Advance Care Planning Facilitator Course · The quality of advance care planning discussions will be reflected in a document that ... Living wills are restrictive because they address

Respecting Choices®

Advance CarePlanning Facilitator

CourseChapter 3

Copyright 2007 Gundersen Lutheran Medical Foundation, Inc. Chapter 3.2

Chapter 3 Contents: Creating an Advance Directive: Communicating the Plan .............................................................................................................................3

Creating an Advance Directive: Options for Communicating Choices for Future Medical Care ..................................................................3 Competencies for Assisting with Completion of an Advance Directive.........................................................................................................7 Tools for Promoting and Assisting with Advance Care Planning: The Respecting Choices Example..........................................................9

Educational Options.................................................................................................................................................................................10 The Basic Information Card.....................................................................................................................................................................10 Video ........................................................................................................................................................................................................11 Advance Care Planning Informational Booklet.......................................................................................................................................11 Advance Care Planning Guide.................................................................................................................................................................12 Advance Care Planning Education Record..............................................................................................................................................12 Wallet Card ..............................................................................................................................................................................................12 Advance Care Planning Poster.................................................................................................................................................................12 Advance Care Planning Display ..............................................................................................................................................................13 Information Card for Healthcare Agents .................................................................................................................................................13

Exercises ..............................................................................................................................................................................................................14 Appendix I...........................................................................................................................................................................................................15

State Statute Information Regarding Advance Directives: Template ...........................................................................................................15 Appendix II .........................................................................................................................................................................................................18

State Statute Information Regarding Advance Directives: Wisconsin .........................................................................................................18 Appendix III........................................................................................................................................................................................................21

State Rulings Regarding End-of-Life Decisions: Wisconsin ........................................................................................................................21 Appendix IV........................................................................................................................................................................................................22

The La Crosse Power of Attorney for Healthcare Document .......................................................................................................................22 Further Reading .................................................................................................................................................................................................23


Chapter 3 Creating an Advance Directive: Communicating the Plan

The quality of advance care planning discussions will be reflected in a document that effectively communicates individual goals, values, and beliefs about future medical treatments and end-of-life preferences. Optimally, individuals, their healthcare agents, and other family members, as appropriate, have spent considerable time reflecting upon, and understanding their choices for future medical care and will present to you their ideas verbally or on an advance care planning worksheet or planning guide. Individuals may need assistance and/or recommendations for choosing the communication tool that best serves their needs. Once a tool is selected, an advance care planning facilitator must ensure the accuracy and completion of the document.

This chapter will discuss the options for creating an advance directive that accurately communicates an individual’s choices for future medical care and will explore the tools and materials for promoting and assisting with advance care planning. Advance directive documents, tools, and language vary widely across the world. As you read this chapter, it would be helpful for you to refer to the advance directive document and advance care planning materials recommended by your organization or in your community.

Creating an Advance Directive: Options for Communicating Choices for Future Medical Care

1. Directives or plans about future medical care communicated verbally to the physician, surrogate decision maker, other health professionals or family members.

2. Written directives

a. Formal (require signature, date, and witness or notarization)

(1) Specified in legal/regulatory guidelines, e.g., state statute/provincial law (a) Living Will (Instructive Directive)


(b) Power of Attorney for Healthcare (2) Meets all or most of the legal/regulatory requirements

(a) Medical Directives (b) Five Wishes (c) Other national and/or local forms

b. Informal

(1) A physician’s dictation that documents a conversation with a patient (2) Letter or note from an adult (3) Values history

It is important to recognize the various options for communicating choices for future medical care and to recommend the one that best meets the individual’s needs. In order to make recommendations, knowledge of the advantages and disadvantages of each type of communication plan will be explored.

Written documents offer several advantages over oral directives, but many types of written tools are available. Living Will is the term for the advance directive most widely recognized by the general public. When adults ask for help in completing a living will, they might be given a statutory or legal document that provides for the completion of only a narrow set of instructions. These documents often state that treatment may be stopped if the person is terminally ill or in a persistent vegetative state (PVS), conditions that are often very strictly defined by the law. While an adult may think of a condition described as terminal as any fatal condition, the law may define it as a condition that will cause death soon despite treatment. And although an adult may conceive of a vegetative state as being a broad set of conditions, including severe dementia, the law may define it narrowly as a condition of permanent unconscious with the brain stem intact.

The terminology and language are confusing, and many adults who complete a living will believe the document applies to a wider set of circumstances than it actually does. Living wills are restrictive because they address only a limited number of end-of-life treatment decisions. Decision makers must rely on limited instructions provided. Living wills give some information about what a person wants, but no information about who will make decisions or how decisions might be made. If respect of the individual is to be promoted, the individuals’ goals, values, and beliefs need to be carefully explored and expressed. If the statutory/legal document is too limited, then other documents or additional options must be considered.

The preferred advance directive document is one that designates a person who will make substitute decisions and specifies how and what decisions will be made (e.g., the Power of Attorney for Healthcare). This document allows for the designation of another person


(healthcare agent, healthcare proxy, representative) with authority to make a broad range of healthcare decisions when the principal becomes incapacitated. These documents have several advantages over a living will type of document. First, if adults have close, trusting relationships, they typically find it easy to choose a healthcare agent to make decisions for them. Second, these documents are more flexible that the living will, allowing a whole range of healthcare decisions, including how decisions will be made if a patient is incapacitated but may recover, that reflect an individual’s unique circumstances. Third, these documents are extremely important for those adults who have no close family, who live in alternate family structures, or who have dysfunctional family relationships. In these cases, appointing a healthcare agent(s) may be the only way to ensure that the person chosen to make decisions will have clear authority and may be given some sense of the process of decision making with other involved individuals.

