Advance Directives: Why You Should Put Your Wish (cont.)

MODERATOR:
And if that would happen and the family then presents the hard copy, would a physician then be required to remove the feeding tube?

SWANSON:
I'm not sure if a physician would feel required to do so, but if the family produced the document and the family members and medical power of attorney were all in agreement, I think the physician would honor those wishes. If for some reason he felt an ethical conflict, the physician might bring this case to the hospital ethics committee. But most often, in my experience, physicians will honor a living will document, particularly after they've consulted with the medical power of attorney.

MODERATOR:
So it is very important to discuss your wishes with your doctor before there is a need to insure that your wishes and your doctor's personal code of ethics are not in conflict.

SWANSON:
This brings us to the importance of identifying and completing a health care power of attorney form which allows you to designate someone to speak on your behalf.

MODERATOR:
Please explain "medical power of attorney."

SWANSON:
An MPA [Medical Power of Attorney], sometimes called a durable health care power of attorney, is a document that allows any individual to appoint another person to be their agent and make decisions for them should they become unable to make decisions for themselves. The health care power of attorney can make health care decisions only according to the patient's directions that are either stated in the living will or that they believe to be in the best interest of the patient and the patient's wishes. A health care power of attorney is oftentimes a family member, such as a spouse or adult child, but could be anyone the patient chooses. It could be a friend.

It's important to know that the durable health care power of attorney is limited to end-of-life situations. An example might be that if you have a stroke or heart attack, but you get proper medical treatment, and during that time you may be unable to communicate your wishes, the doctor and hospital would then want the power of attorney to give them direction for care. Once you've recovered and are able to speak for yourself, then the power of attorney isn't in force. A power of attorney can only speak for the patient when the patient is incapacitated. An example is an acute medical crisis; it may be short term, only a few days or a week. But in the event of a chronic debilitating illness like dementia, it may be from the time they start to the end of the patient's life.

It's also important to note for both the medical power of attorney and for a living will, that they can be changed at any time. Also with a living will, just because you've written something down stating your wishes, if you are conscious and alert, the physician and medical personnel will always directly ask you what you want and consult with you on treatment options.

MODERATOR:
The third document you mentioned is the DNR -- Do Not Resuscitate Order.

SWANSON:
A DNR order is an order by a physician that generally occurs while a patient is in a short stay in a hospital. It's a request to not have cardiopulmonary resuscitation if the patient's heart stops or they stop breathing.

Some states also have what they call a pre-hospital or out of hospital DNR form, and that's a form that's used for a patient who is living in their home, and if somebody panics or calls 911 in an emergency, this pre-hospital or out of hospital DNR communicates to the emergency medical personnel the patient's wishes regarding CPR. But again, the form has to be displayed in the patient's home. It usually only applies to patients with chronic life-limiting illnesses, or patients in nursing homes.

MEMBER QUESTION:
How do a DNR and a living will differ?

SWANSON:
As I said, a living will is a document that generally applies when a person has a life limiting illness or when they are in a permanent vegetative state. It describes the wishes for a variety of treatments that could be offered to the patient, including CPR, nutrition and hydration, mechanical ventilation, and so on. The DNR applies only to CPR.

MEMBER QUESTION:
Who or what determines when someone is incapacitated?

SWANSON:
That's a good question. Generally, a physician or a social worker in a hospital or in a medical setting, agency or facility can do a brief assessment to help determine the patient's capacity. As I said earlier, capacity refers to the patient's ability to comprehend information, to contemplate options, to evaluate the risks and consequences, and communicate decisions. So it's generally an informal conversation in evaluating the patient's ability to respond effectively in that conversation.

Sometimes the word capacity is interchanged with the word competent. It's important to know that the word competency is a legal term and can only be defined by the courts. So capacity is somewhat subjective, and would involve several individuals providing evidence or opinion.

MEMBER QUESTION:
Does the DNR order affect the pay-out of life insurance?

SWANSON:
No. Not that I'm aware of.

"It's not unusual for family members to disagree about what is best for their loved one and coming to terms with being able to let go."

MEMBER QUESTION:
What do you do at your hospice if a family disagrees over whether a person should be let go or not?

SWANSON:
In a hospice setting, or with VistaCare, it's not unusual for family members to disagree about what is best for their loved one and coming to terms with being able to let go. So the best ways to address those issues are to continue an open dialogue with the family to educate them fully on the patient's condition, and the prognosis; to identify the benefits and perhaps burdens of any treatment options that might be available. And also really begin to identify what the patient's wishes would be in the situation. From my standpoint, it always comes back to that. What would the patient want?