1	Advanced Medical Directives Planning for your health care future
2	History In April 1990, the State of Wisconsin passed a law which permits a person to execute a document call a Power of Attorney for Health Care decision making.
3	Law Wisconsin law treats family members, including spouses, as strangers for decision-making purposes. Family members are NOT authorized to make decisions for incapacitated adult family members—Wisconsin is not a “next of kin” or “family consent” state for adults Decision makers can be appointed only when a person is of “sound mind”
4	What are Advanced Medical Directives? Documents used to communicate, in writing, with family and medical persons your wishes and desires for your medical care should you be unable to communicate them Document types include Living Will, Do Not Attempt Resuscitation, and Health Care Power of Attorney
5	Living Will Also known as ‘Declaration to Physicians’ They are called living wills because they take effect while a patient is still alive Tell physicians what life-sustaining treatment you do or do not want in certain situations if you are unable to make your own decisions Only addresses life-sustaining procedures (those that only serve to prolong the dying process but not avert death) and feeding tubes
6	"A living will applies only..." A living will applies only when a person has a terminal condition and death is imminent or is in a persistent vegetative state Terminal condition is “an incurable condition…medical judgment finds would cause death imminently…that…life sustaining procedures serves only to postpone the moment of death” Persistent Vegetative State is “a condition that…results in a complete, chronic, and irreversible cessation of all cognitive functioning…and a complete lack of behavioral responses that indicate cognitive functioning.”
7	"A living will takes effect..." A living will takes effect when two physicians who have examined the patient certify in writing the condition to be terminal or persistent vegetative state and that the patient is unable to make their health care decisions Does not include appointing a surrogate decision maker
8	How to complete a living will Complete the form Sign and date the form in the presence of two witnesses Witnesses must be: 18 years old Not related to you be blood, marriage or adoption Not directly financially responsible for your health care or have claim to any portion of your estate Not a health care provider or employee of inpatient health care facility, except social worker or chaplain
9	How to revoke a living will Can be done at any time by: Destroying the document Must be done by principal or by someone who is directed to do so in the presence of the principal All parties who have copies should be notified to destroy their copies Signed and dated written revocation Oral revocation with notice to physician Making a new document Document with most recent date is the legal one
10	Do-Not-Attempt-Resuscitation Also called DNAR, DNR, or ‘no code’ DNAR orders direct EMS, first responders, and emergency health care facility personnel to not attempt CPR on a person suffering cardiac or respiratory arrest Standardized DNR bracelets identify those with a valid DNR order Bracelets must be on the person for EMS to honor Metal bracelets from MedicAlert only
11	"When a DNR patient needs..." When a DNR patient needs care ONLY full resuscitative care will be withheld Emergency provider will not provide Chest compressions Insert advanced airways Defibrillate Provide ventilator assistance Administer cardiac resuscitation drugs
12	"Comfort care will be given" Comfort care will be given Emergency providers will provide Clear airway Administer oxygen Splint and control bleeding Provide pain meds Position for comfort Contact any service providers that have been involved in care—MD, home health or hospice agencies Provide emotional support
13	How to obtain DNR Speak with your physician Must meet WI state statute criteria in order to qualify for DNAR bracelet (Chapter 154, subchapter III) Over 18 years old Have terminal condition or condition such that resuscitation would be unsuccessful, cause significant pain or harm, or be only temporarily successful Physician must write an order
14	How to revoke a DNAR Patient, guardian, or activated HCPOA removes or asks someone to remove the bracelet and informs physician Family members or friends cannot request revocation. Their wishes do not supersede patient wishes.
15	Health Care Power of Attorney Allows principal to appoint another person, known as the health care agent, to speak on their behalf in the event they are incapable regarding health care decisions only May be used to make or refuse anatomical gifts Does not require an attorney to complete
16	"By executing a document you..." By executing a document you select someone who knows your intentions and wishes and will make choices that follow these Agents can be anyone except your health care provider or employee of a health care institution unless they are related to you Agents must be 18 years or older Good idea to appoint an alternate agent It is important to choose someone who knows you well and to discuss with them your preferences in advance
17	"Person making the document continues..." Person making the document continues to make own decisions until document is activated Also known as being declared incapacitated Activation requires the signatures of two physicians or one physician and one psychologist to a statement that the principal is no longer able to make decisions
18	How to complete a HCPOA Fill in the blanks and answer the questions Nursing home and CBRF Answering ‘yes’ allows for admit for any reason Answering ‘no’ or leaving blank allows for short term admit only Provision of Feeding Tube Answering ‘yes’ allows for withholding or stopping Answering ‘no’ does not allow to withhold or stop Leaving blank does not allow to have stopped
19	"Pregnant Patients" Pregnant Patients Answering ‘yes’ allows for decision to be made Answering ‘no’ or leaving blank means no decisions if pregnant Statement of desires, special provisions or limitations Anything you wish-remember if you write it done is must be followed Can be left blank or use additional pages and write in “see separate addendum” Title the addendum “Addendum to the Power of Attorney for Health Care for __________”
20	"Sign and date the form..." Sign and date the form in the presence of two witnesses If you are physically unable to sign you can direct someone to sign for you--not agent or witness Witnesses must be: 18 years old Not related to you be blood, marriage or adoption Not directly financially responsible for your health care or have claim to any portion of your estate Not a health care provider or employee of inpatient health care facility, except social worker or chaplain Agents do not need to sign for it to be valid Sign, date, and witness addendums in same manner as HCPOA
21	How to revoke a HCPOA Can be done at any time by: Destroying the document Must be done by principal or by someone who is directed to do so in the presence of the principal All parties who have copies should be notified to destroy their copies Signed and dated written revocation Oral revocation with notice to physician Making a new document Document with most recent date is the legal one If your agent is your spouse, divorce/annulment makes the document invalid
22	Consequences of not having HCPOA If you cannot speak for yourself and have not made an advanced directive a Guardian of the Person must be appointed to make decision for you Until a decision maker, or guardian, is appointed you will continue to receive medical care however, there is a greater chance you will not receive the types of care and treatments you want
23	"The court is not required..." The court is not required to appoint a family member as guardian. The person chosen may not know your wishes about your health care and care you would or wouldn’t want. They are required to make decisions that are in your “best interests.” The guardianship process can be costly, time-consuming, cumbersome, and emotionally draining.
24	Extra! Extra! Copies of completed HCPOA and Living Wills should be given to your physician, agents, hospital, and family Keep original in a accessible place—NOT a safe deposit box If a HCPOA is done in another state and is valid, it is valid in WI however….the agent only has the authority that is permitted by WI law i.e. specific authority for nursing home, CBRF, feeding tubes, and decisions for pregnant women is needed
25	Additional Information More information and assistance is available from Social Services at MBMC or on the website for the Coalition of Wisconsin Aging Groups Blank documents can be obtained from Social Services at MBMC, by writing to the Wisconsin Division of Public Health, or on the internet at: www.dhfs.state.wi.us/forms/AdvDirectives/index.htm
26	QUESTIONS