be thou my vision, o lord of my heart; naught be all else to me, save that thou art. thou my best...

Be Thou my Vision, O Lord of my heart;

Naught be all else to me, save that Thou art.

Thou my best Thought, by day or by night,

Waking or sleeping, Thy presence my light.

Be Thou my Shield and my Sword for the fight;

Be Thou my Dignity, be Thou my Might;

Thou my soul’s Shelter and Thou my strong Tower:

Raise Thou me heavenward, O Power of my power.

Riches I heed not, nor man’s empty praise,

Thou mine Inheritance, now and always:

Thou and Thou only, first in my heart,

High King of Heaven, my Treasure Thou art.

High King of Heaven, my victory won,

May I reach Heav’n’s joys, O bright Heaven’s Sun!

Heart of my own heart, whatever befall,

Still be my Vision, O Ruler of all.

What are Medical Ethics?

rules of behavior based on what is morally good and bad

Core Beliefs

Guiding Principles

Ethical Decision

CORE BELIEFS

Core Beliefs

• God as the Life Giver• God as Trinity• God incarnate as Jesus• God the Redeemer• God is Just• God and Community

God the Life Giver

• Gift of life in Creation• Created in His image

God as Trinity

• Personhood comes from an understanding of God’s Person

• Relationship is intrinsic to God

God incarnate as Jesus

• Demonstrate selfless love and care for humans• Physical and Spiritual are continuum• Creation is not apart from God but sustained

and infused by God’s presence

God the Redeemer

• Grace is the hallmark of God’s relationship with us

• Grace should be the hallmark of our relationship with others

God is Just

• Our treatment of the vulnerable is viewed by Jesus as our treatment of Him

God and Community

• Church as the Body of Christ• We are His agents on earth• Love your neighbor as yourself

GUIDING PRINCIPLES

Guiding Principles

• Affirming life• Caring for the vulnerable• Building community• Respect for individual persons

Affirming Life

• Each life has purpose, value, meaning• That life has a right to exist and should be

protected

Caring for the vulnerable

• Ensure vulnerable people/groups are supported, cared for, enabled to live fulfilled lives

• Entrusted with all of His creation

Building Community

• Individual autonomy and freedom are limited• Christian community upholds affirmation of

life and caring for the vulnerable

Respect for Individuals

• No discrimination: sex, race, religion, age, disability, social class, sexual orientation

When do ethics often come into play?

Issues

• Beginning of life• End of life• Traditional medical treatments• Alternative medical treatments• Organ donation• Resource allocation• Medical research

Questions to ask

• What is the meaning of suffering?• How important is physical life?• How should a person be valued?• What is a person?

What medical options might I need to consider?

Principles

• Ordinary vs. Extraordinary• Curative vs. Palliative• Outcomes• One thing leads to the next• Who is decisional

Basic

• Symptomatic medications• Sedation• IV fluids• Comfort measures

More aggressive medical therapies

• Chemotherapies• IV medications• IV feeding• Feeding tube

Procedures/Surgeries

• Low risk surgery• High risk surgery• Central lines• Pacemakers/defibrillators• Cardiac cath/intervention• Endoscopy

Resuscitation

• CPR• Medical resuscitation• Defibrillation• Intubation/ventilation

Mechanical life support

• Dialysis• Life sustaining IV medications• Mechanical ventilation• Artificial heart• Transplants

“Do everything”

“Try it temporarily”

Options

• Literally do everything• No intubation/ventilation• No CPR/resuscitation• Palliative care• Hospice• Withdraw support• Euthanasia• Assisted suicide

Examples

Example

82M acute stroke after gall bladder surgery. Can’t swallow, needs feeding tube to live.

Example

21M history brain tumor. Recurred after 15 years. Prolonged chemo and radiation therapy much of life.

Example

88M severe valve disease. Multiple hospitalizations for heart failure. Needs valve surgery, which would likely result in need for dialysis. Patient absolutely against dialysis. Some dementia, family wants procedure done.

Example

67M history heart attack/poor heart function. Resuscitated after cardiac arrest. Needs ventilator and strong IV meds to live. Brain functioning but damaged; no response to environment. Family wants to withdraw support.

Suggestions

• You need to decide these things for yourself• You need to talk to your loved ones about

these things ahead of time – what you want, what they want

• You need to communicate these things to a personal physician you trust, or find a new doctor

• Communicate to the hospital doctors

• An advance directive is a document that outlines people’s preferences for medical care when, in the future, they are unable to communicate their wishes. It is particularly useful when someone is terminally ill, critically ill or has advanced Alzheimer’s disease.

• Advance directives give people a voice in their own medical decisions even after they have lost the ability to speak for themselves.

WHAT IS ANADVANCE DIRECTIVE?

