2. Objectives
• Familiarize yourself with our CentraCare packets
• To understand the background and value of the Honoring
Choices Minnesota form
• For each of you to have your own Health Care Directive!
• To look at the unique needs of oncology patients regarding
Health Care Directives
• To examine how we might encourage our patients at Coborn
Cancer Center to have a Health Care Directive
3. Review:
What is a Health Care Directive?
A Health Care Directive is a planning tool and a written legal
document in which a competent adult can communicate health
care instructions in the event that they are no longer able to
communicate their wishes. It can also be used to appoint a
particular person to make health care decisions for a patient
who is unable to do so for him- or herself.
Two elements:
Living wills: the instructions
Medical power of attorney: the agent
4. A compliance issue
Congress enacted the Patient Self–Determination Act (PSDA) in
1991.
This act requires that all health care facilities receiving Medicare
or Medicaid reimbursements must inform patients of their rights
to make choices about the treatment they receive and to
prepare advance directives. Advance directives are not only
focused on what treatments one does not want— they are
equally applicable and viable to indicate all of the treatments
that one does want.
5. What our packet contains
• A welcoming letter
• Health Care Directive information sheet
• Return envelope and authorization to release to other medical
clinics or hospitals
• End-of-Life Decision Making Guide
• Honoring Choices Minnesota
• Wallet card
6. Honoring Choices Minnesota
• Honoring Choices Minnesota (HCM) was began in 2008 with
the Twin Cities Medical Society.
• Advisory Board formed. By 2009 logo chosen, educational
events, and specific directive developed
• Honoring Choices website:
http://www.honoringchoices.org
7. Honoring Choices Minnesota:
It’s for you!
The best teacher is experience! Take it home and fill it out.
Chances are if you have questions, others may as well.
Both elements of living well and ability to name a health care
agent.
8. Why should you have a HCD?
Same reason everyone should have a HCD - you don’t know
what tomorrow holds.
Rational decisions are more difficult to have in a time of crisis –
have the conversation before the crisis.
Most people have strong ideas about the ways they wish to face
the death, yet often, their loved ones or their physicians do not
know these choices.
9. Why should you have a HCD?
It is a gift to your loved ones.
Health Care Directives reduce stress and anxiety on families.
Reduces depression and grief after the loss of a loved one due
to enhanced understanding and the ability to honor wishes.
To facilitate the discussion among patients here at Coborn
Cancer Center.
10. Key points to keep in mind
“It’s about the conversation” – Tagline from the Minnesota
Honoring Choices website
You must share it.
“Communication is the single most important step in advance
care planning. When a loved one communicates their wishes
ahead of time, it decreases the chance of future conflict,
decreases the potential for ethical dilemmas, and takes the
burden off the family. “ – National Association of Social Workers
11. Key points to keep in mind
They can be changed over time.
Who will speak for you? Who in your family can make those
choices and follow through on your wishes? Two components:
willing and able.
It gives a person the chance to explain what does meaningful life
mean to them.
Doesn’t need to be sign by a notary republic although it could
be. Signed by a minimum of 2 witnesses.
The witness cannot be the agent.
No cost.
12. Unique needs of oncology patients
Video: http://www.youtube.com/watch?v=wFMPDUvUPrg
We need to start the conversation because reality is they need it
as much or more than anyone.
“Appropriately honoring patients’ wishes within the overall goals
of care is crucial.” – National Cancer Institute
“The mental and physical effects of end-stage cancer often
render people unable to make decisions for themselves.” – Ditto
& Hawkins, 2005
Cancer is a uniquely feared disease. Therefore, end of life
planning has the potential to relieve some of this fear and the
suffering that surrounds it. - Ditto & Hawkins, 2005
13. Unique needs of oncology patients
They want to “stay positive.” They my feel like focusing on end
of life is negative thinking. - Ditto & Hawkins, 2005
Because of sometimes severe swings in mental and physical
well-being, their desire to complete a HCD may depend on how
they are feeling on the day it is asked. - Ditto & Hawkins, 2005
While it is usually easier for individuals and family members to
discuss end of life care when before a crisis, deteriorating health
was associated with an increasing willingness to make a HCD. –
Hommel & Sahm, 2005
14. Unique needs of oncology patients
Values based HCD are less threatening and more likely to be
filled out than traditional, medical driven HCD . – Prommer,
2010
Empirical research shows that patients usually express positive
attitudes about HCD but seldom complete them. - Prommer,
2010
15. Suggestions
Have your own Health Care Directive.
Confidence. State-wide. Value based components.
Put social workers card in the packet. Refer to her as a resource
who could take the time to sit and go through it with them if
they desire.
Have Honoring Choices forms alone available for spouses or
family members.
Take the packet in the room with you. They are sitting there for
hours at times.
Know that you are planting seeds.
