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Advance Directives: Understanding Arizona’s Combined Health Care Power of Attorney and Living Will

Advance Directives: Understanding Arizona’s Combined Health Care Power of Attorney and Living Will. Updated March 2009.

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Advance Directives: Understanding Arizona’s Combined Health Care Power of Attorney and Living Will

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  1. Advance Directives: Understanding Arizona’s Combined Health Care Power of Attorney and Living Will Updated March 2009

  2. This presentation is based in part on a publication by Charles L. Arnold and James E. McDougall, of the law firm Frazer, Ryan, Goldberg & Arnold LLP. Modifications have been made; every attempt, however, has been made to ensure the provided information is both accurate and beneficial to the reader. A Special Note… The information contained in this training is important for you for two reasons. First, you may determine that you would benefit from an Advance Directive yourself. In this case, you can pursue developing one. Second, as a public behavioral health service provider in Arizona, you are requiredto inform those adult Members you serve (or the Member’s surrogate if the Member is incapacitated) about Advance Directives; you also must offer them the opportunity to develop one. As you complete this training, please consider the information from both perspectives. With this in mind, let’s look at the goals of this module…

  3. Module Goals This module is designed to help behavioral health providers and staff better understand Advance Directives to: Provide at the time of Member enrollment, at minimum, written information to adult behavioral health clients (or the Member’s surrogate if the Member is incapacitated)regarding Advance Directives. Assist Members (or the Member’s surrogate)who are interested in developing and executing an advance directive. As described in CPSA Provider ManualSection 3.12: Advance Directives

  4. Learning Objectives Upon completion of this training module, you will be able to: • Describe and understand Arizona’s Combined Health Care Power of Attorney and related documents and what information should be included. • Determine the importance and function of the agent. • Understand the enforceability of the document. • Access and complete an Advance Directive. • Understand and carry out your Advance Directive responsibilities as you serve your behavioral health recipients. Let’s look next at your responsibilities surrounding Advance Directives…

  5. Your Professional Responsibilities • When an adult individual initially enrolls as a behavioral health member, he/she (or the Member’s surrogate) receives the Member Handbook, in which Advance Directives are described. • You should become familiar with the information in the Handbook and communicate with the Member about Advance Directives. • You are required to offer the Member the opportunity to execute an Advance Directive. • Learn how your agency expects you to fulfill your obligations to provide Advance Directives information and assist the Member (or the Member’s surrogate) in the execution of these documents. Talk to your supervisor for assistance with meeting the expectations of your employer agency.

  6. Your Professional Responsibilities (continued…) • Per the Provider Manual Section 3.12… • As a behavioral health service provider, your position requires that you: • Provide information regarding Advance Directives to adult Members (or their surrogate) at their time of enrollment. • Document that each adult Member (or their surrogate) has received this information and whether a Directive was executed. • Assist the Member (or their surrogate), as needed, in completing an Advance Directive. • Ensure that you or your agency do not discriminate against a Member due to the presence or lack of a Directive. • Provide a copy of the Member’s executed Advance Directive, or documentation of refusal to execute an Advance Directive, to the Member’s primary care provider for inclusion in their medical record.

  7. Definitions and Directive Purpose

  8. What is an Advance Directive? • It is… • Specific instructions, prepared in advance, that are intended to direct a person’s medical and mental health care if he or she becomes unable or incapable of doing so in the future. • Made up of legally binding documents. • Executed by a person (the ‘agent’) chosen by the member/client as a surrogate decision-maker to carry out the wishes and directives on behalf of the member/client. What documents make up the Advance Directive? Read on…

  9. What is an Advance Directive? • These documents typically make up an Advance Directive in the State of Arizona: • Health CarePower of Attorneyand Mental Health CarePower of Attorney(Together these 2 Documents make up the ‘Combined Health Care Power of Attorney’): these two forms allow Members to name someone to make decisions regarding desired medical and mental health treatments if they are not able to do so themselves. • Addendum to Combined Health Care Power of Attorney: allows Members to articulate their specific wishes to aid their designated agent in making care and treatment decisions on their behalf. • Living Will:allows Members to specify treatment they want or do not want in certain situations (i.e., end-of-life care). Click on each form name to view the form on CPSA’s website

