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National Healthcare Decisions Day 2008: The Law, the Talk and the Care. Ira Byock, MD, Dartmouth-Hitchcock Medical Center Betsy Clark, PhD, ACSW, MPH, National Association of Social Workers (NASW) Bill Colby, Esq, Center for Practical Bioethics Moderated by: Nathan Kottkamp, Esq.
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Ira Byock, MD, Dartmouth-Hitchcock Medical Center
Betsy Clark, PhD, ACSW, MPH, National Association of Social Workers (NASW)
Bill Colby, Esq, Center for Practical Bioethics
Moderated by: Nathan Kottkamp, Esq
Bill Colby, J.D.
Senior Fellow, Law and Patient Rights Center for Practical Bioethics
Durable Power of Attorney for Healthcare Decisions
I, _________________________, SS#_____________________, appoint the person(s) named below as my agent to make healthcare decisions for me when I cannot communicate what I want done. I want my agent to have the broadest power possible to make all healthcare decisions for me. If federal law provides broader power than state law, then I choose that federal law apply. I want my agent to have the power to make any decision she chooses, just as if I was making the decisions myself.
My agent’s power certainly includes the power to accept or reject any medical treatments, including artificial nutrition and hydration. This broad power, in fact, extends to all areas – like reviewing records, or moving me home, to a nursing home, to a hospice house, or wherever she chooses. My agent can enter a DNR or Do-Not-Transfer or any similar kind of order for me, decide about organ donation, autopsy – all decisions.
I intend this document as evidence beyond a reasonable doubt of my wishes: I have only one wish – that my agent is allowed to make any and all decisions for me. It does not matter if the medical team agrees with her. It does not matter if that team believes that she is making a decision that, in their view, is not in my best interest or not in accord with what someone believes is my previously-expressed view. I care only about her view. She gets to decide, period. Lastly, I prefer that no one seek to appoint a legal guardian for me for any reason. If such a proceeding somehow happens, I request that my agent be appointed my legal guardian.
Agent’s Name______________________________ Phone________________________
First Alternate Agent Second Alternate Agent
Name_______________________ Name________________________ Address_____________________ Address______________________ Phone_______________________ Phone_______________________
Witness#1________________________ Date_____ (Witness should not be related or
Witness#2________________________ Date_____ financially connected to you).
Notarization On this ___ day of __________, in the year of ____, personally appeared before me the person signing, known by me to be the person who completed this document and acknowledged it as his/her free act and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County of ___________, State of __________.
Notary Public______________________________ Commission expires___________
About Advance Care Decision Planning
Betsy Clark, Ph.D., ACSW, M.P.H.Betsy Clark, Ph.D., ACSW, M.P.H,
Executive Director of
National Association of Social Workers
“A person's dying is a unique, fluid process, a time of loss and transition, a loss to be worked through, an experience to be shared, not a symptom to be fixed or cured.”
Best Practice Series / Innovative Practice in Social Work: Care at the End of Life, (SSWLHC, 2001).
The process by which people and systems respond respectfully and effectively to others of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner which recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves their dignity.
Adapted from the NASW Standards of Cultural Competency
Hope is often misunderstood by many professionals and a portion of the confusion is that people hope differently.
While individuals have different ways of hoping, families also have well-established patterns of hoping.
For many clients and families dealing with ACP, the concept of hope is an important aspect to have and hold on to.
Hope is a way of thinking, feeling and acting.
Hope includes the desirability of personal survival and the ability of the individual to exert a degree of influence on the surrounding world and on one’s own world.
Professionals need to recognize its importance in coping with ACP and decision making.
Professional grief usually takes the form of hidden grief -- grief that is internalized and not openly expressed.
There is no natural outlet for it, and the demands of work overshadow it.
This lack of expression may result in cumulative grief, or what sometimes is referred to as bereavement overload.
This can further lead to a legacy of vulnerability, burnout, or post-traumatic stress reaction.
Hiding grief is not new to professionals.
There has always been an expectation that professionals who work in high loss settings get used to dying and death.
In fact, familiarity with death does not make it easier to accept loss or to manage professional grief more effectively.
When Healthcare Providers Assess or Communicate with Individuals and Families involved in Advance Care Decision Planning, it is important to consider:
Turning Obligations into Clinical Opportunities
Ira R. Byock, MD
Director of Palliative Care
Recently dx’d glioblastoma
Underwent craniotomy this admission
VF cardiac arrest 4 days post-op
Unresponsive; intermittently agitated
Medical Record: No Advance Directive on file
No pre-op discussion of CPR preferences
s/p AAA repair ~3 month prior
ESRD on HD
s/p recent STEMI
Moderate dementia - longstanding
Full CPR status
3 sons in conflict
St. Paul Pioneer Press Dying Well: The miracle of death, Spring 2000
…and what they are not
Deidre Scherer collection
and what they are not
but illness happens to a family.”
“Either this is the wrong chart or – let’s just hope this is the wrong chart.”
Facilitating Advance Care Planning & Advance Directives
If you became seriously ill or injured and could not speak for yourself, do you know what healthcare treatments you would or would not want?
Do other people know what your wishes are?
When They Are Needed Decision making in Serious Illness
Bastienne Schmidt & Philippe Cheng
…and what they are not
Patient had explicitly refused it in the AD
“Such treatment would have the unintended consequence of hastening death or causing irreparable harm…”New Hampshire Advance Directive Law
3 Note Templates
What do you believe are the two or three best strategies to engage the American public and increase the number of advance directives, particularly the appointment of more POAs?
NASW Professional Resources on Advance Directives and Planning
NASW Consumer Resources
www.HelpStartsHere.org--NASW's consumer website with information and articles written by social workers to assist consumers in understanding and obtain help on a number of topics including advance care planning.
This site includes a consumer web course on Understanding End of Life Care, which is available at no charge at http://www.helpstartshere.org/health_and_wellness/death_and_dying/resources/understanding_end_of_life_care_course.html
This site includes important links to resources such as Aging with Dignity which provides access to a document called, The Five Wishes, which is recognized in many states as an advance directive.
I encourage each of my patients/clients to help me and others protect their wishes for future medical care. It does not take long and it is free. This is something I have done for myself and hope you will, too.
An advance directive is a legal document that tells us who you wish to make medical decisions for you, if you are ever not able to tell us what you want for yourself. It can also tell us what treatments you would want or not want at that time. I like to protect my patients’/clients’ wishes in that way, so I encourage them to complete an advance directive while they are here in the hospital/before a health crisis.
Is that something you would be willing to consider doing?
Today is National Healthcare Decisions Day and all Americans are encouraged to ensure that their future healthcare choices are known and protected. The process does not take long and it is free. This is something I have done for myself and hope you will, too.
An advance directive is a legal document that tells healthcare providers who it is that you wish to make medical decisions for you and what treatments you would want or not want, if you are ever not able to tell us what you want for yourself. Here’s a blank form.
National Healthcare Decisions Day exists to remind all people, regardless of age or current health of the importance of making these decisions known.
Please be sure to complete your advance directive today and also encourage all your loved ones to do the same.
I’m happy to answer any questions you have and for more information, please visit: nationalhealthcaredecisionsday.org