New advance directive in Oklahoma.

Oklahoma's advance directive law was amended in the last legislative session. Changes to the law and statutory form are significant and every nurse should become familiar with the new information. Most fields of nursing practice may involve end-of-life care planning. Additionally, nurses can make their personal plans for advance care planning and talk to their families about the important issues and decisions at the end of life.

Any written or spoken instruction that a person makes about wishes for end-of-life treatment is to be considered an advance directive. Many people call these directions a living will. Conversations with patients about end-of-life issues should be documented thoroughly in the medical record. However, a written document completed by the patient is always preferable.

CHANGES IN OKLAHOMA LAW AND FORM

Four major changes to the new law and form were made earlier this year. First, the new document goes into effect any time two physicians declare that a patient is incapable of making an informed decision regarding health care. Under the old law the advance directive was not in effect until a person was considered terminally ill or persistently unconscious as well as incapacitated.

Second, the health care proxy who is named now can make whatever medical decisions the patient would make if he or she were able. This expands the powers of the proxy beyond end-of-life decisions.

Third, the advance directive now covers other medical conditions. In addition to terminal illness and persistent unconsciousness, a new definition has been added. It describes an "end-stage condition." This is any "... condition caused by injury, disease, or illness, which results in severe and permanent deterioration indicated by incompetency and complete physical dependency for which treatment of the irreversible condition would be medically ineffective." This refers to Alzheimer's disease and other conditions which meet the definition.

Fourth, the advance directive now offers clear choices about artificially administered hydration and nutrition. The choices as outlined in the new Oklahoma Advance Directive for Health Care are for (1) no life-sustaining treatment except tube feeding, (2) no life-sustaining treatment of any kind, or (3) all life-sustaining treatment and tube feeding. Other life-sustaining treatment might include a ventilator, dialysis, or other medical treatment.

OTHER ASPECTS OF THE ADVANCE DIRECTIVE

It is very important to know patients' wishes about tube feeding at the end of life. Another Oklahoma law, the "Hydration and Nutrition for Incompetent Patients Act," declares that every incapacitated person in Oklahoma who is unable to take water and food by mouth wants to be tube fed. This presumption can be overcome if health care providers know that the patient, while competent to make the decision, did not want tube feeding at the end of life.

The new advance directive form contains space to write down directions to health providers about specific treatments or procedures. For example, patients can say they want effective relief from pain even if it may hasten the dying process. If someone suffers from serious chronic illness and does not wish to be resuscitated, this information may be included in this section.

The patient's signature on the form must be witnessed by two persons who will not inherit from them. Nurses and other health care providers can witness the signature. The completed form should be copied and distributed to physicians, other health care providers, the proxy and alternate, and other relevant family and friends.

As long as patients are capacitated and able to communicate their wishes, there is no reason to use the advance directive. The written instructions about tube feeding and other treatments are only relevant if two physicians have declared that the patient is terminally ill, persistently unconscious or in an end-stage condition. The law defines a terminal condition as one that is incurable and irreversible and expected to result in death within six months. It defines persistent unconsciousness as a condition in which thought and awareness of self and environment are absent.

In the Oklahoma Advance Directive for Health Care form a health care proxy and alternate can be named. In the new law, the health care proxy is "... authorized to make whatever medical treatment decisions I could make if I were able," but can make decisions regarding life-sustaining treatment and tube feeding only as the person has indicated in the document. This language expands the powers of the health care proxy.

Patients should talk at length with the person they name as their proxy. The proxy should be willing to be a voice and advocate with health care providers when the patient is unable to speak for themselves. The proxy should have a clear idea about the patient's wishes at the end of life.

TALKING ABOUT ADVANCE CARE PLANNING

Talking to patients about advance directives is something that health care professionals know should be done. However, time and circumstance sometimes limit or prevent the conversation. The amendments to the Oklahoma law and changes in the form give new importance to these end-of-life discussions with patients. To think about where to start, ask this question about patients in the hospital, office, or caseload: "Would I be surprised if this patient died in the next six months or year?" If the answer is "No, I would not be surprised if they died soon," then the time for discussion of end-of-life wishes and documentation is now. An advance directive must be filled out before the patient becomes incapacitated by dementia or too ill to make his or her wishes known.

Dr. Joanne Lynn, director of Americans for Better Care of the Dying, has offered some tips for talking about end-of-life care. First, be willing to take the openings that patients offer. Many times they will refer to their own death or ask an oblique question about their prognosis. This is a time for honest answers and discussion, not avoidance. If possible, find a time for the discussion before a crisis hits. When patients have a change of condition that requires new treatment, medication, a change of living situation or decreased functioning, it is logical to take a few minutes to look ahead. Making advance care planning a routine part of nursing assessment is a realistic goal.

Learn to talk naturally about a time when the patient will no longer be alive. Talk about their current hopes and fears, and explore the questions they may have about the future. Recognize that the patient has a past, is living in the present, and is facing an uncertain future. Talking about the past, exploring what is going well and what is going badly at the present, and asking about their future hopes, dreams and fears is a compassionate part of nursing practice. Take time to hear this narrative, check what has been said; talk not just about practical things, but also emotions and spiritual issues.

CONCLUSION

The new law specifically states that the older forms of the Oklahoma advance directive are still valid. However, because of the many changes in the new law, it is recommended that everyone complete the new form, even if they have an earlier document. Advance directives are not just for patients. If nurses and their loved ones have not documented their wishes, this is a good time to do so.

In summary, the new Oklahoma Advance Directive for Health Care now goes into effect any time the patient is incapacitated, not just when he or she is terminally ill or persistently unconscious. It has added a new "end-stage condition" to the end-of-life definition. The powers of the proxy have been greatly expanded to speak on behalf of the patient about all medical decisions, not just end-of-life decisions. And it provides clear choices about artificial hydration and nutrition.

A copy of the form can be downloaded from the website of the Oklahoma Palliative Care Resource Center, http://okpalliative.nursing.ouhsc.edu/ or by calling 405-271-1491, extension 49194, or e-mail [e-mail]. The Oklahoma Palliative Care Resource Center is a comprehensive on-line resource for Oklahoma health care providers interested in palliative care and end-of-life issues.

Linda Edmondson, LCSW, [e-mail] has more than twenty years experience as a medical social worker in end-of-life care. She is a volunteer Co-Chair for the Attorney General's Task Force to Improve End-of-Life Care in Oklahoma.