  10. Why Complete an Advance Directive? • If a Member becomes unable to make the best decisions for their physical and mental health treatment, an Advance Directive provides them the opportunity to take charge of their health care in advance. • Individuals who have, or may in the future have a mental illness have the right to make decisions about their treatment until their illness presents a danger to themselves or others, or otherwise renders them incapable of caring for themselves. • The decisions that are made on their behalf during a period of incapacity will be guided by their wishes and authority as described in their Advance Directive. • (continued…)

  11. Why Complete an Advance Directive? • The Directive can identify: • Specific symptom progression - including pre-crisis symptoms. • At what point a Member feels treatment should be sought. • What doctors and which medications or other treatments may have helped them in the past. • A plan of action for how to best address their situation. • A decision-making ‘agent’ to direct the Member’s care in times of incapacity. As critical as Advance Directives are, currently in the United States only 20-25 percent of adults have completed a written Advance Directive. The proactive involvement of developing an Advance Directive means the Member is engaged in his/her treatment and planning!

  12. Why Complete an Advance Directive? Advance Directives offer several key benefits. Correctly implemented and executed, they can: • Promote individual autonomyand empowerment in the recovery from illness and mental illness. • Enhance communication between individuals and their families, friends, healthcare providers, and other professionals. • Protectindividuals from being subjected to ineffective, unwanted, or possibly harmful treatments or actions. • Promote individual treatment planning. • Provide opportunities to create a team approach to treatment. • Foster ‘recovery’ approaches. • As described in CPSA Provider Manual Section 3.12 – Advance Directives

  13. Advance Directives: What’s Included

  14. Advance Directives: What’s Included Advance Directives in Arizona consist of the following documents: • Combined Health Care Power of Attorney (made up of the Health Care Power of Attorney andthe Mental Health Care Power of Attorney) • Addendum to Combined Health Care Power of Attorney • Living Will Let’s examine the function and content of each of these documents…

  15. Arizona’s Advance Directive:The Combined Health Care Power of Attorney • The Combined Health Care Power of Attorney: • Is made up of two documents - the Health Care Power of Attorney and the Mental Health Care Power of Attorney. • Islegally binding, giving the Member power to control the physical and mental health care decisions made for them during a time of incapacity. • Transfers decision-making authority to a person of their choice, known as “the agent” with specific directions regarding the Member’s wishes and any limits to the agent’s authority. • May also provide information regarding the Member’s autopsy, organ donation and funeral/burial preference.

  16. Arizona’s Advance Directive:The Combined Health Care Power of Attorney (continued…) A Health Care Power of Attorney versus A Combined Health Care Power of Attorney This comparison may be especially important if the Member already has a Health Care Power of Attorney… The Health Care Power of Attorney logically includes mental health care but there is a distinction, and the Member must clearly and specifically give their agent authority to make mental health care decisions. This is accomplished by also executing the Mental Health Care Power of Attorney which provides specific instructions involving the Member’s mental health needs.

  17. Arizona’s Advance Directive:The Addendum • The Addendum to the Combined Health Care Power of Attorneyprovides crucial and specific information to the agent by describing in detail the circumstances at which point the agent would direct the Member’s care and their overall health and mental health care wishes and desires. • This document also allows the Member to specify such things as: • • Current medical conditions. •Medications they can and cannot take. •Religious and spiritual considerations. •Past treatments that have been helpful. •Treatments/medications they prefer as well as those they refuse to consider.

  18. Arizona’s Advance Directive:The Living Will • The Living Willportion of the Advance Directive allows Members to: • State the physical treatment they would accept and refuse when unable to communicate this for themselves because of a terminal condition, persistent vegetative state, or coma. • Specify instructions regarding comfort care, limits on treatment, pregnancy, and the prolonging of the Member’s life (End of Life Care). • Attach any additional information not specified on the Living Will form. The Living Will is the last of the four documents that typically make up an Advance Directive. Before we move on to discussing the role of the agent, there is a circumstance regarding Advance Directives that warrants a special mention - admission to Level I behavioral health care facilities…

  19. A Special Note on: Admission to a Level I Licensed Behavioral Health Facility Regardless of the decisions indicated in the Combined Health Care Power of Attorney, admission to a Level I licensed behavioral health facility (inpatient psychiatric care) is always based upon a physician’s assessment. While the agent will have the authority to have the Member admitted as a voluntary patient, the hospital staff has the legal responsibility to determine whether hospitalization is medically necessary. So, a Member’s admission to a Level I behavioral health care facility may not always be voluntary…

