Healthcare Directive

An important part of dealing with any serious illness is to ensure that patients are made as comfortable as possible so they can focus on their recovery and overall well-being. Palliative care, also known as comfort or supportive care, is an area of healthcare that provides vigorous treatment for pain and other symptoms, as well as the emotional distress patients may feel when they are seriously ill. Patients can receive palliative care before, during and after treatments for your disease(s) or illness. The goal of palliative care is to give the patient the best possible quality of life by aggressively fighting symptoms while other care is fighting the disease or illness. When diseases cannot be cured, palliative care efforts are enhanced to increase the patient's physical, emotional, psychological, social, and emotional comfort.

Palliative care treats a broad range of conditions, including pain, nausea, fatigue, breathlessness, constipation, depression, and anxiety. The palliative care program works with physicians to help build a treatment plan with the patient and family wishes in mind. The palliative care program can help coordinate the multiple sources of treatment and care that patients with advanced illness need. This coordination includes communicating with different physicians, explaining treatment choices and options, and finding resources for counseling, spiritual support and daily living needs inside and outside the hospital. Comfort care always includes adequate pain control.

Altru Health System has a palliative care program to provide this care to our patients and families. Physicians can provide a referral to the service so that patients can benefit from this care. Ask your physician or healthcare provider about palliative care.

Healthcare Directives and Code levels are not the same. A Healthcare Directive takes effect if the patient is unable to express their wishes. This is a serious decision which allows the patient to be an active participant in their medical care while they are still able to do so. The Healthcare Directive is a document that states the patient’s medical considerations regarding life sustaining interventions for the future or should they become unresponsive.

Code Levels are determined by the patient’s medical considerations regarding life sustaining intervention.

Admission: When admitted, a physician will initially discuss with the patient what life sustaining treatments are available and what their desire is for these treatments. Below are some points considered when making decisions:

• Why are you in the hospital?
• What is your health status now and the foreseeable future? 
• What is your desired quality of life? 
• What are your personal values? 
• Is your condition/situation reversible? 
• Would continuation of treatments be medically ineffective?

POLST (Physician’s Orders for Life-Sustaining Treatment) is a physician order that documents and directs the patient’s medical considerations regarding life-sustaining interventions (i.e., Code Level). The POLST is used not only as an agreement between the physician and the patient, but it is used for the present situation as well as for the future. It may be updated and reviewed at any time.

The POLST takes the following into consideration:

• DNR or CPR - only if the patient has no heart beat and is not breathing.
• Artificial Nutrition: When a patient can no longer eat or drink by mouth. Liquid food can be provided to them through a tube. 
• Intravenous Fluids (IV): A small plastic tube (catheter) is inserted directly into the vein and fluids are administered through the tube. Typically, IV fluids are given on a short-term basis. 
• Tube Feeding: On a short-term basis, fluids and liquid nutrients can be given through a tube in the nose that goes into the stomach (nasogastric or “NG” tube). For long term feeding, a tube can be inserted through a surgical procedure directly into the stomach (gastric or “G” tube) or the intestines (jejunal or “J” tube).
• Antibiotics: Antibiotics treat some infections (such as pneumonia) that can develop when a patient is seriously ill. 
• Mechanical Ventilation/Respiration: When a patient is no longer able to breathe on their own, a tube is put down the throat to help breathing. A machine pumps air in and out of the lungs through the tube. 
• Comfort Measures: Care provided with the primary goal of keeping a patient comfortable (rather than prolonging life). A patient who requests “comfort measures only” would be transferred to the hospital only if needed for his or her comfort. 
• Medically Ineffective: Any course of treatment that offers no beneficial outcome or is medically ineffective and contrary to generally accepted healthcare standards. This judgment is based on standards of medical care, recognizing the uniqueness of patients and diseases and weighing the relevant medical literature, opinions of consults, clinic experience, patient’s wishes, and patient’s determinations of quality of life. 
• Dialysis: You have the right to make your own choices about how you are treated for kidney failure. That means you can choose when to start or stop dialysis.

Who should have a POLST? 