In some cases, an adult does not want to create a Power of Attorney for Healthcare, or has no one to appoint to make healthcare decisions. For example, a woman who is the healthcare decision maker in her family recognizes that other family members would not be able to fill her role should she become incapacitated. In a situation such as this, an individual sometimes chooses to complete only an instructional document, such as a living will. By doing so, responsibility for making decisions is removed from family members who would have difficulty making such decisions.

Although it is important to become familiar with the legal/regulatory requirements in your community or organization, some general points can be made about advance directive documents that appoint a decision maker:

1. In a Power of Attorney for Healthcare–type of document, the person creating the document is often called the principal. The person appointed is called an agent, proxy, or representative. The legal requirements for signing, witnessing or notarizing, and dating need to be fully understood and followed. It is unfortunate when these basic legal points are not addressed and therefore interfere with decisions when the principal is incapacitated and important decisions must be made. Even when a legal document is not correctly completed, it should not be ignored or disregarded decision making. A technically invalid document, however, might open the door to doubt or question, which could make decisions more complex or impossible.

2. Often principals wish to appoint co-agents (proxies), rather than an agent and alternate agents because the principal does not want to show favor for one family member over others, or there is simply a preference for group decision making. Legal/regulatory guidelines may or may not address this request. In general, is not recommended to appoint co-agents because circumstances arise in which decisions must be made quickly and one of the co-agents may not be available. This may undermine the usefulness of the


document. A principal’s concerns for inclusive decision making can generally be addressed by speaking with alternate agents and other loved ones. Many times, candidates are relieved not to be selected and are willing to participate in discussions and listen to their loves ones goals, values, and beliefs. The following type of instruction in the Power of Attorney for Healthcare document may satisfy the need to maintain an inclusive approach to healthcare decision making: “I have appointed my son X as my agent and my daughter Y as my alternate agent. When time and circumstance permits, I ask that they discuss decisions with each other and their other siblings.”

3. Advance care planning is a dynamic process, and advance directive documents often need to be amended for many reasons. Individual goals, values, beliefs and preferences may change with age or health condition. Appointed healthcare agents may die, divorce, become incapacitated, or become estranged. Changing or amending an earlier document requires as much attention to legal detail as when the document was first created. Changes or additions to instructions require either an addendum that is signed, dated, and witnessed in accordance with legal/regulatory requirements or the creation of a new document. The new preferences of the principal should be clear to the physician and healthcare agent. When a new document is created, all copies of the outdated document should be found and destroyed. When an addendum is created, it should be filed at the front of the original so this new information is not overlooked.

Some individuals may feel that the advance directive document recommended by their organization or community does not meet their needs. They may prefer an alternate document because it is more personal, more understandable, or less intimidating. While considered legal documents, in some jurisdictions these informal documents may not provide legal or regulatory protection for physicians who act according to the individual’s stated wishes. Examples of formal documents include the Medical Directive, Five Wishes, and My Voice. Informal documents include Values Histories and Instructional letters. While these documents can be used as communication plans, they may also be used to explore the goals, values, and beliefs of the individual and used as addenda to the legal/regulatory document.

The Power of Attorney for Healthcare document widely used in the La Crosse community and in other regions in Wisconsin was developed to meet statutory requirements as well as to help individuals document goals, values, and beliefs for future medical care. Advance care planning facilitators find this document helpful in guiding discussions and in helping individuals clarify their preferences. Please review the La Crosse Power of Attorney for Healthcare document in appendix IV.


Competencies for Assisting with Completion of an Advance Directive

Note: These are guidelines only. Refer to the legal/regulatory requirements for your organization/community for more specific guidance on the accurate and thorough completion of an advance directive document. In appendix I and appendix II of this chapter, Respecting Choices has provided a template (i.e., state statute information regarding advance directives) for use in developing your own specific guidelines, as well as a sample from the State of Wisconsin.

1. Determine that the person has the capacity to participate in advance care planning and to create an advance directive. If there is any doubt, assess the individual’s decision-making capacity or make a referral to an appropriate health professional.

2. Assess the individual’s understanding of the purpose of creating an advance directive and of the tool selected for documentation of healthcare preferences.

3. Obtain basic information, including

a. state of residence.

b. general health, medical condition.

c. family members who are closely involved.

4. Assist with evaluation of the appropriateness of the healthcare agent chosen by the individual (if completing a Power of Attorney for Healthcare–type of advance directive). Ask the following:

a. Is the selected person(s) willing to accept the responsibility?

b. Is the person able to make difficult decisions under stress?

c. Does the person know the individual’s (principal’s) goals, values, and beliefs?

d. Will the person be able to make decisions in accordance with these goals, values, and beliefs?

e. Does the individual (principal) have confidence in the healthcare agent’s ability to make decisions in stressful situations?

5. Make arrangements to involve the chosen healthcare agent(s) if the answers to the questions in item 4 above suggest a need to do so.


6. Record the healthcare agent’s (s’) evening, daytime, and mobile/cellular telephone numbers.

7. Record the chosen end-of-life preferences as identified in the advance care planning discussions, using the following suggestions:

a. Record the patient’s statements about each scenario discussed. If the person has serious, underlying medical problems and does not want, at any time, a specific medical treatment, clearly document specific preferences that are consistent with the patient’s expressed views (e.g., “Do Not Resuscitate,” “Do Not Intubate,” “Do Not Use Antibiotics,” “Do Not Hospitalize”).

b. Comply with legal/regulatory guidelines regarding completion of specific questions and the need for initials on the document.

