Advance Directives and Do Not Resuscitate Orders

Advance Directives and Do Not Resuscitate Orders

What is an advance directive?
An advance directive tells your Attending Physician (AP) what kind of care you would like to receive if you become unable to make medical decisions (if you are in a coma, for example). A good advance directive describes the kind of treatment you would want to receive depending on how sick you are. For example, the directives would describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are unconscious. Also, advance directives usually include certain kinds of treatment you would not want to receive. However, they can also say that you want to receive a certain treatment no matter how ill you are. Advance directives can take many forms- a living will, a special power of attorney or a do not resuscitate order.

What is a living will?
A living will is one type of advance directive. It is a written, legal document that describes the medical treatments or life-sustaining treatments you would want if you were seriously or terminally ill.   A living will doesn't let you select someone to make decisions for you.

What is a special power of attorney for health care?
A special power of attorney (SPA) for health care is another kind of advance directive. A SPA states whom you have chosen to make health care decisions for you.  It becomes active any time you are unconscious or unable to make medical decisions. A SPA is generally more useful than a living will. But a SPA may not be a good choice if you don't have another person you trust to make these decisions for you.

What is a do not resuscitate order?
A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to revive all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your AP that you don't want to be resuscitated in case this happens. In this case, a DNR order is written in your medical chart by your AP. A DNR is usually discussed by the health care team with the relatives of patients without other advance directives in situations like: a comatose patient, persistent vegetative state, and brain death.

Should I have an advance directive?
By creating an advance directive, you are making your preferences about medical care known before you're faced with a serious injury or illness. This will spare your loved ones the stress of making decisions about your care while you are sick.   Any person 18 years of age or older can prepare an advance directive.

People who are seriously or terminally ill are more likely to have an advance directive.  Someone with terminal cancer might write that she does not want to be put on a respirator if she stops breathing. This action can reduce her suffering and increase her peace of mind. However, even if you are in good health, you might want to consider writing an advance directive. An accident or serious illness can happen suddenly, and if you already have a signed advance directive, your wishes are more likely to be followed.

How can I write an advance directive?
You can write an advance directive in several ways:

• Use a form provided by your doctor.
• Write your wishes down by yourself.
• Seek the advise of a lawyer.

Advance directives/ living wills/ special power of attorney do not have to be complicated legal documents. They can be short, simple statements about what you want done or not done if you can't speak for yourself.  Remember, everything should be in conformity with Philippine law. You may also want to have what you have written reviewed by your doctor or lawyer to make sure your directives are understood exactly as you intended. When you are satisfied with your directives, the orders may be notarized (if possible), and copies should be given to your family and your attending physician.

Can I change my advance directive?
You may change or cancel your advance directive / special power of attorney at any time, as long as you are considered of sound mind to do so. Being of sound mind means that you are still able to think rationally and communicate your wishes in a clear manner. Again, your changes must be made, signed, and if possible, notarize. Make sure that your AP and any of the family members who knew about your original directives are also aware that you have changed them.

If you do not have time to put your changes in writing, you can make them known while you are in the hospital. Tell your AP and any family or friends present exactly what you want to happen.  Usually, wishes that are made in person will be followed in place of the ones made earlier in writing.  Be sure your instructions are clearly understood by everyone you have told.

Definitions to Know

Advance directive / special power of attorney
A written document (form) that tells what a person wants or doesn't want if he/she in the future can't make his/her wishes known about medical treatment.

Artificial nutrition and hydration
When food and water are fed to a person through a tube.

Autopsy
An examination done on a dead body to find the cause of death.

Comfort care
Care that helps to keep a person comfortable but doesn't make him/her get well.  Bathing,  turning and keeping a person's lips moist are types of comfort care.

CPR (cardiopulmonary resuscitation)
Treatment to try to restart a person's breathing or heartbeat. CPR may be done by pushing on the chest, by putting a tube down the throat or by other treatment.

Special power of attorney for health care
An advance directive that names someone to make medical decisions for a person if in the future he/she can't make his/her own medical decisions.

Life-sustaining treatment
Any medical treatment that is used to keep a person from dying. A breathing machine, CPR, and artificial nutrition and hydration are examples of life-sustaining treatments.

Living will
An advance directive that tells what medical treatment a person does or doesn't want if he/she is not able to make his/her wishes known.

Organ and tissue donation

When a person permits his/her organs (such as the eyes or kidneys) and other parts of the body (such as the skin) to be removed after death to be transplanted after use by another person or to be used for experimental purposes.

Persistent vegetative state or irreversible coma

When a person is unconscious with no hope of regaining consciousness even with medical treatment. The body may move and the eyes may be open, but as far as anyone can tell, the person can’t think or respond (comatose). Another term for this is a state of being clinically dead.

Terminal condition

An ongoing condition caused by injury or illness that has no cure and from which doctors expect the person to die even with medical treatment. Life-sustaining treatments will only prolong the dying process if the person is suffering from a terminal condition.

For further information, please consult your attention physician.

You may also contact the Customer Service Division at tel. no. (632) 988-1000 / (632) 988-7000 ext. 6167/6168    

CANCER:
END-OF-LIFE CANCER
END-OF-LIFE ISSUES FOR THE CAREGIVER

How long does grief last?
You'll probably start to feel better in 6 to 8 weeks. The whole process usually lasts 6 months to 4 years.

