Te l l i n g M e d i c a l P r o v i d e r s W h a t t o
D o W h e n Y o u C a n ’ t Te l l T h e m W h a t
Yo u W a n t T h e m t o D o : A d v a n c e
Directives & Medical Orders For
Scope of Treatment (MOST )
Good to Go
October 20, 2015
John A.K. Boyd, MD
MRMC Ethics Committee Chair
revised 9/14/15
Historical Perspective
• 1930 – my grandfather builds the first
hospital in Wickenburg AZ (penicillin
not discovered till 1928 and not
available until 1941)
• 1960 – my father dies in the Phoenix
VA hospital of an MI at the age of 43
(the first ICU was established in 1958)
• 1972 – I start medical school (high
tech life support now available)
Dr. James Alfred
Copeland (18711941), circa 1937
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Common Problem Case Scenarios
• Grandpa breaks his hip.
– develops pneumonia and
ARDS
– aunt Lucie from California
shows up at the 11th hour
• Persistent Vegetative State
(PVS)
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Persistent Vegetative State
(PVS)
• due to injury of the upper
brain sparing the brain stem
• characterized by the return of
sleep-wake cycles and of
various reflex activities, but
wakefulness is without
awareness
• can “live” for years on tube
feedings
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Informed Consent
• the basis for
modern medical
ethics
• historically a
response to the
Nuremburg trials
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Informed Consent
Prior to being treated:
– the patient will receive a
description of the
treatment to include its
risks, benefits and
alternatives, and
– the patient will agree to
accept the treatment.
MRMC Policy
Definition
of
Decisional Capacity
A patient has decisional capacity to consent to
or to refuse treatment when the patient has:
1) the ability to comprehend information relevant to the
treatment being offered, and
2) the ability to deliberate in accordance with his/her
own values and goals, and
3) the ability to communicate with care givers.
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Advance Directives
Available in Colorado
• Living Will
• Medical Durable Power of
Attorney
• CPR Directive
“Advance Directive” means an expression of
treatment preferences, guidelines, or
instructions regarding medical treatment made
by an individual, or for an individual by that
individual’s authorized agent, in advance of the
need for such treatment.
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Living Will
•
a written statement made when a
patient (declarant) has decisional
capacity which gives directions for
withholding or withdrawing certain
life- sustaining procedures when the
patient:
1) has a terminal condition or PVS and
2) has lost decisional capacity.
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“Terminal Condition”
Colorado Law Definition
“Terminal Condition” means an incurable or
irreversible condition for which the
administration of life-sustaining procedures will
serve only to prolong the dying process.”
Living Will
•
•
•
•
must still have 2 witnesses
two physicians must certify terminal
condition or PVS
may include other instructions for care
following certification of terminal
illness/PVS
may include a list of persons to be notified
of that certification, as well as a list of
persons with whom healthcare providers
may discuss the declarant’s condition and
care
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Medical Durable Power of Attorney
(MDPOA)
• a written statement made when a patient has
decisional capacity which appoints specific
surrogate decision-makers (agents)
• not limited to a terminal condition or PVS
• takes effect at time of signature or when patient
loses decisionality
• witness recommended but not required
When Can Your MDPOA Agent
Begin Making Decisions?
Living Will vs MDPOA
Proxy Decision-Makers
For Medical Treatment
CRS 15-18.5-103
• Used to establish a surrogate decision
maker when there is no Medical Durable
Power of Attorney or Guardian.
• Physician must declare that the patient
has lost decisional capacity.
• Physician (or representative) contacts
“interested persons.”
• “Interested persons” choose the proxy
decision-maker.
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Colorado Designated Beneficiary Act (CRS
15-22-101-111)
• allows for two adult (over 18) persons to designate
each other as beneficiaries of a number of items and
instruments related to health care, medical
emergencies, incapacity, death, and administration
of estates
• the two adults cannot be married to each other or
anyone else nor party to any other DB agreement
• a DB may assign the other DB the right to act as a
Proxy Decision-Maker
CPR Directive
• A written order signed by a patient with
decisional capacity and his/her physician
instructing pre-hospital emergency personnel
and other providers to withhold CPR
(cardiopulmonary resuscitation).
• May be signified by wearing a necklace or
bracelet.
CPR Directive
Bracelet or Necklace
A unique and easily identifiable logo is engraved on the
front side of the metal bracelets and necklaces. The name,
birth date, sex, and race of the declarant are engraved on
the back side along with the words "DO NOT
RESUSCITATE." Wearing a bracelet or necklace is
encouraged but not mandatory.
Ordering a No-CPR
Bracelet or Necklace
For more active folks with CPR directives, a
special no-CPR bracelet or necklace can be
obtained from:
• Award and Sign Connection
(http://awardandsign.com/ or 303.799.8979)
or
• MedicAlert Foundation
(http://www.medicalert.org/ or
888.633.4298).
Out-of-Hospital CPR Outcomes
UpToDate 1/22/15
• “resuscitation from out-ofhospital Sudden Cardiac Arrest
(SCA) is successful in only onethird of patients”
• “only about 10 percent of all
patients are ultimately
discharged from the hospital,
many of whom are
neurologically impaired”
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In-Hospital CPR Outcomes
UpToDate 1/22/15
• “the outcome of patients who experience SCA
in the hospital is poor”
• “49 percent of patients had return of
spontaneous circulation”
• “15 percent overall survival to hospital
discharge”
Nursing Home CPR Outcomes
Prehosp Emerg Care; Apr-Jun, 1997;
“Outcomes of cardiac arrest in the
nursing home: destiny or futility?”
• 182 nursing home patients received CPR
from July 1989-December 1993
• none survived
UpToDate Review 2/5/15
• “Other studies have reported that only 1
percent of individuals who arrested in a
SNF survived to be discharged from the
acute hospital.”
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CPR Directive
Legislative Changes 2010
• ANY form clearly stating refusal of CPR, signed by
patient and patient’s physician is valid.
• Even if NOT signed by physician, any form signed by a
patient should be honored.
• Copies, faxes, scans are just as valid as original.
• Downloadable template on Colorado Advance
Directives Consortium and CDPHE Web sites.
• Do Not Resuscitate ≠ Do Not Treat! Palliative care
should always be provided.
Medical Orders for Scope of Treatment
(MOST)
• A document that consolidates and summarizes patient
preferences for key life-sustaining treatments.
• Persons may refuse treatment, request full treatment, or
specify limitations.
• It is primarily intended to be used by the chronically or
seriously ill person in frequent contact with healthcare
providers, or already residing in a nursing facility.
• Translates patient preferences into physician’s orders.
• “Travels” with the patient and is honored in any setting:
hospital, clinic, day surgery, long-term care facility, rehab
facility, hospice, or at home.
• Prompts patients and providers to regularly review, confirm, or
update choices based on changing conditions.
MOST Orders
1. CPR: Yes or No
2. Medical Intervention & Transfer: Full
Treatment, Selective Treatment or ComfortFocused Treatment
3. Artificially Administered Nutrition &
Hydration: Long Term, Short Term, or None
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Practical Suggestions
• Consider Five Wishes – it incorporates
a Living Will and A Medical Durable
Power of Attorney.
• Discuss your Advance Directives with
close friends and family – especially
with the agent(s) designated in your
Medical Durable Power of Attorney.
• Talk to your physician if you are
considering a CPR Directive.
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Colorado Advance Directives
Consortium
• http://coloradoadvancedirectives.com/
• website contains great sample forms and
educational materials