  20. One Advance Directive Goal:Avoid Involuntary Treatment The process of involuntary treatment can be very intrusive, degrading and frightening - one which most of us would choose to avoid if at all possible. Having an agent make decisions when the Member may be incapable of doing so for themselves will, hopefully, prevent Members from ever having to experience the involuntary treatment process. Involuntary treatment usually involves the Member’s current ‘capacity’ to make decisions for themselves…

  21. Understanding Capacity Decisions Typically, an individual is able to make his/her own decisions until he/she is deemed incapable. The decision regarding a Member’s capacity, however, can be a part of their Directive… Only licensed physicians, licensed behavioral health care providers, or courts can determine that Members “don’t have legal capacity” and, therefore, cannot understand, make, or communicate physical and mental health treatment decisions for themselves. Arizona’s Combined Health Care Power of Attorney empowers Members to decide who, besides a court, can make that important decision for them. The Member can identify a particular physician to help make this capacity determination. Now that we’re familiar with the documents that make up the Advance Directive, let’s look more closely at the role the agent plays…

  22. The Role of The Agent

  23. Specifying an Agent & Alternate One of the main purposes of the Combined Health Care Power of Attorney is to identify an agent: • Members designate one person as their “agent” and another person as their “alternate agent” to carry out Directive instructions. • The alternate agent only acts as the designated agent if the primary agent is unable or unwilling to act as the Member’s designated representative. • Members should be encouraged to select an agent whom they trust completely so they feel comfortable giving that person the responsibility for their treatment decisions and overall well-being. Let’s look next at the ‘authority’ of the agent and alternate agent…

  24. The Agent’s Authority The Member’s designated agent: • Has the authority to make health and mental health care decisions for them after they become incapacitated. • Must follow the wishes as expressed in the Advance Directives documents. • Must act in accordance with what he/she, in good faith, believes is in the Member’s best interest if the Member’s wishes are not expressed in the document or otherwise known by the agent. Member communication with the agent is critical…

  25. Communication with the Agent Communicating with the agent goes beyond form completion… • In addition to the Directive specifics, Members should communicate to their agent: • Their overall life view and philosophical/religious beliefs so the agent can make appropriate decisions regarding issues that may not have been spelled out in the Directive. • Any revisions or changes to the Combined Health Care Power of Attorney. • Any substantial life or situation changes - this information could be crucial for the agent in a time of crisis. Okay, we have discussed the Directive and the agent. How can a member help ensure that their Directive wishes are going to be followed?...

  26. Enforcement of the Advance Directive

  27. Enforceability of the Combined Health Care Power of Attorney There is not a 100% guarantee that wishes expressed in an Advance Directive will be followed. However, Members can improve its enforceability by: • Providing a copy of the Power of Attorneys to the Member’s physician or health care provider and to designated and alternate agents. • Ensuring the individuals chosen to act as agents are aware of both the documented choices and the rationale behind them. • Having the agent/alternate agree in writing to accept all of the roles and responsibilities the Member is requesting that they take on. • (continued…)

  28. Enforceability of the Combined Health Care Power of Attorney Members can improve enforceability by: (continued…) • Having the agents acknowledge in writing that they have received a copy of the document. • Keeping extra copies of the Directive just in case they need access to the document. • Letting those close to them know they have a Combined Health Care Power of Attorney; their support and advocacy during times of incapacity can be critical. • Ensuring documents are written in a concise manner that clearly indicates all the choices and considerations made in advance. Another consideration for Directive enforcement is ‘revocability’...

  29. Enforcement & Revocability Members may develop the Combined Health Care Power of Attorney as irrevocableor revocable. Making the Power of Attorney “irrevocable” means the Member can make changes to it only if they have the capacity to do so at that time. Alternatively, if the Member makes the Power of Attorney “revocable at all times” they can make changes to the document at any time, regardless of their capacity. ‘Petitions’ can also affect Directive enforcement ...

