PATIENT SELF-

DETERMINATION
POLICY
A PROPOSAL
INTRODUCTION

 Advance care planning involves learning about the types of decisions that the
patient might need to be made, considering those decisions ahead of time, and
then letting others know - both the family and the healthcare providers - about
these preferences
 These are put into an advance directive, a legal document that goes into effect
only if the patient is incapacitated and unable to speak for himself, either due to
disease, severe injury or mental issues
 An advance directive also allows to express values and desires related to end-of-
life care
 Sometimes decisions must be made about the use of emergency treatments to keep
the patient alive, relating to CPR or ventilator use, among others
BACKGROUND

 In 2019, Filipinos aged 60 and above accounted to 8.6 percent of the total
population or about 9.5 million
 The World Population Prospects 2019 projects that by 2050, older people will
make up around 16.5 percent of the total population of the Philippines or around
24 million
 According to the National Health Institute of the University of the Philippines
(UP-NIH), six of ten Filipinos who succumb to sickness die without ever seeing a
doctor
BACKGROUND

 In 2010, the late Sen. Miriam Santiago proposed a bill to develop and implement
a national public education campaign on the importance of advance care planning
and of an individual’s right to direct and participate in his or her health care
decisions
 In 2019, a survey was conducted among staff nurses in Medical Surgical 1
Division using Frommelt Attitudes Toward Care of the Dying (FATCOD) to
assess readiness in taking care of dying patients. Out of the 137 staff asked to
participate, 85% or 117 were found out to have a positive attitude on caring for
these patients. This is despite the fact that only 66% or 89 of them have no formal
training or education in end-of-life education
GOALS AND OBJECTIVES

 Goal
 To create agency policy on Patient Self-Determination that will help elderly patients
exercise their right to decide on their medical management and care
 Objectives
 To make agency guidelines on end-of-life plans like advance care planning and similar
patient-initiated actions on their care and management
 To formulate forms that would institutionalize self-determination in the institution
ADVANCE DIRECTIVES

 documents a person completes while still in possession of decisional capacity

about how treatment decisions should be made on their behalf in the event they
lose the capacity to make such decisions
 legal tools directing treatment decision-making and/or appoint surrogate decision
makers
 only acted upon when the patient has lost the ability to make decisions for
themselves
 can be revoked orally or in writing by the patient at any time as long as they have
maintained decisional capacity
PRIMARY INSTRUMENTS FOR
ADVANCE DIRECTIVES
 Durable Power of Attorney for Health Care or Medical Decision Maker
 signed legal document authorizing another person to make medical decisions on the
patient’s behalf in the event the patient loses decisional capacity
 Living Will or Health Care Choices
 document summarizing a person’s preferences for future medical care
 takes effect if the person is terminally ill without chance of recovery and outlines
desire to withhold heroic measures
 Physician Orders for Life-Sustaining Treatment (POLST)
 outlines what specific care should be administered or withheld at the present time for a
specific patient, as directed by a physician
FLOW OF ADVANCE CARE
PLANNING
 Criteria for Selection of Participants
 patient aged 60 and above
 GCS 15 during admission
 admitted for medical management
 with presence of chronic disease
 Hypertension
 Diabetes
 Chronic Kidney Disease
 Cancer
Place locus of responsibility
FLOW OF ADVANCE CARE
PLANNING
 Provision of brochure regarding advance care planning (ACP) to patient
 Where: Non-critical care unit
 Who: Geriatric Nurse
 Why: Provides an overview on ACP and answers commonly encountered questions
regarding ACP
FLOW OF ADVANCE CARE
PLANNING
 Facilitating Readiness for ACP Form
 Where: Non-critical care unit
 Who: Geriatric Nurse
 Why: Assesses readiness of patient to perform ACP and to accomplish related
documents
FLOW OF ADVANCE CARE
PLANNING
 Assessment of decision-making capacity
 Where: Non-critical care unit
 Who: Attending physician / Fellow on duty
 Why: Patient must be evaluated if he or she is capable of making sound decisions
regarding his or her medical treatment
FLOW OF ADVANCE CARE
PLANNING
 Facilitating ACP
 Where: Non-critical care unit
 Who: Geriatric nurse
 Why: In-depth discussion regarding ACP including aspects that influence decision
making of the patient as well as the key elements of ACP such as selecting a health
care decision maker, among others
 Step Purpose Question

Permission Invites the patient to discuss their current condition “Would you like to talk about what might happen in the
and desires regarding future medical care future, and how we could make sure your wishes are
followed?”

Preference Allows patient to determine how involved they are in “Would you like to talk about this by yourself, or are there
planning, and whether they want others involved others you would like to join us?”

Establish the baseline To determine what the patient’s understanding is “What is your understanding about your medical situation?”
regarding their medical situation at the present time
”What have your doctors told you?”

