Transcript Advance Care Planning in South Carolina

Advance Care Planning
Senior Mentor Program
Gere B. Fulton, Ph. D., J. D.
School of Medicine
The University of South Carolina
Advance Care Planning (ACP)

There are two (2) components to advance
care planning:
– 1) advance care planning (process) – clarifying one’s
values concerning care, including medical
treatment, at the end of life
– 2) advance care plan (product) – preparation of a
document reflecting one’s values, e.g., a living will or
a health care power of attorney (HCPOA)
Reasons for Advance Care Planning

To assure that your wishes about end-oflife care are known and respected
 To facilitate communication and
autonomy in the patient-physician
relationship
 To provide guidance to your family and
physician when you are unable to make
decisions for yourself
Ability to consent
Incompetence – a legal term. Competence is
presumed and incompetence can only be
pronounced by a court of law. Due process.
 Incapacity – a medical term. Inability to make
the decision at hand.
 Unable to consent – Section 44-66-20(6)

– “…unable to appreciate the nature and implications
of the patient’s condition and proposed health care,
to make a reasoned decision concerning the
proposed health care, or to communicate that
decision in an unambiguous manner.”
Inability to consent

Does not include minors
 Certified by two licensed physicians, each of
whom has examined the patient
 Exception for emergencies if physician puts in
writing that delay would be detrimental to the
patient’s health
 Record should include an opinion regarding
the cause and nature of the inability to consent,
its extent, and its probable duration
Four Statutes

Adult Health Care Consent Act (44-66-10)
 Declaration of a Desire for a Natural Death
(44-77-50)
 Health Care Power of Attorney (62-5-501)
 Emergency Services Non-Resuscitation Order
(44-78-10)
Adult Health Care Consent Act

Allows a surrogate to make all health care
decisions when the patient has permanently lost
capacity to do so
 Creates broader authority to withhold or withdraw
LSMT than exists under the Living Will statute
 Any decision must be based on 1) the patient’s
wishes (if known), or 2) the patient’s best interest.
 Establishes an order of priority for identifying the
proper surrogate
Order of Priority







Guardian
Attorney-in-fact (?)
Person with statutory authority (?)
Spouse, unless separated (with qualifications)
Parent or adult child of the patient
Adult sibling, grandparent or adult grandchild
Any other relative by blood or marriage who is
believed to have a close personal relationship
Declaration of a Desire for a
Natural Death

Living Will
 Applicable only to terminal illness or permanent
unconsciousness
 Permanent unconsciousness cannot be certified
until the declarant has remained unconscious
for 90 consecutive days or another
characteristic allows the diagnosis to be made
with a high degree of medical certainty
 Diagnosis must be made by two physicians who
have personally examined the patient
Living Will (continued)

Intention to refuse food or water by tube
must be specifically authorized
 Comfort care can never be refused
 Document must be appropriately witnessed
and notarized
 If the declarant is a patient in a hospital or
nursing home, one of the two witnesses
must be an ombudsman
Witnessing the Living Will

Not related to declarant by blood, marriage or
adoption, either as spouse, lineal ancestor,
descendant of the parents of the declarant, or
spouse of any of them
 Not directly responsible for declarant’s medical
care
 Not entitled to a portion of the estate under will or
intestate succession
 Not a beneficiary of a life insurance policy
Witnesses (continued)

No more than one witness an employee of
health facility in which the declarant is a
patient
 Not the attending physician or an employee
of the attending physician
 No claim upon the estate (not a creditor)
Health Care Power of Attorney




The HCPOA allows you to appoint a surrogate
decision maker, i.e. attorney-in-fact.
The powers of the surrogate are broader than the
terms of the living will, i.e. not limited to terminal
illness or permanent unconsciousness.
Since it is not limited to terminal illness or permanent
unconsciousness, the legislatively-imposed
waiting period for PVS would not apply.
Arguably, unlike the living will, the HCPOA does
not require notarization.
Emergency Services
Non-Resuscitation Order

Allows for a person with a terminal illness to
refuse out-of-hospital CPR
 Must be ordered by physician (health care
provider) and entered into the patient’s file
 Status may be identified by a form, a bracelet, or a
necklace
 If there is a form, it should be transported with the
patient if the patient is taken to a hospital
For DNR patients the following procedures
shall not be performed…

CPR
 Endotracheal intubation and other advanced
airway management
 Artificial ventilation
 Defibrillation
 Cardiac resuscitation medication
 Cardiac diagnostic monitoring
The following procedures may be
provided as appropriate…

Suctioning
 Oxygen
 Pain medication
 Non-cardiac resuscitation medication
 Assistance in the maintenance of an open airway, but
not intubation or advanced airway management
 Control of bleeding
 Comfort care
 Support to patient and family
Planning for End-of-Life Care
in South Carolina

USC Institute of Public Affairs (2002)
 18.7 % with living will (17.9% in 2001)
– 7.1% (18 to 29) to 45.3% (65 and older)
– 2001 figures were 7.2% and 45.2%

3.8% with health care power of attorney (7.5%
in 2001!)
 10.6 % with both (up from 7.6% in 2001)
 Percentage with “nothing” increased from
58.9% to 59.2%!
 ^ better educated
Gere B. Fulton, Ph. D, J. D.
Palmetto Professor of Clinical Internal Medicine
School of Medicine
The University of South Carolina
Columbia, SC 29208
Telephone: 803.419.4106
E-mail: [email protected]