Advance Care Planning

Advance Care Planning (ACP) is a process of conversation which provides information to assist with making your own medical decisions, sharing these decisions with your loved ones and care givers.

While most people do not like to think about it, a sudden event may occur where we are unable to make health care decisions for ourselves (for example, a sudden illness or accident). If this should happen…Who will speak for you? Who will know the decisions you would have chosen? Who will make sure decisions are made per your wishes?

It may be difficult to determine your treatment preferences, as these decisions may be different depending on the situation. The most important step is to take time to identify what is important when considering treatment options. Your values, goals, & beliefs should guide your decisions for treatment, including end-of-life care.

Once you’ve talked it over, create an Advance Directive – a document that spells out your healthcare wishes. Finding the right words to express your wishes can be difficult, so we encourage you to seek assistance from individuals trained to assist in this process. Covenant provides free assistance in completing Advance Directives.

“Advance Directives” are legal documents that include treatment preferences and designation of a Patient Advocate (person selected to make health care decisions for another person) if that person should become unable to make decisions on their own behalf. There are two types of Advance Directives:

• Durable (or Medical) Power of Attorney for HealthCare (DPOA-HC): Allows you to choose a “Patient Advocate” and your instructions regarding medical decisions; This is the document recognized by Michigan Legislation.
• Living Will: Includes instructions regarding medical decisions, but does not always provide a Patient Advocate; Not legally recognized in the state of Michigan.

*It is important to understand:

• A DPOA-HC gives your Patient Advocate the right to make only health care decisions, not financial or estate decisions.
• An Advance Directive can only be used in situations when you are unable to make your own decisions.

Everyone over 18 is encouraged to start advance care planning. You can make changes to your document(s) at any time.

While most adults have the capacity to make their own decisions most of the time, there may be situations in which your ability to make decisions is questioned. These situations may be temporary and only last for a short period - for example, someone with an illness such as severe dehydration, sepsis or intoxication with alcohol; or more long-term – such as someone experiencing a severe brain injury. When these types of situations occur and there is a question of whether you have the ability to make your own decisions, the state of Michigan requires an evaluation by two physicians or one physician and a licensed psychologist to determine if you cannot make your own decisions before your Patient Advocate has the right to make decisions for you.

Everyone 18 and older should complete a DPOA-HC, as it cannot be predicted when a serious illness or injury may occur. Therefore, it is best to be prepared. In certain situations, if you do not choose a Patient Advocate it may be difficult for your health care team to know who should be making decisions on your behalf. If you do not share your wishes for health care treatment, it can be very difficult for your loved ones to try to guess what you would want.

Think of an Advance Directive as a way of making sure you have a say in your treatment, even when you may not be able to communicate and as a gift for your loved ones to help them make decisions they know you would have wanted.

“Patient Advocate” is the term used in Michigan for the person(s) you have chosen to designate to make decisions for you. Your patient advocate may be a spouse, or relative, but is not required to be related. For some people, a friend, partner, clergy or co-worker might be the right choice. The legal requirements for a Patient Advocate include: 1) at least 18 years of age; and 2) be of sound mind.

This person should be:

• Someone you trust
• Understands your wishes for treatment and is willing to honor your wishes even if they disagree with them
• Feels comfortable making healthcare decisions for you, no matter how difficult the situation
• Can be easily available if needed

Most state laws do not allow your physician or any professional caregiver to be a Patient Advocate.

It is recommended to select one or two alternative person(s) to act as a Patient Advocate if the first person appointed is not available or unable to make choices.

When the Patient Advocate selected is not a close family member, it is important to inform family members who would still be included at the bedside.

The DPOA-HC requires the following signatures:

• Patient
• Two witnesses
• Patient Advocate(s)

The document does NOT require the signature of an attorney or a notarized signature.

Often people feel the need to make decisions based on a “yes” or “no” for a particular treatment (For example, “I do not want to be on a ventilator.”). This may be the desired wish if the outcome would require an individual to remain on a vent for the rest of their life. However, if this same person came down with an infection that may require being on a ventilator temporarily this would be acceptable. As every possible scenario cannot be predicted, it is better to base decisions for treatment on the degree of quality of life that may be offered by treatment, rather than just making a "yes" or "no" option for a particular treatment.

The first step toward deciding on your health care is to think about what is important to you to enjoy life. Your beliefs about pain, independence or being cared for at home or in the hospital are a few questions to consider.

The following questionnaire may help you to better understand your thoughts on quality of life when considering treatment options: Advance Care Planning Questionnaire

The overall outcomes (quality of life) for each of the treatment options below are dependent on the severity of underlying illnesses or injury an individual is experiencing. If you have a chronic illness, you should discuss with your doctor the severity of your illness and the course of the particular illness. Before deciding, be sure to learn about the risks and benefits of each treatment option.

This information will be useful when selecting a treatment.

The most common decisions your Patient Advocate may need to make for you involve:

• An order to Do Not Attempt Resuscitate (DNAR), also known as Do Not Resuscitate (DNR) - Allows aggressive treatment to continue, while limiting the use of life-sustaining treatment if the heart or breathing would stop, such as: Cardiopulmonary Resuscitation (CPR), Intubation for use of a Ventilator (breathing machine), and Defibrillation (electric shock to the chest).
• An order to Allow Natural Death (AND) or Comfort Measures Only - Allows care to focus on comfort only and limits emergency life-sustaining treatment and aggressive treatment if your heart or breathing would stop.
• Tube Feeding - Involves a tube put into the stomach to provide food and water to someone who may not be able to swallow. Tube feeding works best if you are healthy or need feeding for a short time. When someone with a serious illness is no longer able to eat naturally, it usually means the body is shutting down and therefore does not require the same amount of fluid and nutrition. Side effects of offering tube feeding include:
• Food and fluids entering the lungs and causing an infection
• When the body is not working well, it does not use food and fluids the same. Therefore, fluids may build up in the body. This fluid buildup can occur in the lungs, stomach, legs, hands and other places leading to discomfort.
• Risk of pulling out feeding tube
• Potential to have hands tied down to avoid accidentally removing feeding tube
• Dialysis - Uses machines to remove toxins and fluids from the body when the kidneys are no longer functioning.
• Organ & Tissue Donation - If your wishes are to donate organ and tissue, be sure your Patient Advocate is aware of your wishes.