BASIC RULES OF LAW OF DECISION-MAKING FOR ADULTS IN WISCONSIN

• An adult age 18 or older is the only person who can make decisions for that adult.

• Wisconsin is NOT a “next of kin” or “family consent” state for adults. This means family members are not automatically authorized to make decisions for other family members. This includes spouses.

• Caveat: in emergency and some long-term care situations, if family present are in agreement, medical professionals will generally proceed with agreed upon treatment.

• In order for a person to legally complete an advance directive, he/she must have “decision-making capacity”, meaning that person:

1. Understands the situation

2. Knows what the options and consequences are

3. Can make a decision with understanding

4. Can communicate his/her decision

• A living will contains written instructions from the patient (called the “declarant”) directly to the treating physician which directs the physician to refuse certain life sustaining procedures when the patient’s death is imminent due to:

1. a terminal condition

2. the patient being in a persistent vegetative state

• A living will does not apply to any other health care situation

• A living will does not appoint anyone to make health care decisions for anyone else. It is a directive meant for the physician.

• Living wills must be signed and dated by the patient as well as signed by two witnesses. Witnesses:

• Must be adults that are not related by blood, marriage or adoption to the patient,

• Must not have any claim to a portion of the patient’s estate, and

• Must not be directly financially responsible for the patient’s health care.

• A Power of Attorney for Health Care will also cover these situations.

LIVING WILLS, AKA “DECLARATION TO PHYSICIANS”

• People with early dementia or Alzheimer’s disease may still have decision-making capacity. They may be forgetful, but they continue to know what their values are and what they want to happen to them.

BASIC RULES OF LAW OF DECISION-MAKING FOR ADULTS IN WISCONSIN, CONTINUED

POWER OF ATTORNEY FOR HEALTHCARE“POA-HC”

• A document that authorizes another person (called the “agent”) to make health care decisions for the person executing the document (called the “principal”) and directs the agent as to the principal’s wishes. The POA-HC may also name an alternative agent in case the primary agent is unable or unwilling to act as agent.

• IMPORTANT: the person you choose to be your agent will have full decision making authority once the POA-HC is activated. Although they are required to act in “good faith”, be sure you choose your agent carefully and make sure they understand your wishes.

• A POA-HC does not grant power over the principal’s finances. A separate document, a Power of Attorney for Finances, grants those rights.

POWER OF ATTORNEY FOR HEALTHCARE“POA-HC”, CONTINUED….

• IMPORTANT: the person you choose to be your agent will have full decision making authority once the POA-HC is activated. Although they are required to act in “good faith”, be sure you choose your agent carefully, and make sure they understand your wishes. And be sure they know you have chosen them to be your POA-HC!

• To be valid, a POA-HC must be:

1. In writing

2. Dated and signed by the principal or by an adult at the express direction and in the presence of the principal

3. Signed in the presence of two qualified witnesses

• Qualified witnesses are disinterested, unrelated, not directly financially responsible for the principal’s healthcare

• The agent being appointed in the POA-HC may not be a witness

4. Voluntarily executed

5. Contain certain notice language found in the state form or a specific statement by your lawyer

POWER OF ATTORNEY FOR HEALTHCARE“POA-HC” CONTINUED…..• Once executed, the POA-HC goes “dormant” until it’s needed. When the principal

becomes incapacitated, the POA-HC needs to be “activated” and then the agent begins making health care decisions on behalf of the principal.

• POA-HC does not go into effect (“become activated”) until:

1. Two physicians OR

2. One physician and one psychologist

Who are not related to the principal and have no interest in the principal’s estate have physically examined the principal and “certify” that the he/she has become “incapacitated.” This certification must be then attached to the signed POA-HC.

Incapacity means that a person is unable to “receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her own health care decisions.” Old age, eccentricity or physical disability are not enough to find incapacity.

• Incapacity can be temporary. A POA-HC can be activated and deactivated many times. Each activation requires the same determination of incapacity.

• Incapacity vs. Incompetence

POWER OF ATTORNEY FOR HEALTHCARE“POA-HC” CONTINUED…..

• In Wisconsin, certain actions may not be taken by an agent without specific authorization spelled out in the POA-HC:

1. Admission to a nursing home on a long term basis

2. Withholding/withdrawing feeding tubes

3. Health care decisions for a principal who is pregnant

• If the principal dies, the POA-HC dies with him or her. The POA-HC does not grant rights to settle the estate of the principal to the agent.

• POA-HC can be revoked by any of the following methods:

1. Destroying the POA-HC document

2. Executing a statement, in writing and signed and dated by the principal, that expresses the principal’s intent to revoke

3. Verbally expressing the principal’s intent to revoke in the presence of two witnesses

4. Executing a subsequent POA-HC

GUARDIANSHIPIf an incapacitated person does not have a POAHC and has either no family or a family that cannot agree on their treatment, a guardian must be appointed to make decisions for them.