8. Date, sign, and witness or notarize the document according to legal/regulatory requirements.

9. Provide copies and recommend that they be distributed to the patient, healthcare agent(s), and others as desired (e.g., family members, attorneys).

10. Enter the document into the medical record or other storage retrieval system per protocol. Typically, it is best if the document is provided to the hospital where the person would be taken first in the event of a medical emergency. Review the following:

a. Is it from the person who signed it?

b. Is it a legal document correctly signed, dated, and witnessed?

c. If it gives instructions, are they reasonably clear and able to be followed?

d. Is there any reason to believe that the principal was non-decisional or was coerced into completing the document.

11. If the document was completed without the involvement of the individual’s physician and/or healthcare agent, recommend that the individual schedule an appointment to review the content of the document with the physician and healthcare agent or ask permission to send a copy directly to the physician. Offer to meet jointly with the physician and/or healthcare agent.

12. Provide wallet cards that indicate where the advance directive document can be located (e.g., hospital) and the date the document was signed.


13. Discourage completion of the document in one advance care planning session. Encourage patients to take information home and discuss their preferences with all involved parties. Schedule a follow-up session to review the document and make any necessary revisions.

Tools for Promoting and Assisting with Advance Care Planning: The Respecting Choices Example

A variety of tools are available to assist adults in assessing goals, values, and beliefs, providing specific information and adequate understanding that will eventually lead to the creation of an advance directive document. It is useful to reach agreement on the educational materials your organization/community will provide so they can become integrated at all levels of the healthcare continuum and become familiar to all health professionals, patients, and consumers.

A program to promote and assist with advance care planning needs to do more than provide information about rights and types of advance directive documents. Materials should be created with the conceptual framework underpinnings discussed in chapter 1 of this manual. Materials should help identify barriers to the planning process, actively engage the individual, use narrative and storytelling as a primary tool, and focus on advance care planning as an ethic of caring relationships. In addition, a quality advance care planning community engagement campaign needs to

1. be visibly present and expose adults to the idea of advance care planning on a regular basis.

2. be seen in a variety of settings to make it seem like an activity that every person should consider.

3. motivate individuals to move from not wanting to participate to being open to discussing and considering the issues.

4. assist individuals in concretely understanding the most important issues related to future healthcare decision making and to help them consider how they would want to be treated and cared for. Using short, compelling stories is one way to assist with understanding and reflection.

5. help persons who are interested in advance care planning discuss their goals, values, and beliefs with loved ones.

6. be flexible, so that a person who wants basic information is not provided an everything-you-wanted-to-know manual about advance care planning.


7. understand the limitation of materials in assisting with advance care planning. Many people will need personal assistance or motivation from trusted health professionals.

8. address the cultural diversity that exists within the community.

Educational Options

In developing materials to educate people about the importance of advance care planning, we recommend that the following options be considered:

1. written information (brochures, pamphlets) or videos on the following topics:

a. the importance of advance care planning for all adults

b. rights of individuals to make their own choices

c. descriptions of life-sustaining treatments—their benefits and burdens

d. stories that depict some of the most common situations where advance care planning is important

e. resources available in the community and healthcare organizations that can assist in advance care planning

2. informational posters and displays communicating the importance of advance care planning

3. samples of the program’s advance directive documents

4. advance care planning worksheets that can be used by patients, healthcare agents, and families to explore goals, values, and beliefs and begin to process the information they are receiving into treatment decisions.

To illustrate how the La Crosse community organized its approach to consistent and reliable consumer and patient education, a brief description of the Making Choices® materials follows. More detailed information about these materials is available at www.respectingchoices.org.

The Basic Information Card

The information card assists healthcare providers in offering reliable and consistent information about an individual’s right to advance care planning and briefly describes the different types of advance directives. It addresses the use of an advance directive in an emergency situation and also reassures individuals that having an advance directive is optional. It directs individuals to appropriate sources for more information.


This information card can be used in many different settings. It may be used to meet the requirement in the Patient Self-Determination Act (PDSA) to provide adult patients with information upon inpatient admission or enrollment. The card can also be used in the outpatient setting when an individual requires basic information about advance care planning.

Video

The video emphasizes how individuals’ goals, values, and beliefs influence their healthcare decisions. It encourages people to accept the responsibility to reflect and to discuss medical treatments they may or may not want.

The video demonstrates the need for advance care planning through real-life examples of patients and families involved in healthcare choices, and their feelings regarding these situations. It is an effective tool that provides an in-depth look at the process people must engage in to complete an advance directive document by focusing on the importance of conversations rather than completing the document.

The video can be used in individual advance care planning facilitation or as a part of a group educational presentation when a resource person would be available to answer specific questions. Before showing the video, it is important to warn viewers of its frank and emotional impact. Many viewers may have already had experiences with end-of-life decisions or may be facing serious illness themselves. The professional using the video needs to be prepared to deal with the emotional reactions that occur. For viewers who have faced or will be facing serious illness, it may be best to show the video in a private setting with carefully chosen family members or other loved ones.

It is always important to determine if showing the video is necessary. Many people are already motivated to consider end-of-life issues and do not need to view the video, or they may learn more readily by face-to-face discussion.

Advance Care Planning Informational Booklet

The booklet expands on the information provided on the information card and video. It emphasizes individuals’ rights to make healthcare choices, defines advance care planning, and describes types of advance directives in greater detail, answering commonly asked questions. It provides several stories about when advance care planning was useful and includes a glossary of terms with a resource list for more information.

