the healthcare provider who has undertaken primary responsibility for an individual's healthcare.

Supportive Care – Humane efforts directed toward maintenance of a patient's comfort and dignity, but not necessarily intended to prolong life.

Surrogate – An individual, other than a patient's agent or guardian, authorized under the Uniform Health-care Decisions Act to make a healthcare decision for the patient.

Terminally Ill – An individual for whom a prognosis of death has been made, based on the diagnosis of an illness that has a predictable fatal progression that cannot be stopped by any available treatment.

Ventilator – A medical device that assists or replaces the natural mechanisms for breathing. The terms ventilator and respirator are used interchangeably, but ventilator is currently the preferred term.

Hospital Ethics Committee

The Hospital Ethics Committee serves patients and their loved ones as well as physicians and staff members by providing medical ethics education, reviewing cases, developing hospital policies and providing consultation and support during difficult decision-making times.

Physicians, nurses, social workers, chaplains, attorneys, administrators and members of the community volunteer their time to serve on the committee. Ethics Committee consultations may be requested to resolve ethical dilemmas. A consultation may be requested by any patient, family member, doctor or staff person if there are concerns or lack of agreement about a course of treatment. The committee reviews information from the patient's primary care physician, specialists and other hospital staff involved with the patient's care in addition to information from the patient and his or her family and loved ones.

While it is not necessary to have the Hospital Ethics Committee review this kind of decision, the committee is available for advice and support in these situations. Often the decision is reached by the attending physician, patient and family or has been communicated through an advance healthcare directive executed by the patient.

If you would like to know more about the Hospital Ethics Committee, please contact medical education or the Department of Chaplaincy Services.

Click here for an advance directive form for you or your family members.