Below is a brief discussion of a number of legal issues that are relevant for clients of homecare services and their families. This discussion is a brief, layman's version of a very important and complex subject. Please consult professionals with expertise in this area for more information.

Advance Directives

The Patient Self-Determination Act, Senate Bill 1766, was passed by the United States Senate and was signed into law by President Bush on November 5, 1990. The purpose of this bill was to establish and protect people's rights allowing them to make health care decisions for themselves if they are capable of doing so.

According to the Act, people in situations where medical interventions may be called for must be given written information concerning their right to determine treatment decisions. The information must include the client's rights, the agency policies and be provided at the time the client is admitted for care. When using a home caregiver, the agency will inquire whether the client does or does not have an Advanced Directive.

Advance Directives are legal documents signed by an individual while they are still able to make health care decisions for themselves. Advance Directives include: Living Will, Health Care Power of Attorney and DNR (Do Not Resuscitate orders). The individual explains in Advance their wishes regarding future medical care. The document also names someone to make decisions for them when they are no longer competent to do so. The doctor determines competency.

This document then protects the individual from receiving unwanted treatment or from being refused treatment that they might wish to have when a terminal condition is present or if an irreversible coma is present.

Issues covered in Advance Directives include: tube feedings, IV therapy, ventilators, dialysis, pain relief, comfort measures, and can also include organ and tissue donation.

Generic forms can be found at stationary stores, in the admission department of hospitals, and as part of the admission process in other health care facilities.

Advanced Directives may be canceled or changed at any time while the patient is still competent to do so. This can be done either in writing or the patient may inform the doctor verbally.



DNR or Do Not Resuscitate Orders

A do not resuscitate order informs health care workers not to perform CPR. These orders clarify what measures should be taken in a medical emergency should a person's heart stop beating, or their respiration stops.

If an Advance Directive has not been prepared it puts an additional burden on family members and the caregiver when the individual is no longer able to make their health care decisions. Often family members cannot agree with each other or the physician on what is best for their loved one and subsequently do not know what their loved one would have wanted in a particular situation.

An example of the way DNR Orders work in a home care situation is as follows. An 87-year-old woman has 24-hour live-in care. Her caregiver goes to waken her in the morning and discovers she is no longer breathing and has no pulse. With a DNR in place, the caregiver would call the agency and not 911. If a DNR was not in place, (depending on the rules of the agency) the caregiver would call 911 and start CPR. Some agencies do not let their employees perform CPR due to the infrequency of this occurrence and the fact that in a home environment you are by yourself until help arrives. In these instances 911 would be called and the caregiver would wait for assistance.

There are important issues to discuss and agree on before one loses their ability to make their own decisions.