  30. Enforcement & Petitions Regardless of the treatment choices made in a Member’s Power of Attorney, their instructions can be changed if they are faced with a petitionfor emergency psychiatric evaluation or treatment, or if they are the subject of a court order for treatment. In these cases, the Member may receive treatment and/or medications that he or she does not want. However, keep in mind that their doctor can act against their wishes and directives only under extremely strict legal guidelines. After this detailed discussion about the development and execution of Advance Directives, let’s look next at the process of completing an Advance Directive...

  31. Completing the Advance Directive

  32. Completing the Advance Directive As a behavioral health staff you should be available to your Members for assistance in their completion of an Advance Directive. Briefly, the main steps for completing this process: 1) Access the Advance Directives forms 2) Complete the four forms 3) After the forms are completed Members should: a) Distribute copies of the forms to all concerned parties b) Register the Advance Directive c) Review the Advance Directive every year or so and consider any updates/changes Let’s look at the first step, accessing the Directive forms…

  33. Completing the Advance Directive:1) Accessing the Forms Accessing the appropriate forms is easy; these are options that may pursued: • Visit the Arizona Secretary of State web site • Visit the Arizona Attorney General web site • Or… perhaps the most convenient method: • Go to the Advance Directives Information Center • on the • CPSA Website! • (see next slide…)

  34. Completing the Advance Directive:1) Accessing the Forms • On the CPSA Website • Everything needed to understand, complete and register an Advance Directive is available in theAdvance Directives Information Center on the CPSA Web Sitewhich is accessible from the icon on the Home Page of the CPSA Web Site : www.cpsa-rbha.org

  35. Completing the Advance Directive:1) Accessing the Forms • On the CPSA Website • • From theAdvance Directives Information Centeryou can link to: • Understanding Advance Directives– resources to help make care decisions and understand and complete an Advance Directive. • Completing an Advance Directive– Advance Directive forms, instructions for completing the forms, and what to do after completing the forms. • Four Steps to Registering Your Advance Directive– application form and information for registering an Advance Directive into the Arizona Health Care Directives Registry. • Additional Advance Directive Resources– Contact information and information specific to Members.

  36. Completing the Advance Directive:1) Accessing the Forms • On the CPSA Website • • Understanding Advance Directives • Before completing Advance Directive forms, a Member may want to learn more about Advance Directives, and identify the person to make decisions for the member should he/she become incapacitated. The following tools are available: • Advance Directives: A Helpful User-Friendly Guide – a presentation designed to help Members understand and complete their Advance Directive (available in text, audiovisual, and DVD formats). • Answers to Frequently Asked Questions About Advance Directives • Definitions of Advance Directive Terms • Advance Directive Rights, Choices and General Information

  37. Completing the Advance Directive:2) Completing the Forms • Advance Directive Forms • This section contains the forms to complete the Arizona Combined Health Care Power of Attorney, Addendum and Living Will. The forms may be completed electronically or printed and filled out with a pen. • Health Care Power of Attorney– allows Members to name someone to make medical decisions if they are not able to do so themselves. • Mental Health Care Power of Attorney–allows Members to name someone to make mental health decisions if they are not able to do so themselves. • Addendum to the Combined Health Care Power of Attorney– allows articulation of subtle things regarding wishes which may be too specific for the Power of Attorney form. • Living Will– allows Members to specify the treatment they want and do not want in certain situations.

  38. Completing the Advance Directive:2) Completing the Forms When completing the forms, the Member should initial each page of the document in the lower right-hand corner to signify that they have read and understand the information contained on each page. The documents need to be dated and signed by the Member and two witnesses in front of a Notary Public. The Notary and any witness should not be: • A person designated as the agent/alternative agent. • A care professional providing care to the Member at the time of signing. • An individual related to the Member by blood, marriage or adoption. • A potential recipient entitled to any part of the Member’s estate by will or operation of law at the time of signing.

  39. Completing the Advance Directive:2) Completing the Form Legal assistance is available free of charge. Options include: • Visit the Arizona Center for Disability Law Web site. • Contact the Phoenix or Tucson Center office Monday through Friday, 8:00am to 5:00pm: • Phoenix : (602) 274-6287 • Tucson:(520) 327-9547 • Toll Free:(800) 927-2260 In addition, CPSA Member Services is available to provide information and referrals for assistance. Contact Member Services toll free: (800) 771-9889 After the Directive forms have been completed there’s still a bit more work to be done…

  40. Completing the Advance Directive:3) After the Forms are Completed • Distribution / Registration / Review • • Things to Do After Completing the Advance Directive Forms • In this section are instructions for: • What to do with the Advance Directive forms after the Member completes them; • How the Member can cancel and/or revise their Advance Directive forms; • How to register the Advance Directive with in the Arizona Health Care Directives Registry.