The booklet is intended to stimulate reflection and encourage people to talk with their families and their healthcare providers about their treatment preferences. Again, it does not tell an individual how to complete a specific advance directive document. The booklet can be used in individual advance care planning facilitation or may be provided to individuals or families who request more detailed information about advance care planning. It should also


be used when facilitation time is limited and the person would prefer to take something home to read.

Advance Care Planning Guide

The advance care planning guide helps individuals reflect upon and discuss their personal goals, values, and beliefs through a series of questions. Individuals are encouraged to look back at life experiences and then deal with present feelings, ranging from fear to joy. They are also encouraged to communicate their feelings as they relate to their future healthcare. The advance care planning guide begins to define basic treatment choices and encourages individuals to seek more information about them. This process facilitates the identification of some preliminary values and preferences about end-of-life decisions.

The planning guide can be used along with the informational booklet and video as the initial step in the advance care planning process. Your organization may choose to use additional patient educational materials.

Advance Care Planning Education Record

The education record serves as a communication tool among healthcare providers. It documents existing written advance directives by type, records the date documents were filed, and identifies the professional who entered them into the medical record. It records the informational materials given and provides space for discussion of advance care planning issues and comments.

The education record is to be kept in a designated part of the medical record. It can be copied and shared among healthcare institutions as appropriate.

Wallet Card

A wallet card serves as a communication tool to alert others that an individual has exercised his or her right to have a written advance directive. The wallet card documents when the advance directive was initiated, what type it is, and with which healthcare institution it is filed. It does not indicate specific information about the individual’s preferences. The wallet card reminds individuals that they have initiated an advance directive and that they may need or want to update it.

This card should alleviate concerns some people express about how they can alert healthcare professionals to the fact that they have executed an advance directive if something should happen when they are traveling.

Advance Care Planning Poster

The Making Choices poster is a simple way to remind both patients and providers about the importance of end-of-life treatment planning and advance directives. In the outpatient setting,


this poster can be used in examination rooms and in public places in a health facility (e.g., the admissions office). It provides a simple, gentle way to constantly remind everyone that advance care planning discussions are important.

Advance Care Planning Display

This attractive 32” x 40” display can be hung on a wall or set on an easel in lobby areas, waiting rooms, or at the local library or mall. It brings attention to advance care planning in a very subtle and respectful way. Making Choices materials can be placed in the brochure folders attached to the display to provide additional information and to direct people to the proper resources.

Information Card for Healthcare Agents

The information card helps healthcare agents understand what it means to be an agent and what types of decisions they may be asked to make. The information is enclosed in an attractive Hallmark card that can be sent to individuals as an invitation to accept appointment as healthcare agent. It suggests action agents can take to prepare for their important role and is intended to engage them in dialogue. The importance of understanding the preferences of the individuals who selected them to serve as healthcare agents is also stressed.


Chapter 3: Exercises

1. Identify three options for communicating an individual’s end-of-life treatment plan.

2. Describe the advantages of the durable Power of Attorney for Healthcare–type of advance directive over the Living Will–type for documenting decisions for future healthcare.

3. Complete one of the advance care planning worksheets. What feelings emerged? What questions did you have?

4. Describe the types of educational materials that would be useful in assisting with advance care planning.


Appendix I

State Statute Information Regarding Advance Directives: Template

Complete this template by reviewing your state statute or local regulations. Use the Wisconsin example (appendix II) as a guide.

State: ______________________________________

I. Terminology

A. Name of the Power of Attorney for Healthcare (POAHC) document and the relevant state statute chapter number ____________________________________________________________________

1. Define the term POAHC. _______________________________________

2. Add any specific qualifications.

3.

4.

B. Name of the Living Will statute, if one exists ____________________________________________________________________ ____________________________________________________________________

1. The term for the Living Will _____________________________________

a. Define the term Living Will. __________________________________________________________

b. List qualifications.

(1)

(2)

2. Name of the prehospital Do Not Resuscitate statute (if one exists) ______________________________________________________________

List main qualifications. a.

b.

c.

II. Completing the Power of Attorney for Healthcare document


A. Designating a substitute decision maker (make changes as needed)

1. This person is called a ________________________.

2. Must be ______ years old

3. Can or cannot be one of the individual’s healthcare providers, unless he or she is a close relative

4. Alternate agents can/cannot be designated.

5. The name(s) of the agent(s), day and evening telephone number(s), and address(es) are required.

B. Authority of substitute decision maker _______________________(name)

1. General authority

Eliminate or revise the following:

a. make choices about starting or stopping medical care

b. interpret instructions given in document

c. review and release medical records and personal files

d. move principal to another state if needed

e. determine by whom and where medical care will be provided

2. Specific authority

Identify those actions, if any, for which specific authority must be granted in order for an agent to take them. Eliminate or revise the following:

a. admit the individual to a nursing home or community-based residential facility for long-term care

b. order the withholding or withdrawing of feeding tube or IV hydration

c. make decisions if the individual is pregnant

C. Additional statements of preferences

Identify how additional statements of preferences can be written.

1.

2.

3.

D. Requirements for dating, signing, and witnessing

1. Must be signed and dated ____________________________________


2. Witnesses must be (list qualifications)

a.

b.

c.

d.

3. Witnesses must provide their signatures, print their names, provide complete addresses, and indicate date witnessed.

E. Making changes to the document


Appendix II

State Statute Information Regarding Advance Directives: Wisconsin

I. Terminology

A. The Power of Attorney for Healthcare (Chapter 155)

1. Designates an agent to make decisions when the person is declared incapable of decision making by two physicians (or a physician and a psychologist).