16. References
American Cancer Society. (3013, 5 31). Why do you need an
advance directive?. Retrieved from
http://www.cancer.org/treatment/findingandpayingfortreatmen
t/understandingfinancialandlegalmatters/advancedirectives/adv
ance-directives-why-do-we-need-advance-directives
Conversation Before the Crisis - Helpstartshere.org. (2007, July
19). Helpstartshereorg. Retrieved from
http://www.helpstartshere.org/seniors-and-aging/advanced-
care-planning/advance-care-planning-tip-sheet-conversation-
before-the-crisis.html
Ditto, P., & Hawkins, N. (2005). Advance directive and cancer
decision making near the end of life. Health Psychology, 24(4),
S63-S70. doi: 10.1037/0278-6133.24.4S63
17. References
Hommel, G., Sahm, S., & Will, R. (2005). Attitudes towards and
barriers to writing advance directives amongst cancer patients,
health controls, and medical staff. Journal of Medical Ethics, 31,
437-440. doi: 10.1136/lme.2004.009605
Honoring Choices Minnesota. (2014). Honoring Choices
Minnesota. Retrieved April 24, 2014, from
http://www.honoringchoices.org
National Cancer Institute. (n.d.). Communication in cancer care.
Retrieved from
http://www.cancer.gov/cancertopics/pdq/supportivecare/comm
unication/patient
Prommer, E. (2010, January 16). Using the Values-Based History
to Fine-Tune Advance Care Planning for Oncology Patients.
Journal of Cancer Education, 25, 66-69. doi: 10.1007/s13187-
Editor's Notes
Also called Advanced Directive or Medical Directive. Advance directive is a general term used to describe two types of documents, living wills and medical powers of attorney. Living Wills (sometimes called medical directives) are written instructions for care in the event that a person is not able to make medical decisions for him or herself. A medical power of attorney (sometimes called a health care power of attorney) is a document that appoints a particular person (health care proxy/agent or surrogate) to make health care decisions for a patient who is unable to do so for him-or herself.Contain one or both. Also called health care power of attorney or health care proxy/agent or surrogate.
* Letter: explains the what's in the packet and describes the HCD. It gives them contact information if they would like assistance filling it out. Own social worker here* HCD info sheet: what to do with it when done * Return Envelope once you’ve completed it to return to Medical Records along with an authorization to release to clinics and hospitals. End-of-Life Decision Making: geared toward palliative care, hospice care, defines terms talks about what is CPR, dialysis, ventilators, tube feedings HCM form which is what we are going to talk about What is the card?
- HCM is the meat of the packet and the Directive. - HCM 2008 Twin Cities Medical Society. They held exploratory meetings with community members and senior leaders of hospital systems and health plans. The purpose of both meetings was to gauge the interest level in collaborating and coordinating resources related to advance care planning. Huge interest in collaborating and working together and provide resources could be used statewide. -In 2009, a name and logo were selected,, and educational events began. A new Minnesota-specific health care directive was developed by the advisory committee and is available online at no charge in five languages. What I want you do see When hold this form in your hand is that this is a state-wide collaborative effort and that a lot of research and development and feedback has went into this form. Training provided social worker, Tracy, Mary, Jane have been. .
The best teacher is experience. I filled one out for class7 pages. Pretty straight forward. It takes thought but not a lot of time.Write in feeling thoughts vs checking boxesOrgan donation – let family know – it’s ok, they won’t have to wonder.Doesn’t need to be sign by a notary republic although it could be – signed by a minimum of 2 witnesses. Page 4 part 3 – don’t make it optional
Tragedies and catastrophic events happen all the time. We all have known someone. Why do we think we are immune?It may seem as though there is never a “good time” to talk about death and dying. Oftentimes loved ones are uncomfortable discussing the topic – particularly if they are relatively healthy. Although these conversations are often difficult to have, they are vitally important. We need not wait for a tragedy before anticipating what rational decisions will need to be made in time of crisis. We must have the conversation before the crisis.**Personal example how I do** the physician on the website says “he shares his with patients”
Personal example - ICU
Tag line for Honoring Choices Minnesota.Who do you you share it with? Share especiallyFamily and agent. Think of siblings.If it’s never shared, can’t be honored.Personal example
What is quality of life vs just DNRAdvance care planning has to reflect changing preferences and circumstances; patient’s preferences change over the course of their illnessWho can follow thru? Doesn’t have to be a spouse. Certain child, cousin No attorney no cost!!
Show video The study I read from Health Psychology said that seriously ill individuals have been found to complete living wills at rates only slightly higher than those found in non-patient populations.** Ethical consideration with patients Appropriately honoring patients’ wishes within the context of overall goals of care is crucial. Thoughtful consideration of the role of and relationship with oncology physicians, nurses, palliative care experts, communication barriers, sources of interpersonal conflict, symptom control, and end-of-life care is paramount to optimal management strategies in this patient population. How can we honor if we don’t know their wishes ** Near end of life, cancer patients often endure intense pain, fatigue, delirium, agitation, and a host of symptoms that can severely diminish their quality of life.
Optimism and positive thinking are encouraged for physical and mental health.
Values based means that patients are allowed to expressed beliefs and values rather than simply check boxes and refer to medical terminology. They also focus on quality of life and overall health. They don’t have to feel there is a right answer.
Filling one out for yourself is the best way to begin to help others. It will help you be familiar with the Honoring Choices form and it will lend credibility and platform for you to be able say, “ I have one. I have one. Everyone should have one really.”Be confident. Know the Honoring Choices form has research and feedback when developed and is being used across MN. Value based means people can free write thoughts and feelings about beliefs and quality of life. Let them look it over. We can’t force anyone to do something. But we can offer it. And every time it’s offered we are planting seed and helping them process the idea. Remember the lady in the video
