Advance Care Planning
NY State Advance Directives
Health Care Proxy
A health care proxy form allows you name someone, your agent, to make decisions about your health care—including decisions about life-sustaining treatment—if you can no longer speak for yourself. The health care proxy is especially useful because it appoints someone to speak for you any time you are unable to make your own healthcare decisions, not only at the end of life.
A living will lets you state your wishes about health care in the event that you can no longer speak for yourself. You are to record your organ donation, pain relief, funeral, and other advance planning wishes. Your living will is an important source of guidance for your agent.
CPR, Hospital Do Not Resuscitate (DNR) and Do Not Intubate (DNI)
Cardiopulmonary resuscitation (CPR) is a treatment for conditions that cause one’s heart or breathing to stop. It usually involves IV medications, chest compressions, and electrical shocks to the heart. A plastic tube, called endotracheal tube, is almost always placed in the mouth and into the windpipe to protect a patient’s airway and/or to provide oxygen to a patient. Placement of the tube is called intubation and the tube is generally connected to a machine called a ventilator. Some patients do not wish to receive CPR. Other patients will not benefit from CPR because of their medical conditions.
A DNR order is a form that tells hospital staff not to attempt CPR.This form may be completed by a patient or, if a patient is unable to do so, a surrogate who may be a family member or close friend.
A DNI order is a form that tells hospital staff not to place an endotracheal tube and to not use a ventilator if a patient has breathing problems. Medications for comfort can be used in its place.
Speak to your physician about your likelihood of benefiting from CPR and whether you should have a trial on a ventilator.
There are some medical conditions that place individuals at greater risk for intubation (lung cancer, COPD, pneumonia). In these situations, intubation may provide a benefit and help to resolve an acute breathing problem. In these instances, people may still elect to not be resuscitated if their heart stops(maintain a DNR), but may choose to be intubated for a period of time to see if they can breathe again on their own. In the hospital, you may hear this situation described as “DNR/NOT DNI.”
The Non-Hospital DNR form is completed by an attending physician ordering that an individual not receive cardiac resuscitation in the community. If an ambulance is called, and a patient is found to need cardiac resuscitation, then the procedure is performed unless this order is in place.
In hospitals and nursing homes, this form may be used to issue any orders concerning life-sustaining treatment. In the community, the form may be used to issue non-hospital Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, and in certain circumstances, orders concerning other life-sustaining treatment. The signed MOLST form should be transported with patients as they travel to different healthcare settings. The medical orders on the form need not be re-issued by the patient's new health care provider, but should be reviewed and may be revised by a physician, when the patient transitions to a different setting and when the patient's preferences and/or medical conditions change.
Palliative Care Information Act
Effective February 9, 2011, the Palliative Care Information Act requires physicians and nurse practitioners to offer their patients information and counseling concerning palliative care and end-of-life options. Palliative care, as defined by the law, is "health care treatment, including interdisciplinary end-of-life care, and consultation with patients and family members, to prevent or relieve pain and suffering and to enhance the patient's quality of life, including hospice care."
Under the law, providers are required to offer this information to those an illness or condition that is reasonably expected to cause death within six months.
The law is intended to ensure that patients are fully informed of the options available to them when they are faced with a terminal illness or condition, so that they are empowered to make choices consistent with their goals for care, and wishes and beliefs, and to optimize their quality of life.
Palliative Care Access Act
The Palliative Care Access Act ("PCAA") places requirements on hospitals, nursing homes, home care agencies and two types of assisted living residences (enhanced and special needs) regarding palliative care. The Palliative Care Information Act requires physicians and nurse practitioners to offer information and counseling about palliative care to patients with a terminal illness. The "PCAA" builds upon the "PCIA" in the following ways:
- It applies directly to health care facilities, home care agencies, and assisted living residences, as well as individual practitioners;
- It applies to patients/residents with "advanced life limiting conditions or illnesses who might benefit from palliative care" and not just those who are terminally ill;
- It requires, not only an offer of information and counseling, but also that the covered health care provider or residence "facilitate access to appropriate palliative care consultation and services, including associated pain management consultations and services."
Like the PCIA, the PCAA is intended to ensure that patients are fully informed of the options available to them when they are faced with a serious illness or condition, so that they are empowered to make choices consistent with their goals for care, and wishes and beliefs, and to optimize their quality of life. The law is not intended to limit the options available to patients. Nor is it intended to discourage conversations about palliative care with patients who have distressing symptoms and serious conditions, but do not technically fall within the law's requirements.
Patients and providers should recognize that palliative care and disease-modifying therapies are not mutually exclusive. Patients may opt to pursue palliative care while also pursuing aggressive treatment. Palliative care may be provided together with life-prolonging or curative care or as the main focus of care.