A Step-by-step guide to help you tell healthcare workers what YOU want. And what you would NOT want. Audio available at the last slide.

1. Beginner’s Guide
to Advance
Directives
Kelly Welton BA, RRT-NPS
© 2015 The Breathing Specialist
© 2015 The Breathing Specialist

2. © 2015 The BreathingSpecialist
When Am I Going To Talk
About This ?

3. © 2015 The BreathingSpecialist
“I have a Living Will, do I need
an Advance Directive also” ?
 DPAHC- Appoints someone straightaway to make the
decisions
 AD- Outlines their wishes
 Living Will- Outlines what you do or do not want, and
appoints someone to make those decisions if the patient
cannot

4. © 2015 The BreathingSpecialist
DECLARATION
I, (Name) , being of sound mind, willfully and voluntarily make this
declaration to be followed if I become incompetent. This declaration reflects my
firm and settled commitment to refuse life-sustaining treatment under the
circumstances indicated below.
I direct my attending physician to withhold or withdraw life-sustaining treatment that
serves only to prolong the process of my dying, if I should be in a terminal condition
or in a state of permanent unconsciousness. I direct that treatment be limited to
measures to keep me comfortable and to relieve pain, including any pain that might
occur by withholding or withdrawing life-sustaining treatment.
In addition, if I am in the condition described above,
Living Will example
Excerpted from LegalTemplates.net

5. © 2015 The BreathingSpecialist
How Do You Feel About Each
of These Treatments?
 Receiving blood or blood products Yes No
 Having to have Surgery Yes No
 Invasive Testing Yes No
 Cardiac Resuscitation (CPR) Yes No
 Mechanical Ventilation Yes
No
 BiPap Ventilation Yes No
 Tube Feeding Yes No
 Dialysis Yes No
 IV’s Yes No
 Antibiotics Yes No

6. © 2015 The BreathingSpecialist
Directive to Physicians
Directive made this __ day of ____ in the year ____.
I,_____, being of sound mind, willfully and voluntarily make known my desire that
my life shall not be artificially prolonged under the circumstances set forth in this
directive.
If at any time I should have an incurable or irreversible condition caused by injury,
disease, or illness certified to be a terminal condition by two physicians, and if the
application of life-sustaining procedures would serve only to artificially postpone the
moment of my death, and if my attending physician determines that my death is
imminent or will result within a relatively short time without the application of life-
sustaining procedures. I direct that those procedures be withheld or withdrawn, and
that I be permitted to die naturally.
In the absence of my ability to give directions regarding the use of those life-
sustaining procedures, it is my intention that this directive be honored by my family
and physicians as the final expression of my legal right to refuse medical or surgical
treatment and accept the consequences form that refusal.
.
Advance Directive Sample

7. © 2015 The BreathingSpecialist
This directive is in effect until it is revoked.
I understand the full import of this directive and I am
emotionally and mentally competent to make this
directive I understand that I may revoke this directive
as any time.
I request that only comfort care be provided to me, no
antibiotics, no artificial nutrition, no mechanical
ventilation, and no hydration. It is my strong preference
to be allowed to die outside of a care facility if possible,
even if that preference is determined by my physician
to shorten my period of dying. The only condition under
which I desire these preferences for end of life care to
be altered is in the case of possible organ and tissue
donation. I request that any and all organs and tissue
that may be salvaged be provided for transplant. My
remains may then be cremated.
Signed ______________ in the City of
____________etc.

8. © 2015 The BreathingSpecialist
What Does all of this Mean?
What am I signing?
 Revocable: If you can say it, we will do it
 But, saying yes to one thing often means saying yes to
many things that are connected

9. © 2015 The BreathingSpecialist
BiPap- The new cover-all
solution (NOT!)
 Bipap is ventilation without the endotracheal tube
 =ventilator=life support
 Often done for the family
Photo courtesy of Respironics

10. © 2015 The BreathingSpecialist
Photo courtesy of Respironics Inc.

11. © 2015 The BreathingSpecialist
What in the world is “The
Peri-operative Period?”
 Pre-hospital DNR or Advance Directive in place
 Procedures, surgeries, etc.

12. © 2015 The BreathingSpecialist
Surgery = -pre, -peri, and –
post op
 DNR or any limitations gets rescinded during any
‘procedure’ in many hospitals
 Immediate post-operative time is considered “the
extended peri-operative period”
 Aggressive treatment to ensure success of the
procedure
 Once treatment is started, very difficult to stop
 After a ‘procedure’, when will the full Advance
Directive kick in?