2. Agents may be given decision-making authority for nursing home placement and tube feeding.

3. Agents may not be given decision-making authority for admission to a mental facility.

4. This directive supersedes other directives.

B. The Natural Death Act (Chapter 154)

1. Declaration to Physicians (Living Will)

a. Allows an adult to identify when treatment should be discontinued if a terminal condition or persistent vegetative state exists.

b. These conditions must be determined by two physicians.

2. Prehospital do-not-resuscitate bracelet

a. Allows a qualified* adult to obtain from the physician a wrist bracelet instructing emergency personnel not to provide resuscitation and to provide comfort care.

b. The bracelet is designed by the Department of Health and Human Services to be of a uniform size, color, and description.

*A qualified adult is one who has a terminal condition or an adult for whom resuscitation would not likely be effective or for whom resuscitation may cause significant harm.

II. Completing the Power of Attorney for Healthcare document

A. Designating a substitute decision maker

1. called a healthcare agent

2. must be 18 years old


3. cannot be one of the individual’s healthcare providers, unless he or she is a close relative.

4. can designate alternate agents

5. name(s) of the agent(s), day and evening telephone number(s), and addresses are required

B. Authority of healthcare agent

1. General authority

a. make choices about starting or stopping medical care

b. interpret instructions given in document

c. review and release medical records and personal files

d. move principal to another state if needed for medical treatment

e. determine by whom and where medical care will be provided

2. Specific authority

Specific authority must be granted in order for an agent to take any of the following actions:

a. admit the individual to a nursing home or community-based residential facility for long-term care

b. order the withholding or withdrawing of feeding tube or IV hydration

c. make decisions if the individual is pregnant

C. Additional statements of preferences

1. Written instructions may be provided regarding medical care, including instructions for cardiopulmonary resuscitation (CPR), when to stop life-sustaining interventions, pain and symptom control, preferences during and after death, etc.

2. donation of organs or tissue

3. autopsy preferences

D. Requirements for dating, signing, and witnessing

1. Must be signed and dated in the presence of two witnesses.

2. Witnesses must be

a. at least 18 years old

b. not a healthcare agent appointed by the person

c. not related to the person signing the document by blood, marriage, or adoption


d. not a healthcare provider directly caring for the person at the time

e. not an employee (other than a social worker or chaplain)

f. not aware of entitlements against the person’s estate

3. Witnesses must provide their signatures, print their names, provide complete addresses, and indicate date witnessed.


Appendix III

State Rulings Regarding End-of-Life Decisions: Wisconsin

Advance care planning facilitators will also need to become familiar with case law that may influence healthcare decision making. As an example, Wisconsin has two important state rulings that may impact the assistance and recommendations provided by a facilitator. You will need to investigate the existence of such precedents in your own geographic area. This understanding assists with clarification of questions and misunderstandings, and may guide the development of organizational policies and procedures.

In the Matter of Guardianship of L.W.

The Wisconsin Supreme Court ruled that all patients, whether competent or not, have a constitutionally protected right to refuse unwanted life-sustaining medical treatment, including artificial nutrition and hydration. This constitutionally protected right is equally applicable to patients who are diagnosed to be in a persistent vegetative state. A legal guardian for a patient in a persistent vegetative state may direct the withholding or withdrawal of life-sustaining treatment if the guardian determines that doing so is in the best interests of the patient. The guardian may direct the withholding or withdrawal of such treatment from a patient without prior court approval, although the guardian’s decision is subject to review by a court upon request of family members and other interested persons.

In the Matter of Guardianship of Edna M.F.

The Wisconsin Supreme Court ruled that unless a patient is in a persistent vegetative state, it is not in the patient’s best interests to withhold or withdraw life-sustaining treatment unless the patient expressed a preference not to receive such treatment under those circumstances. Further, guardians may not substitute their own judgment of quality of life for that of such patients, nor may they speculate about the choices a patient might have made.


Appendix IV

The La Crosse Power of Attorney for Healthcare Document

There are many types of power of attorney for healthcare documents. The La Crosse Advance Directive Task Force developed the following document through the course of many revisions and by listening to the needs of individuals and advance care planning facilitators. It is provided for your review as one example of a document that can assist in facilitating the creation of written plans.

How to Complete ThisPower of Attorney for Healthcare

OverviewThe attached power of attorney for healthcare form is a legal document, developed to meet the legalrequirements for Wisconsin Minnesota, and Iowa. This document provides a way for a person tocreate a power of attorney for healthcare that will meet the basic requirements for these states.

This power of attorney for healthcare form allows you to appoint another person and alternatepersons to make your own healthcare decisions if you become unable to make these decisionsfor yourself. The person you appoint is your healthcare agent. This document gives your health-care agent authority to make your decisions only when you have been determined incapable byyour physicians to make your own healthcare decisions. It does not give your healthcare agentany authority to make your financial or other business decisions. In addition, it does not giveyour healthcare agent authority to make certain decisions about your mental health treatment.

Before completing this power of attorney for healthcare form, take time to read it carefully. It isalso very important that you discuss your views, values, and this document with yourhealthcare agent. If you do not closely involve your healthcare agent and you do not make aclear plan together, your views and values may not be fully respected because they will not beunderstood.

If you want to document your views about future healthcare, but do not want to or cannot usethis power of attorney for healthcare form, ask your health organization or attorney for adviceabout alternatives.

How to Complete This DocumentThis power of attorney for healthcare form is divided into four parts.