If you feel like you're having trouble getting through the process at any point, ask for help. People who can help include friends, family, clergy, a counselor or therapist, support groups and your family doctor.

Be sure to talk to your family doctor if you have a lot of trouble eating, sleeping or concentrating for more than the first couple of weeks. These things can be signs of depression. Your family doctor can help you work through your depression and start to feel better about your loss.

Tips on dealing with a loss 

• Talk about how you're feeling with others.
• Try to keep up with your daily tasks so you don't feel overwhelmed.
• Get enough sleep, eat a well-balanced diet and exercise regularly.
• Avoid alcohol.   Alcohol can make you feel more depressed.
• Get back into your normal routine as soon as you can.
• Avoid making major decisions right away.
• Allow yourself to grieve—to cry, to feel numb, to be angry or to feel however you're feeling.
• Ask for help if you need it.

GRIEVING:
FACING ILLNESS, DEATH
AND OTHER LOSSES

Grieving: Facing Illness, Death and Other Losses

What is grief?
Grief is a normal, healthy response to loss. One of the greatest losses that can occur is the death of someone you love. Other losses include the loss of your health or the health of someone you care about, or the end of an important relationship, such as through divorce. Healing from a loss involves coming to terms with the loss and the meaning of the loss in your life.

• Anger
• Nausea
• Blaming yourself          
• Not being able to get organized
• Crying spells    
• Diarrhea           
• Not feeling hungry or losing weight
• Dizziness         
• Fast heartbeat  
• Restlessness and irritability
• Sadness or depression
• Seeing images of the dead person
• Feeling like there's a lump in your throat
• Feeling like what's happening around you?
• Shortness of breath isn't real? Tightness in your chest
• Headaches
• Hyperventilating
• Tiredness
• Trouble concentrating – sighing and yawning     
• Trouble sleeping

What are the normal feelings of grief?
As you face a loss, you may have different feelings at different times. These feelings include shock, denial, anger, guilt, sadness and acceptance. You may find yourself going back and forth from one feeling to another. For example, right when it seems that you're starting to accept your loss, you may find yourself feeling sad or guilty again. Your grief may never completely go away. But the pain you feel will lessen with time as you work through these feelings.

What usually happens first?
In the first hours or days after the loss, you may feel shocked, numb and confused. You may not remember what people are saying to you. You may feel dazed and as though you're going through things like a robot. You may think and act as though the loss hasn't occurred. This is called denial.

As your shock wears off, reality will slowly break through. You'll begin to realize that the loss has happened.  It's normal to feel abandoned and angry. You may direct your anger toward God, religion, doctors and nurses, the one who has died or other loved ones, or even yourself.

What happens after the anger wears off?
After you get through some of the anger and denial, it's normal to try to pretend things are like they used to be. If someone you love has died, you may play memories over and over in your mind. You may also feel the presence of your loved one, think you see him or her, or think you hear his or her voice.

You may also find yourself talking to your loved one as though he or she were in the room with you. As you begin to realize that your loved one is gone and you can't bring him or her back, you'll begin to feel the full impact of your loss.  These feelings may be scary because they're so strange and so strong. They may make you feel like you're losing control.

What happens then?
When you begin to realize the full impact of the loss on your life, you may feel depressed and hopeless. You may also feel guilty. You may find yourself thinking things like "if only" or "why me." You may cry for no apparent reason.  

This is the most painful stage of healing, but it won't last forever. In normal grief, the depression will begin to lift with time.

What is the first sign of relief?
You may start to feel better in small ways. For example, you may find it's a little easier to get up in the morning, or you may have a small burst of energy. This is the time when you'll begin to reorganize your life around your loss or without your loved one.

What is the final stage?
The last stage of accepting a loss is when you begin to reinvest in other relationships and activities. During this time, it's normal to feel guilty or disloyal to your loved one because you're moving on to new relationships. It's also normal to relive some of your feelings of grief on birthdays, anniversaries, holidays and during other special times.

Cancer: End-of-Life Issues for the Caregiver

Not everyone who has cancer succumbs to the disease. In fact, there are nearly 9 million cancer survivors living in the United States today.  However, if your loved one's cancer cannot be cured or controlled with treatment, then planning for how you and your loved one will handle the last stages of the disease can ease the burden for both of you. Ideally, you should make these decisions together, while your loved one is well enough to participate. Doing so can help give your loved one a sense of control over his or her future and relieve you from having to make difficult decisions on your own.

What kinds of things should we plan for?

Hospice care: Talk with your loved one about hospice care and advanced directives.  Hospice care focuses on providing people whose illness can't be cured or controlled with treatment with the most dignified, pain-free existence possible in their last stage of life. Advance directives are instructions on what kind of care your loved one wishes to receive when he or she becomes unable to make medical decisions. Financial and legal issues: You and your loved one may wish to have an accountant or lawyer help you sort through financial and legal issues. You can review things such as your loved one's insurance policy, finances and his

Funeral arrangements: Perhaps the most difficult part of this process is planning your loved one's funeral. Talk with your loved one about his or her preferences (for example, burial vs. cremation) in relation to your budget. Ask your loved one how he or she wants the service to be conducted. For example, you may want to discuss things such as what hymns or readings to include in the ceremony and whom your loved one wants to have as his or her pallbearers. Don't feel that any detail is too small to discuss. When selecting a funeral provider, be sure to compare prices, services and payment options.