• If you have a serious health condition and need to make advance decisions about life sustaining treatment here and now. Your physician or nurse practitioner can use the POLST form to represent the patient’s wishes as a clear, specific written medical order. 
• The form must be signed by a physician or nurse practitioner for it to be followed. Other health care professionals can complete the form, but it requires a physician, or nurse practitioner signature.

I have a Healthcare Directive - Do I Need a POLST? 

• Yes, it is recommended. It reflects your desires here and now. It will be discussed by a member of the healthcare team if there are changes in the medical condition. 
• At any point of care you have the right to review and change your code level/POLST.

Code Levels: 

• Full Code: defined as full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing. 
• DNR: The patient does not want CPR the person has no heart beat and is not breathing, but may want other life-sustaining treatments. 
• COMFORT CARES ONLY: defined as end of life care, with emphasis on comfort care. This treatment includes a patient’s physical and/or emotional comfort. Comfort care always includes adequate pain control. At this point, medications and treatments for cure attempts are discontinued. No attempts will be made for resuscitation (i.e., DNR) and allows natural death. Everything will be done to provide comfort and dignity for the patient and family.
• Cardiopulmonary Resuscitation (CPR): Refers to the medical procedures used to attempt to restart a patient’s heart and provide oxygen if the patient suffers heart failure. CPR may involve efforts such as mouth-to-mouth resuscitation and external chest compressions. Advanced CPR (or ALS Advanced Life Support) may involve electric shock and/or insertion of a tube to open the patient’s airway and hooked to a ventilator to support breathing until the patient can breathe on their own. Medications may be required to regulate the heart and blood pressure. It is important to talk to your physician about chances of recovery and survival based on your medical condition.
• Do Not Resuscitate (DNR): This means that physicians, nurses and emergency medical personnel will not attempt emergency CPR if the patient’s breathing or heartbeat stops. The DNR tells medical professionals not to perform CPR. DNR would allow a natural death.

Please feel free to talk openly at any time to any member of your healthcare team.

There are times when making a decision for yourself or a family member about whether or not to undergo treatment presents some difficulties or conflicts. A source of assistance that is available to you or your family is the Altru Health System Ethics Advisory Committee. The purpose of the Ethics Advisory Committee is to provide a mechanism to ensure that communication about ethical issues and decisions occurs among health care providers, patients, and families. The Ethics Advisory Committee does not make decisions itself; rather, it serves in an advisory capacity to the decision maker, whether that be the physician, patient, family, or legal decision maker.

Any patient, family member, physician, or staff member may request a review by the Ethics Advisory Committee of situations which involve ethical issues. To refer an issue to the Altru Health System Ethics Advisory Committee, you may call the Pastoral Services office 701.780.5300) or social Work/Case management office 701.780.5345 during the day between 8:00 am and 4:30 pm. In the evening or on weekends, you may request a referral to the Ethics Advisory Committee by contacting the hospital supervisor. Call the hospital operator (dial 0 if you are in the hospital; dial 780.5000 if you are out of the hospital) and ask for the hospital supervisor.

Altru Health System recognizes its responsibility to its patients, staff, physicians and the community it serves to conduct patient care and all other operations in an ethical manner based on its values, mission, vision, and strategic plan. Values serve as the guiding principles for ethical behavior in all activities and are supported by policies, procedures, practices, and quality service. A Code of Ethics is the mechanism by which values are brought to life. The six value statements of Altru Health System serve as the focal points for the organization’s Code of Ethics.

Respect and Caring for Individuals

• All patients, families, significant others, employees, and medical staff will be treated with dignity, respect and courtesy.
• Patients and families will receive appropriate information about therapeutic alternatives and risks associated with their care and will be active participants in their care. 
• Patients, families, and employees will have their ethnic, cultural, religious, and lifestyle diversity honored. 
• The confidentiality and privacy of patients, families and employees will be respected and protected. 
• Employees will be provided with fair and equitable compensation and support.
• Professional and ethical codes of employees and medical staff will be respected and supported.