• Guardians are court-appointed

• Process through the courts is lengthy and expensive

• Person appointed as guardian may or may not be related to or know you and your wishes

POWER OF ATTORNEY FOR FINANCESA document that authorizes another person (called the “agent”) to make health care decisions for the person executing the document (called the “principal”) and directs the agent as to the principal’s wishes

• Gives the agent specific or general powers over principal’s finances

• Takes effect at a time designated by the principal in the document – can be immediate or at a later date, while principal is competent or incompetent.

• Can be different or same person as POAHC

DO NOT RESUSCITATE ORDER “DNR”A “Do Not Resuscitate” or “DNR” is a request not to have CPR performed if your heart

stops or if you stop breathing.

A person may refuse CPR in the institutional setting such as hospitals and nursing homes by having his or her physician write such an order. Outside of an inpatient setting, Emergency Medical Technicans have a duty to revive him/her unless he/she is wearing a state-approved DNR bracelet.

• Plastic, free, signed by the doctor that signed the DNR, OR a metal Medic-Alert bracelet.

An attending physician may issue a DNR order for a non-hospitalized patient only if all of the following apply:

• The individual is 18 years or older and• Has a terminal condition or

• Has a medical condition such that if the individual were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring such function or the individual would suffer repeated failure within a short period before death;

• Has a medical condition such that resuscitation would cause significant physical pain or harm that would outweigh the possibility that resuscitation could restore function for an indefinite period of time.

If a person has a written DNR order, but is not wearing a state-approved DNR bracelet, EMTs are required by law to begin life-saving efforts. 

DO NOT RESUSCITATE ORDER “DNR”CONTINUED….

• A DNR order can be revoked at any time by one of the following methods:

1. The patient expresses the desire to be resuscitated

2. The patient burns, cuts or otherwise destroys the DNR bracelet

3. The patient removes the DNR bracelet

Nuts and Bolts of a Power of Attorney for Health Care

Karen Ruppier

Completing Advanced Directives/Power of Attorney for Health Care (POA HC)

Objectives:•Knowledge of End of Life, Advance Directives, POA HC document, Living Will•How to choose POA HC agent•Components to consider in creating AD/POA HC•Creating a POA HC

Advance Directive:Declaration to Physician

(Living Will)

Completing POA HC

Choose POA HC agentsConsider Advance Directives–biblical principals, quality of life, medical conditionDiscuss decisions with POA HC agent; use questionnaireComplete document; sign document in presence of two witnesses not related to you or your agents

Who should you choose as Healthcare POA agents?

Is the person willing to accept the responsibility?

Is the person able to make difficult decisions under stress and advocate for you?

Does the person know your values and choices?

Is this person able to deal with tough issues in a crisis?

Can the person speak your wishes even if they do not agree with them?

Role of Agent

Make sure that the agent you choose:

Is entrusted to speak for the patient/principal

Is involved in the discussion related to the patient/principal’s care

Is willing and able to take the agent role

Is willing and able to respect and honor the choices of the patient/principal

Spiritual DimensionsA very personal dimension of one’s life includes

one’s faith.

An appreciation of how your personal faith and biblical principals fits into the discussion on end-of-life

care is important.

An understanding of how your faith community stands on these issues may be beneficial.

Contact your pastor, clergy or spiritual advisor and access other resources to answer questions, if appropriate.

End of Life Decision Choices to initiate life-sustaining treatment

CPRVentilator SupportKidney Dialysis

Choices to withdraw or withhold life-sustaining treatment

Feeding tubes, including stomach, nasogastric (placed down nose), intravenous Ventilator Support

•Choices related to comfort careSurgical proceduresPalliation and pain management

How to begin to talk about Advance Directives/End of Life Care

There may be a time I will not be able to express my wishes about end of life, so I would like to take this time to talk you …I want to talk with you about my advance directives so if/when you are asked what my wishes are you will know…I know it is not easy talking about advance directives but the more you know my wishes, the fewer decisions you need to make without knowing what I would want…I would like to give you some information to help you understand my considerations about end of life decisions…

How to begin to talk about Advance Directives/End of Life Care

•You are important, and so are your wishes…•We want to make sure we take good care of you…•I would like to give you some information to help you with your considerations about end of life decisions…what are your thoughts?•There may be a point in time when you cannot talk about your wishes, so let us talk about this now…

•I do not know all about you that I need to know to take care of you as you would like…•We do not know your preferences and goals. If you cannot tell us in advance, we could do too little or too much, and that is not necessarily serving your needs…

Once POA HC Completed

What do I do once my AD has been completed? Give a copy to:

Primary physicianHospital upon admission

AgentsLawyer

Any health care facility or agency that you useCar when traveling

Communicate placement of document in own home