Part I – Appointing a Healthcare Agent

Part II – Authority of the Healthcare Agent

Part III – Statement of Desires, Special Provisions or Limitations

Part IV – Making the Document Legal

Steps to Follow:In each of the four parts of the attached document you will find instructions. Read andfollow these instructions carefully. The basic things you must do are:

1. Provide the information on page 1.2. Appoint at least one healthcare agent on page 3.3. Indicate choices for sections 1, 2, and 3 on page 5.4. Indicate any written instructions you want in Part III.5. Sign and date the document on page 10.6. Have the document witnessed. Both witnesses must be present when you sign

this document.

How to Complete This Power of Attorney for Healthcare - 3/05

If you wish to donate your body after death to medical science, you should contact theclosest medical school in your state and make arrangements through that medicalschool. Here are some places to contact.

University of Wisconsin-Madison Medical School (608) 262-2888Mayo Medical School 7 a.m.-4 p.m. (507) 284-2201

or (507) 284-2511University of Iowa Medical School (319) 335-7762

After Completing This Document

After you complete the document, make copies to be given out as follows:

• One copy for yourself.

• One copy for the healthcare agent and alternates appointed in the document.

• One copy to share and discuss with your physician.

• One copy for your record at the hospital where you would go in an emergency.

• Extra copies to share with others if you wish (loved ones, your clergy, and yourattorney).

A photo or fax copy is as legally valid as an original.

Need Assistance?

If you need assistance in completing this document you may contact the following places:

Gundersen LutheranGundersen Lutheran Medical Center

• Pastoral Care(608) 782-7300, ext. 53620(800) 362-9567, ext. 53620

• Patient Service Representative(608) 782-7300, ext. 55993(800) 362-9567, ext. 55993

• Advance Care Planning Coordinator(608) 782-7300, ext. 56000(800) 362-9567, ext. 56000

Gundersen Lutheran, Onalaska Clinic

• Social Services (608) 775-8159(800) 362-9567, ext. 58159

Or call the Gundersen Lutheran Regional Clinic or affiliate in your community.

Franciscan Skemp HealthcareMayo Health System

La Crosse Medical Center(608) 791-9754(800) 362-5454, ext. 9754

Elder Services La Crosse(608) 791-9505(800) 362-5454, ext. 9505

Home Health Services/Hospice(608) 791-9790(800) 362-5454, ext. 9790

Or call the Franciscan Skemp Healthcare affiliate in your community. All Franciscan Skemp Healthcare service sites can be accessed through a toll-free number: (800) 362-5454.

How to Complete This Power of Attorney for Healthcare - 3/05

Power of Attorney for Healthcare

for

Name:________________________________________________

Date of Birth: ________________________________________

Address: ____________________________________________

Telephone: __________________________________________

Copies of this document are being or have been given to:

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

4. __________________________________________________________

5. __________________________________________________________

6. __________________________________________________________

7. __________________________________________________________

8. __________________________________________________________

9. __________________________________________________________

Power of Attorney for Healthcare Document - 3/05 1

Power of Attorney for Healthcare Document

Notice to the Person Making This Document:

You have the right to make decisions about your healthcare. No healthcare may be givento you over your objection, and necessary healthcare may not be stopped or withheld ifyou object.

Because your healthcare providers in some cases may not have had the opportunity toestablish a long-term relationship with you, they are often unfamiliar with your beliefsand values and the details of your family relationships. This poses a problem if you be-come physically or mentally unable to make decisions about your healthcare.

In order to avoid this problem, you may sign this legal document to specify a personwho you would want to make healthcare decisions for you if you become unable tomake those decisions personally. That person is known as your healthcare agent. Youshould take some time to discuss your thoughts and beliefs about medical treatment withthe person or persons you might specify. You may state in this document any types ofhealthcare that you do or do not desire, and you may limit the authority of your health-care agent. If your healthcare agent is unaware of your desires with respect to a particu-lar healthcare decision, he or she is required to determine what would be in your bestinterests in making the decision.

This is an important legal document. It gives your agent broad powers to make health-care decisions for you. It revokes any prior power of attorney for healthcare that youmay have made. If you wish to change your Power of Attorney for Healthcare, you mayrevoke this document at any time by destroying it, by directing another person to de-stroy it in your presence, by signing a written and dated statement, or by stating that itis revoked in the presence of two witnesses. If you revoke, you should notify your agent,your healthcare providers and any other person to whom you have given a copy. If youragent is your spouse and your marriage is annulled or you are divorced after signingthis document, the designation of your spouse as healthcare agent shall no longer bevalid.

You may also use this document to make or refuse to make any anatomical gift uponyour death. If you use this document to make or refuse to make an anatomical gift, thisdocument revokes any prior document of gift you may have made. You may revoke orchange any anatomical gift that you make in this document by crossing out the anatomi-cal gifts provision in this document.

Do not sign this document unless you clearly understand it.

It is suggested that you keep the original of this document on file with your physician.

2 How to Complete This Power of Attorney for Healthcare - 3/05

Part I – Appointing a Person to Make My HealthcareDecisions When I Can’t Make My Own Healthcare DecisionsIf I am no longer able to make my own healthcare decisions, this document names the person I choose to make these choices for me. This person will be my healthcare agent. This person willmake my healthcare decisions when I am determined to be incapable to make healthcare deci-sions as provided under state law.

Instructions for Completing This Part:When selecting someone to be your healthcare agent, pick someone who knows youwell, who you trust, who is willing to respect your views and values, and who is ableto make difficult decisions in stressful circumstances. Often family members are goodchoices, but not always. Make sure that you pick someone who will closely followwhat you want and will be a good advocate for you. Whatever you do, take time todiscuss this document and your views with the person(s) you pick to be your agent(s).

Your healthcare agent should be at least 18 years or older and should not be one of yourhealthcare providers or an employee of your healthcare provider unless they are a closerelative. Space has been provided for a second and third alternate healthcare agent.