Provide information To provide clear information about the choices that For a patient with recurrent cancer, for example:
may be faced in the future, individualized to the “Because your cancer came back, it may not be curable. You
patient’s own current medical condition may be living with this disease for the rest of your life, like a
chronic disease.”
 Step Purpose Question
Introduce dilemmas at hand To determine if the patient has thought about the “Has someone close to you had to face end of life decisions,
medical care they would like to receive in the future like deciding about withdrawing treatment? What would you
have wanted in that situation?”

Explore values and beliefs To help the patient define what it means to “live well” ”What is most important to you in life?”

“What are your main worries about your situation?”

“When you think about your future, what do you hope for?”

Elicit advance care planning To guide the patient to state specific preferences about “If you were to stop breathing, would you want to be on a
preferences advance care planning, including cardiopulmonary machine that breathes for you?”
resuscitation and life prolonging treatment,
 Step Purpose Questions/Comments

Identify a health decision-maker To specifically name someone who will carry out their “If you become unable to tell your clinicians what kind of
wishes in the case they are unable to in the future care they should provide you, who would you want to make
medical decisions for you?”

Educate about the role of a health To ensure understanding on how the decision-maker “If you become unable to participate in discussions about
decision-maker would function in the future your care, your health decision-maker would be called in to
tell us what should be done.”

Encourage dissemination among To ensure that the advance care planning decisions of “It would important to let your family know of your wishes
family the patient are known to their loved ones, and and desires for the future. This includes letting everyone
specifically, to the health decision-maker know who you have chosen as your health decision-maker.”

Document Encourages the patient to complete advance care “These are important decisions that will impact your care in
planning forms, which will increase the chances their the future. We should make sure to get them in writing.”
wishes are followed in the future
FLOW OF ADVANCE CARE
PLANNING
 Accomplishment of PHC Advance Care Directive booklet
 Where: Non-critical care unit
 Who: Geriatric nurse
 Why: The booklet is where the patient will be able to document his treatment
preferences as well as health care decision maker
FLOW OF ADVANCE CARE
PLANNING
 Explanation of possibility of undergoing life-saving treatment in the future and
accomplishment of Physician Orders for Life Sustaining Treatment (POLST)
Form
 Where: Non-critical care unit
 Who: Attending physician
 Why: Doctor-patient discussion which is focused on medical treatment aimed to
sustain life and encoding patient’s preferences through a doctor’s order format
FLOW OF ADVANCE CARE
PLANNING
 Documentation and review of ACP
 Where: Non-critical care unit
 Who: Attending physician
 Why: Advance directives need to be photocopied as this will be attached in the
patient’s chart in order to have a reference in situations when decisions need to be
made regarding resuscitation or treatment procedures
EFFECTIVENESS

 Higher rates of completion of advance directives

 Increased likelihood that clinicians and families understand and comply with the
patient’s wishes
 Reduction in hospitalization at the end of life
 Increased likelihood that a patient will die in their preferred place
BENEFITS

 Helps ensure that patients receive care that is consistent with their preferences
 Provides guidance to the family and reduce their decisional burden about whether
they are following these preferences
 Lays the groundwork for surrogates by providing a framework that they may
utilize to inform decision-making, keeping in mind the patient’s goals, values and
beliefs as well as their treatment preferences
 Reduces moral distress among health care providers
CONCLUSION

 Advance care planning is an ongoing process in which patients, their families, and
their health care providers reflect on the patient’s goals, values and beliefs,
discuss how they should inform current and future medical care, and ultimately
use this information to accurately document the patient’s future health care
choices
 Clinicians bear the responsibility of informing patients about their prognosis,
exploring treatment options, and helping formulate preferences based upon a risk-
benefit analysis and their values, whenever circumstances allow
 Advance directives are the documents a person completes while still in possession
of decisional capacity to ensure their values are reflected when considering how
treatment decisions should be made on their behalf in the event that they lsoe the
capacity to make such decisions
CONCLUSION

 The clinician must assess the patient’s decision-making capacity before

concluding that the patient can or cannot speak for himself or herself. A medical
decision-maker should be identified for all patients, regardless of condition,
because lost decisional capacity is common
 If a patient expresses wishes against resuscitation during an ACP discussion, it is
important that they be followed by physician’s orders regarding code status, as
ADs alone are insufficient to prevent a patient from being resuscitated
RECOMMENDATION

 Given the current pandemic that we are in, further studies relating to use of ACP
to patients who acquired COVID-19 and currently admitted in the hospital may be
explored in the long run
 Research studies regarding awareness and likelihood of patients to engage in ACP
after facilitating discussion of ACP may be initiated
 Studies abroad implement nurse-led discussions on ACP as well as group
seminars which are conducted by nurse practitioners who work with the patient in
coming up with making decisions on their treatment