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Advance Directives – End of Life Decisions

Of life’s two great certainties, death and taxes, the first is certainly more certain. Some people can avoid taxes by careful planning, others by poverty or evasion. But no one yet has devised a plan to avoid death.

Forethought and careful planning, however, can help assure that the decision and circumstances at the end of your life are made by your choice. Without a plan, those important, highly personal decisions may be made by family, medical professionals or judges, who can only guess at what they believe would be “in your best interest”. Ohio law provides these three types of documents governing end of life decisions. These are called “Advance Directives”.

THE LIVING WILL: A Living Will is a statement of a patient’s wishes to have or withdraw life support devices (ventilator, heart machine, feeding tube, etc.). This applies if at least two doctors determine the patient is “terminally ill,” meaning he will die in a relatively short time with or without medication; or “permanently unconscious”, meaning that the person is comatose and in the doctor’s opinion to a “reasonable degree of medical certainty” will not recover.

THE HEALTH CARE PROXY: Also known as “The Durable Power of Attorney for Health Care”, this document appoints another person (or series of persons) to make health care decisions if a patient loses capacity to make them himself. In choosing your own proxy, you must be sure that this person understands your wishes and is strong enough emotionally to carry them out when necessary.

DNR: A “Do Not Resuscitate” order is a medical order issued by a licensed physician which directs medical personnel not to initiate heroic efforts to treat a person with a terminal condition or who is “permanently unconscious”. An order can range from limited instructions not to attempt to restart the heart if it stops, to an order providing only “comfort care” to relieve pain, but taking no aggressive medical action to stop the person from dying.

Until July, 1998 the DNR was not “portable”. In other words, a DNR on record at the nursing home might not be on the record at the hospital. A DNR at the hospital might not follow the person to an ambulance. The new law, governed by O.R.C. Section 2133.211 and O.A.C. 3701-62 makes DNR orders portable. Although the exact regulations are not yet finalized, the law provides for a document, card, bracelet or necklace to be issued with the doctor’s DNR order. An emergency medical worker, upon seeing the DNR designation and verifying the person’s identity with friends or family members, health care facility bracelet or photo ID, would not begin the full spectrum of life preserving technology. The DNR can be revoked by the patient’s oral or written statement.

Under the new protocol for a person with a DNR order, emergency medical services would: suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, contact other appropriate health care providers such as hospice, home health, attending physician/CNS/CNP, but would not: administer chest compressions, insert artificial airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than listed above), initiate resuscitative IV, or initiate cardiac

By following the proper protocol, medical workers would be insulated from civil, criminal or administrative liability as a result of the patient’s death. The new law provides for two levels of DNR order. For a patient with a DNR Comfort Care designation, the above protocol would be activated immediately when the order is issued or when a living will requesting no CPR becomes effective. If the designation is DNR Comfort Care – Arrest, protocol is effective only in the event of cardiac or respiratory arrest.

Medical personnel are not required to search for the DNR designation. They cannot be held liable if they do not see it. If a facility or individual physician is morally opposed to the idea of letting the patient die without heroic measures, they must facilitate the patient’s transfer to another facility or physician. The new law makes it a crime to block those transfers; to conceal or deface someone else’s DNR ID without consent; or to falsify or conceal a DNR ID or the revocation of the DNR ID.

The new, Portable DNR means that terminal patients will not need to go to the same lengths as Maria Rodriguez, a nurse from Indianapolis. She had her advance directives tattooed on her chest. The red and black design included a picture of a human heart with a circle and slash over it (the universal symbol for “DO NOT”). Below the picture were the words: “NO CODE”, “COMFORT CARE ONLY”, “ORGAN DONOR”, followed by her initials. Ms. Rodriguez left little doubt of her wishes.

Leave no doubt about yours. Talk to your attorney about a Living Will and Health Care Proxy. Talk to your doctor about DNR orders. Discuss your wishes with your family, your proxy agents and any medical personnel who treat you. MAKE THE CHOICE YOURS.

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