The person I choose as my Healthcare Agent is:

Name: ______________________________________________________________

Day phone: ________________________ Evening phone: ______________________

Cell phone: ________________________

Address: ____________________________________________________________

City: ____________________________ State:__________ ZIP code: ____________

If this healthcare agent is unable or unwilling to make these choices for me, or if myspouse is designated as my healthcare agent and our marriage is annulled or we aredivorced or legally separated, then my next choice for a healthcare agent is:

Second choice (Alternate Agent)

Name: ______________________________________________________________


Cell phone: ________________________

Address: ____________________________________________________________


How to Complete This Power of Attorney for Healthcare - 3/05 3

If this alternate healthcare agent is unable or unwilling to make these choices for me,or if my spouse is designated as my healthcare agent and our marriage is annulled or we are divorced or legally separated, then my next choice for a healthcareagent is:

Third choice (alternate agent)

Name: ______________________________________________________________


Cell phone: ________________________

Address: ____________________________________________________________


Part II – General Authority of the Healthcare Agent

I want my healthcare agent to be able to do the following (Please cross out anything you do not want your healthcare agent to do that is listed below):

• To make choices for me about my medical care or services, like tests, medicine, andsurgery. If treatment has already been started, my healthcare agent can keep it going orhave it stopped depending upon my stated instructions or my best interests.

• To interpret any instruction I have given in this form or given in other discussions according to my healthcare agent’s understanding of my wishes and values.

• To review and release my medical records and personal files as needed for my medical care.

• To arrange for my medical care and treatment in Wisconsin, Minnesota and Iowa or anyother state, as my healthcare agent thinks appropriate.

• To determine which health professionals and organizations provide my medical treatment.


Instructions for Completing These Sections:

Put your initial on the line (eg. DJ ) to indicate you have selected a “yes”, “no” or

“not applicable” in the next three sections. Draw a line through the statements you donot select (eg. No, my healthcare… ). If you do not initial any line in a section andmake no clear choice, the statute in Wisconsin says your choice is considered to be“no.” This means if you do not indicate a choice, in Wisconsin only a court may makesuch a decision and not your healthcare agent.

1. Agent authority to admit me to a nursing home or community-based residential facility for the purpose of long-term care:

______ Yes, my healthcare agent has authority, if necessary, to admit me to a nursinghome or community-based residential facility for a long-term stay, subject toany limits I have set forth in this document.

______ No, my healthcare agent does not have authority to admit me to a Wisconsinnursing home or a community-based residential facility for a long-term stay. IfI initialed “no,” or leave this section blank, I cannot be admitted to a Wisconsinlong-term care facility without a court order.

2. Agent authority to order the withholding or withdrawal of feeding tube and IV hydration:

______ Yes, my healthcare agent has authority to have a feeding tube or IV hydrationwithheld or withdrawn from me subject to any limits I have set forth in this document.

______ No, my healthcare agent does not have authority to have a feeding tube or IVhydration withheld or withdrawn from me. If I initialed “no,” or leave this sec-tion blank, feeding tubes or IV hydration cannot be withheld or withdrawnfrom me in Wisconsin without a court order.

3. Agent authority to make decisions if I am pregnant:

______ Yes, my healthcare agent has authority to make decisions for me if I am pregnant, subject to any limits I have later set forth in this document.

______ No, my healthcare agent does not have authority to make decisions for me if I am pregnant. If I initialed “no,” or leave this section blank, healthcare deci-sions can not be made for me during my pregnancy without a court order.

______ Not applicable, because I am either a male or no longer capable of becoming pregnant.


Part III – Statement of Desires, Special Provisions, or Limitations

My healthcare agent shall make decisions consistent with my stated desires and values and issubject to any special instructions or limitations that I may list here. The following are some spe-cific instructions for my healthcare agent and/or physician providing my medical care. If there areconflicts among my known values and goals, I want my agent to make the decision that wouldbest represent my values and preferences. If I require treatment in a state that does not recognizethis Power of Attorney for Healthcare, or my healthcare agent cannot be contacted, I want theinstructions below to be followed based on my common law and constitutional right to direct myown healthcare.

Instructions for Completing This Part:

You are not required to provide any written instructions or make any selections in Part III.If you choose not to provide any instructions, your healthcare agent will make decisionsbased on your oral instructions or what is considered your best interest. If you choose notto provide any instructions, it is recommended that you draw a line and write “no instruc-tions” across the page.

Stopping Attempts of Life-Prolonging Treatments:

[Either put your initial (eg. DJ ) on the line next to each statement if you agree or draw a

line through the statement if you do not agree.]

______ If I reach a point where it is reasonably certain that I will not recover my abili-ty to interact meaningfully with myself, my family, friends, and environment, I want to stop or withhold all treatments that might be used to prolong myexistence. Treatments I would not want if I were to reach this point includebut are not limited to tube feedings, IV hydration, respirator/ventilator, CPR,and antibiotics.

Pain and Symptom Control:

[Either put your initial (eg. DJ ) on the line next to each statement if you agree or draw a

line through the statement if you do not agree.]

______ If I reach a point where efforts to prolong my life are stopped, I want medicaltreatments and nursing care that will make me comfortable.


Cardiopulmonary Resuscitation (CPR):

My CPR choice listed below may be reconsidered by my healthcare agent in light of myother instructions or new medical information, if I become incapable of making my owndecisions. If I do not want CPR attempted, my physician should be made aware of thischoice. If I indicate below that I do not want CPR attempted, this choice, in itself, will notstop emergency personnel from attempting CPR in an emergency. Other documents may beneeded to control the actions of emergency personnel.