13. © 2015 The BreathingSpecialist
Have We Met?
 Electronic Medical Records- blessing and nightmare

14. © 2015 The BreathingSpecialist
A Personal Choice
 To Live, or to Die
 Definition of Living
 -Cultural
 -Religious
 -Personal Beliefs about the Afterlife
 -Fear in the Moment
 -Understanding of what is available
 -Understanding your own physiology

15. © 2015 The BreathingSpecialist
How Do You Feel About Each
of These Treatments?
 Receiving blood or blood products Yes No
 Having to have Surgery Yes No
 Invasive Testing Yes No
 Cardiac Resuscitation (CPR) Yes No
 Mechanical Ventilation Yes
No
 BiPap Ventilation Yes No
 Tube Feeding Yes No
 Dialysis Yes No
 IV’s Yes No
 Antibiotics Yes No

16. © 2015 The BreathingSpecialist
Quality of Life
 What does ‘quality of Life’ mean to you?
 Would you want to live on a ventilator?
 Would you want to live at home as long as possible?
 Would you want to live in a Care Facility?
 If you had solid answers to these questions, who could
you trust to carry out your wishes for you?

17. © 2015 The BreathingSpecialist
 DNR variations and choices
 “Intubation only, no CPR”
- Often chosen by those with Asthma or COPD
 “Chemical Code only”
 Use of BiPap
DNR: Do Not Resuscitate orders

18. © 2015 The BreathingSpecialist
What is a “Code Blue” ?
 Not like on TV
 MD comes running to put breathing tube in the throat
 RT ventilates with a bag and assists with intubation and
secures the breathing tube
 Pharmacy team comes running
 RN comes running with crash cart, starts IV’s and gives
initial meds
 Someone does chest compressions
 Defibrillator attached - Ouch!

19. © 2015 The BreathingSpecialist
What if family is present
during a code?
 Violent images that are hard to forget
 Shock at how violent and/or chaotic it seems
 Anger – may try to remember all the details
 Guilt- Things unsaid

20. © 2015 The BreathingSpecialist
The Nightmare
 No Advance Directive on file
 “No specific directions = full code
 Patient crashes, gets intubated, and sent to ICU
 Family called
 Conflicting opinions between family members

21. © 2015 The BreathingSpecialist
A different nightmare
 Patient has Advance Directive on file at the Nursing
Home or RCF, but becomes unresponsive and gets
transferred to ED for ‘further evaluation”
 Patient in SNF gets an infection requiring transfer to ER
for Antibiotics.
 Subsequent decline of the patient requires a full code,
because no one can find the original Directive

22. © 2015 The BreathingSpecialist
Worse Nightmare
 Patient’s AD is at her primary care MD’s office, or in a
safe deposit box or attorney’s office somewhere
 Patient’s caregiver get scared, calls 911 despite being
told not to.

23. © 2015 The BreathingSpecialist
Worst Nightmare Ever
 Patient is stating his/her wishes, family is deciding
otherwise
 Family’s choices to prolong include tracheostomy and
home ventilation, or SNF sentence
Photo courtesy of Allegro Medical

24. © 2015 The BreathingSpecialist
The solutions
 Make sure to add a line for Non-Invasive
Positive Pressure Ventilation to AD
 Be sure there are provisions for feeding tubes
 Include a well-defined peri-operative period
 (i.e., 24 hours)
 Include TPN as a choice
 Educate the public on the amount and extent
of choices they have, and the complications
of each
 If bedridden, make provisions for bedsore
care

25. © 2015 The BreathingSpecialist
Doctors are trained to save
lives, not end them.
 DNR for end-stage COPD
 On floor, she gets very short of breath
 Gets to ICU, and is in progress with MI
 Cardiologist talks her into a cath
 Intubated for cath
 Unable to extubate after procedure
 Family furious

26. © 2015 The BreathingSpecialist
What Can You Do?
 Search for Advance Directive Forms for your State
 Discuss with family members your wishes
 Appoint carefully
 Make sure everyone knows where to find your
document.
 For more information, visit us at:
http://www.TheBreathingSpecialist.com

27. © 2015 The BreathingSpecialist
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