Honesty and Dependability

• Potential conflicts of interest in patient care, business practices and contractual relationships will be brought to the attention and addressed by leadership and/or the governing board. 
• Patients and/or third party payors will be billed only for services actually provided and will be assisted in understanding the cost related to their care.
• All public advertising and information disseminated will be truthful and accurate.
• The commitments made with patients, families and one another will be met.

Commitment to Serve

• Patients will be admitted to, transferred and discharged from the hospital on the basis of their medical needs and the ability of the hospital to meet those needs. 
• Patients/families will be informed of the need for admission, transfer, or discharge and given appropriate options so that they can be part of the decision making process. 
• Conflicts and complaints will be addressed in a timely manner and all efforts to reach a mutually satisfactory resolution will be made. Resources available to assist patient/families are: employees, Area and Executive Leaders, Risk Manager, and the Ethics Committee. 

Continuous Quality Improvement

• Care provided will be of the same level regardless of the location within Altru Health System or the patient’s ability to pay. 
• Care will be based upon quality standards with consideration of the patient/family needs. 
• Care will be provided in the most cost effective manner that continues to meet the requirements of patients, families, physicians, and staff. 
• Resolution of problems, issues, and concerns of patients and their families will be addressed.

Teamwork Based on a Common Purpose, Performance Goals, and Mutual Accountability

• Employees and medical staff will be encouraged and supported in efforts to collaborate, problem-solve, and innovate. 
• Employees and medical staff will be kept informed of changes in the health care environment and will be encouraged and supported in responding to the changes.

Stewardship of the Community's Healthcare Resources

• Patient care and organizational processes will be designed using quality improvement methods so that patient’s needs and requirements will be met in a manner that preserves resources of the community and the organization. 
• Competitive costs and prices to ensure access to services needed by the community will be maintained.

A Healthcare Directive is a written document that includes one or more health care instructions, a health care power of attorney, or both.

The Healthcare Directive permits you to make your healthcare wishes known and gives your health care agent the power and guidance to make healthcare decisions according to your wishes when you are unable to make or communicate your decisions. The document may include the type of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state where you want or do not want to receive treatment.

In this document, you may name an agent who would make healthcare decisions for you if you are unable to make them for yourself. The agent has a duty to act consistently with your known wishes. If the agent does not know your wishes, the agent has the duty to act in your best interests. If you do not name an agent, your healthcare providers have a duty to act consistently with your instructions or tell you that they are unwilling to do so.

A Healthcare Directive becomes effective when it meets the requirements of the law and when you are unable to decide or make known healthcare decisions. You cannot be required to sign a Healthcare Directive. Your decision to complete a Healthcare Directive is personal and should be based upon your individual values and beliefs.

To Complete a Healthcare Directive:

1. Use the appropriate form. The law includes a recommended form. Forms are available at Altru Health System from Pastoral Services staff (Chaplain) at 701.780.5300 or write Altru Health System Pastoral Services, 1200 South Columbia Road, Grand Forks, ND 58201, the Hospital Supervisor 701.780.5250, or from Altru Home Services staff 701.780.5880. If you have questions regarding filling out forms contact Social Workers or Case Managers at 701.780.5345 or Pastoral Services at 701.780.5300.
2. Carefully select the person you want to act as your agent and/or alternate agent. Discuss the role of your agent and/or alternate agent with the persons you select.
3. Tell your agent what kinds of health care decisions you want your agent to make on your behalf. 
4. When you are completing a Healthcare Directive, if you have questions or special circumstances to consider, it might be advisable to consult an attorney who is knowledgeable about advance directives. 
5. Make certain you sign your Healthcare Directive and have it properly witnessed or notarized. There are specific limitations under the law on who is qualified to be a witness. 
6. Give a copy of your Healthcare Directive to your physician and any other health care providers such as your nursing facility, hospice or home health agency. Altru Hospital accepts an ORIGINAL form or a copy and will keep it on file in the Medical Records Department. A copy will be kept on your chart while you are a patient. Ask your other healthcare providers if they need an original or if a copy will be sufficient.

In addition, you may want to give originals or copies of your Healthcare Directive to other persons such as close family members and your attorney, if you have one.