(Initial one of the following statements and draw a line through the statements that you donot want.)

______ I want CPR attempted unless my physician determines any one of the following:

• I have an incurable illness or injury and am dying; OR• I have no reasonable chance of survival if my heart stops; OR• I have little chance of long-term survival if my heart stops and the process

of resuscitation would cause significant suffering.

______ I want CPR attempted if my heart stops.

______ I do not want CPR attempted if my heart stops, but rather, want to permit anatural death.

Other Instructions or Limitations I Want My Healthcare Agent to Follow:


If it is possible, when I am Nearing My Death and Cannot Speak, I Want My Friendsand Family to Know I have the Following Thoughts and Feelings:

If I am Nearing My Death, I Want the Following: (List the type of care, ceremonies,etc. that would make dying more meaningful for you.)


Persons I Want My Agent to Include in the Decision Process:

I ask that my healthcare agent make reasonable attempts to include the following persons

in my healthcare decisions if there is time: ______________________________________

____________________________________________________________________________.

Religion:

I am of the _________________________________ faith, and am a member of the_________________________________________________ congregation, synagogue, or worship group. Phone number of congregation, synagogue, or worship group (if known): _______________________________________________________________. Please attempt to notify them.

Upon My Death:

After my death the following are my instructions. If my healthcare agent does not have

authority to make these decisions, I ask that my next of kin and physician follow these

requests if possible.

Autopsy:

(Initial both the first and second choice, or just one choice, and draw a line through thestatements that you do not want.)

______ I would accept an autopsy if it can help my blood relativesunderstand the cause of my death or assist them with theirfuture healthcare decisions.

______ I would accept an autopsy if it can help the advancement ofmedicine or medical education.

______ I do not want an autopsy performed on me.

Donation of My Organs or Tissue:

(Initial one and draw a line through the statements that you do not want.)

______ I wish to donate only the following organs or parts if possible(name the specific organs or tissue):______________________________________________________.

______ I wish to donate any organs or tissue if I am a candidate.

______ I do not want to donate any organ or tissue.


Part IV – Making the Document LegalInstructions for Completing This Part:

Wisconsin residents must have this document signed and dated in the presence of twowitnesses. Minnesota or Iowa residents may have this document signed and dated inthe presence of two witnesses or a notary public.

I am thinking clearly; I agree with everything that is written in this documentand I have made this document willingly.

______________________________________________________ _____________My signature Date

If I cannot sign my name, I can ask someone to sign this document for me.

___________________________________________________ Signature of the person who I asked to sign this document for me

___________________________________________________ Print the name of the person who I asked to sign this document for me.

Statement of WitnessesI know this person to be the individual identified in the document. I believe him orher to be of sound mind and at least 18 years of age. I personally witnessed him orher sign this document, and I believe that he or she did so voluntarily

By signing this document as a witness, I certify that I am:• At least 18 years of age.• Not a healthcare agent appointed by the person signing this document.• Not related to the person signing this document by blood, marriage or adoption.• Not directly financially responsible for that’s person’s healthcare.• Not a healthcare provider directly serving the person at this time.• Not an employee (other than a social worker or chaplain) of a healthcare

provider directly serving the person at this time.• Not aware that I am entitled to or have a claim against the person’s estate.

Witness number 1:

______________________________________________________ _____________Signature Date

______________________________________________________ Print name

______________________________________________________ Address

Witness number 2:

______________________________________________________ _____________Signature Date

______________________________________________________ Print name

______________________________________________________ Address



Instructions for Notarization:

Residents of Iowa and Minnesota may have the document signed by a notary public authorized intheir state instead of having two witnesses.

Notary Public

In my presence on ________________________ (date) _____________________________ (name)acknowledged his or her signature on this document or acknowledged that he or she authorized theperson signing this document to sign on his or her behalf. I am not named as a healthcare agent oralternate healthcare agent in this document.

(Notary Stamp) _________________________________________________Signature of Notary


Chapter 3: Further Reading

Caring connections. www.caringinfo.org

Caring conversations workbook. www.midbio.org/mbc-ccorder.htm

Critical care choices guide. www.aacn.org

Detmar, S. B., Muller, M. J., Schornagel, J. H., Wever, L. D., & Aaronson, N. K. (2002). Health-related quality-of-life assessments and patient-physician communication: A randomized controlled trial. JAMA: The Journal of the American Medical Association, 288(23), 3027-3034.

Dunn, H. Hard choices for loving people: CPR, artificial feeding, comfort care and the patient with a life-threatening illness. www.hardchoices.com

Finding your way: A guide to medical decisions near the end-of-life. www.sachealthdecisions.org/finding.html

Fins, J. J., & Maltby, B. (2003). Fidelilty, wisdom and love: Patients and proxies in partnership. An interactive workbook on end-of-life decision making. www.fidelity-wisdomandlove.org

The Five Wishes advance directive document. www.agingwithdignity.org

The Go Wish game. www.codaalliance.org

Karel, M. J., Powell, J., & Cantor, M. D. (2004). Using a values discussion guide to facilitate communication in advance care planning. Patient Education & Counseling, 55(1), 22-31.

Lynn, J., & Harrold, J. Handbook for mortals: Guidance for people facing serious illness. www.abcd-caring.org

Making Choices patient education materials. www.respectingchoices.org

Shape your health care future with health care advance directives. www.abanet.org/aging

Wisconsin Hospital Association Power Of Attorney For Healthcare document. www.wha.org/legalandregulatory/endoflife.aspx

Documents

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