  41. Completing the Advance Directive:3) After the Forms are Completed •Distribution• • The Member should give the Combined Health Care Power of Attorney with any Addendum and other applicable documents to their designated and alternate agents. • A copy of the directive should be given to any doctorwho is currently providing treatment to the Member, or will be in the future. • Additionally, request that each provider sign the Affidavit and put a copy in the Member’s file. • It is also suggested that family members receive copies of the Advance Directive. • Members may also provide copies to their personal or family attorney

  42. Completing the Advance Directive:3) After the Forms are Completed •Registration• The Member also may register their Combined Health Care Power of Attorney and Living Will directly with the Arizona Secretary of State’s Office by visiting the Secretary of State web page. To facilitate this registration, contact the Phoenix or Tucson office Monday through Friday, 8:00 am to 5:00 pm. Phoenix: (602) 542-4285 Tucson: (520) 628-6583 Members may complete their Directive registration in the State’s registry online, via the CPSA website (see next slide). Step by step directions are available to aid in the registration process.

  43. Completing the Advance Directive:3) After the Forms are Completed •Registration• Four Steps to Registering Your Advance Directive The Arizona Health Care Directives Registry is a secure “virtual file cabinet” where the Member can store their Advance Directive so that it will be easily accessible to them and the people they designate should it be needed in the future. This web page section contains the four steps for filing the Advance Directive in the Registry. It also has the Registry Application form which can be completed electronically or printed and filled out by hand.

  44. Completing the Advance Directive:3) After the Forms are Completed •PeriodicReview• It is important for the Member to regularly review the Combined Heath Care Power of Attorney, Addendum, and Living Will and any related documents. This will allow the Member to note when revisions are necessary, and to include new ideas in treatment as appropriate. In addition, as a Member’s circumstances and wishes change, they should prepare and execute a new Combined Power of Attorney which revokes any previous Power of Attorney documents in place. So, that’s Advance Directives! Let’s take a look back at what you’ve learned…

  45. Module Review

  46. Concept & Objective Review By now, you have read a great deal of information on Arizona’s Advance Directives, especially the Combined Health Care Power of Attorney. You have considered the topic as an individual who may execute an Advance Directive in addition to learning about your responsibilities to Members as a behavioral health care provider. Let’s review the training objectives… As you consider each objective, evaluate for yourself if there are topics you need to revisit with your supervisor.

  47. Concept & Objective Review (Continued…) The module objectives are: • Describe Arizona’s Combined Health Care Power of Attorney. • Explain the information that may be included in the forms making up the Advance Directive. • Determine the importance and function of the agent. • Understand the enforceability of the documents. • Know how to complete an Advance Directive. • Detail your responsibilities as you serve behavioral health recipients (Members).

  48. Additional Information… Listed is information specific to CPSA members as well as contact information and links to theArizona Secretary of State’s office and the Office of the Arizona Attorney General. CPSA Member ServicesInformation Specific to CPSA Members520-318-6946 (Tucson)  800-771-9889 (Toll Free) 866-318-6369 (TTY)Arizona Secretary of State's OfficeAdvance Directives Web Page520-628-6583 (Tucson) 602-542-4285 (Phoenix)Office of the Arizona Attorney GeneralAdvance Directives Web Page602-542-2123 (Phoenix) 800-352-8431 (Toll Free) This contact information is also listed on the CPSA Advance Directives web site under “Additional Advance Directive Resources”

  49. In Conclusion… This module is intended to provide a foundation of information on this important topic. You are not expected to be an ‘expert,’ but are expected to fulfill your obligation to the Members you serve and to understand the concept of Advance Directives. As you continue in your work with Members, you will likely learn more about Advance Directives. As questions and challenges arise, do not hesitate to consult with your supervisor. If you are confident in your understanding of the information included herein, please continue to the post test/final exam. If you are unsure of your knowledge, consider reviewing the presentation again.

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