1	"Advance Directives" Advance Directives Choices Sister Jane Connolly, Director, Spiritual Care Ricky Stachura, RN, Director, Case Management/Social Work
2	Advance Directives Planning in advance the kinds of treatment you would like if you are in a terminal condition and you are not able to speak for yourself.
3	Two Kinds of Advance Directives Surrogate Decision Maker Living Will
4	Wish 1 Who will make medical decisions for me when I no longer can? Picking the right person… knows you well can make difficult decisions will advocate on your behalf to see that your wishes are followed will be available Those who are not eligible: the person who signed your document for you if you were unable to sign it yourself
5	What kinds of decisions will I empower my healthcare agent to make for me? ² choices about appropriate medical treatments interpret the instructions I’ve given in this document ² arrange for medical care in hospitals, nursing homes, etc. make decisions about life-sustaining treatments ² see and release of my medical records
6	"² move me to another..." ² move me to another state for care authorize/refuse medications or procedures for pain management take legal action to assure my wishes are carried out ² make decisions about organ donation apply for Medicare, Medicaid, etc. and have access to personal information needed to do that
7	Wish 2 What kinds of medical treatment do I want, or not want, if I have a terminal illness and am unable to speak for myself? Some basic things I want: I want to be free from pain, even if that means I may sleep more than usual; I do not want anything done or omitted with the intention of ending my life. I want to be offered food and fluids by mouth I want to be kept clean and warm.
8	What does “life-support treatment” mean? Life support treatment is any medical procedure, device or medication to keep me alive. breathing machine/ventilator feeding tube CPR major surgery blood transfusions kidney dialysis antibiotics anything else intended to keep me alive
9	"CPR" CPR Intubation (insertion of tubes) Endotracheal Feeding Ventillator
10	Cardiopulmonary Resuscitation CPR C Circulation (pulse, heart pumping) P Pulmonary (lungs, breathing) Cardiopulmonary Resuscitation is a technique of basic life support for the purpose of oxygenating the brain and heart until definitive medical management can restore normal heart and breathing action.
11	"A responsiveness check is done" A responsiveness check is done The airway is cleared The rescue team then begins “mouth-to- mouth” - breathing into the victim’s mouth. If no pulse is palpable, then external chest compressions are begun. Chest compressions are done by quickly, and with some force, depressing the lower half of the patient’s sternum (breast bone) in an attempt to restore circulation .
12	Definition Endotracheal Intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. The tube is inserted through the mouth into the trachea (the large airway from the mouth to the lungs).
13	What kind of tube is used? The tube that is used today is a flexible plastic tube, with a balloon that is inflated to keep the tube in place in the patient’s throat. The doctor inserts the tube with the help of a laryngoscope, an instrument that the doctor uses to see down the trachea.
14	Purpose of Endotracheal Intubation The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to inflate the lungs. Endotracheal tubes can be connected to ventilator machines to provide aeration and respiration (breathing).
15	Ventilator A ventilator is a machine that breathes for the patient when the patient is unable to breathe on their own or if assistance is needed to maintain oxygen levels required to sustain life. The breathing machine is connected to an endotracheal tube and forces air from the machine into the lungs and essentially breathes for the patient.
16	Ventilator A patient may be dependent on a ventilator temporarily or permanently. A temporary vent would be connected to the endotracheal tube. When the patient’s condition improves, he/she would be weaned from the ventilator when they were able to breathe on their own. If the patient cannot be weaned from the ventilator, a permanent tube called a tracheostomy tube would be inserted directly into the patient’s trachea and connected to a portable ventilator.
17	Tracheotomy A tracheotomy is a surgically created opening in the neck which allows direct access to the trachea (breathing tube). It is maintained open with a hollow tube called a tracheotomy tube.
18	Tracheostomy A tracheotomy may be temporary or permanent if the person’s respiratory system is paralyzed or if the patient will never be able to breathe on their own again. The tracheostomy becomes permanent and the patient is connected to a portable ventilator.
19	Feeding Tubes Feeding tubes are inserted to facilitate meeting the patient’s nutritional need when that patient is no longer able to take oral food or fluids. Feeding tubes may be inserted through the nasal passageway for short-term use (nasogastric tube), through the nose into the stomach, and intermittently liquid nutrition is inserted through the tube into the stomach. A nosogastric tube is always temporary. If the patient requires long-term nutritional support, then a permanent tube called a PEG tube would be surgically inserted.
20	PEG Tube For those patients who require longer use of the tube, it is customary to place the tube directly into the stomach through the abdominal wall. This method is called a PEG or percutaneous endoscopic gastrostomy tube. Feeding tubes are not painful and are not easily visible. The tube extends from the interior of the stomach to the outside of the body through a small incision in the abdomen.
21	PEG Tubes The PEG tube feedings may be administered by a pump or a drip mechanism to allow for controlled feedings. Too-rapid feedings may cause the patient discomfort. A bag containing the liquid nutrition is connected to the tube and allowed to infuse nutrients and water directly into the stomach. Problems and complications, such as infection, could develop if the feedings are not administered properly or the tube site is not cared for .
22	"Three scenarios in which my..." Three scenarios in which my Advance Directives would guide my medical treatment: ² Two physicians decide I am likely to die in a short period of time (terminal condition) and life support would only delay the moment of my death. ² I am in a coma and not expected to wake up. ² I have permanent and severe brain damage and I am not expected to recover.
23	"The Five Wishes Document suggests" The Five Wishes Document suggests three options: I want life support. I do not want life support; if life support has already been started, please stop. Try it; if my doctor thinks it might help, continue; if it does not help my condition or my symptoms, stop.
24	Wish 3 How comfortable do I wish to be? Pain management Handling symptoms that can occur (nausea, depression, etc.) Mouth care and other personal care Cleanliness and comfort Other things that can add to my comfort (music and reading poetry is comforting to some, not others and prayer is helpful to some people, but not others)
25	Wish 4 How do I want people to treat me? Do I want someone with me when it seems that the time of my death is near? Who do I want? My Family? Members of my church or synagogue? Someone else? What do I want them to do? Pray? Talk to me, even if I don’t respond? Play music for me?
26	Wish 5 What do I want my loved ones to know? Thank my family, my friends and those who have been good to me. Ask and offer forgiveness. Encourage family members to reconcile their differences. Frame death, not so much as a time of fear, but as a time of growth for everyone concerned. Express any wishes for place of burial, funeral or memorial service, organ donation, etc.
27	Signing Your Advance Directive Document For your Advance Directive to be a legal document it must be signed in the presence of two witnesses. According to Pennsylvania law, neither witness can be the person who signs the document for you, in the event you are unable to sign it yourself. Although Pennsylvania law does not require an Advance Directive to be dated, it is wise to do so. Pennsylvania law does not require that an Advance Directive be notarized.
28	What should I do with my completed document? Keep the original in your home, available to others who may need it; Give copies to significant people, including your agent, your family and your physician; Discuss it with them so they do not have any surprises if the need arises for it to be used; Present a copy any time you are admitted to a hospital or other healthcare facility; Note to whom you have given the document.