Form B-1576 "Advance Care Planning - Know Your Choices, Share Your Wishes: Maintain Control, Achieve Peace of Mind, and Assure Your Wishes Are Honored - Bluecross Blueshield"

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Community-wide End-of-life /Palliative Care Initiative
Community Conversations on Compassionate Care
Advance Care Planning
Know your choices, share your wishes:
Maintain control, achieve peace of mind,
and assure your wishes are honored.
CompassionAndSupport.org
Excellus BlueCross BlueShield is a nonprofit independent licensee of the BlueCross BlueShield Association.
Community-wide End-of-life /Palliative Care Initiative
Community Conversations on Compassionate Care
Advance Care Planning
Know your choices, share your wishes:
Maintain control, achieve peace of mind,
and assure your wishes are honored.
CompassionAndSupport.org
Excellus BlueCross BlueShield is a nonprofit independent licensee of the BlueCross BlueShield Association.
Dear Fellow Citizens,
What would happen if you experienced a sudden illness that prevented you
from making your own medical decisions? How would you ensure that you
receive the kind of care that you wanted? Would your family or loved ones
know enough about what you value and believe to feel comfortable about
making decisions about your care?
According to the 2008 End-of-life Care Survey of Upstate New Yorkers, nearly nine of ten local
adults said it is important to have someone close to them making medical decisions for them if they
were to have an irreversible terminal condition and were unable to make these decisions. Yet less
than half have designated a spokesperson (a “Health Care Agent”, known as a “Durable Power of
Attorney for Health Care” in other states) to assure their wishes are carried out.
With the input of more than 150 community volunteers, the Community-wide End-of-life/Palliative
Care Initiative developed a two-step approach to advance care planning that is outlined in this
comprehensive Advance Care Planning booklet. A Spanish version of the booklet is available.
Section One outlines the Community Conversations on Compassionate Care (CCCC) Program that
encourages all adults 18 and older to start a conversation and use Five Easy Steps to complete
an advance directive:
1. Learn about Advance Directives
New York State Health Care Proxy and Living Will
Advance Directives from other States
2. Remove Barriers
3. Motivate Yourself - View the CCCC videos
4. Complete Your Health Care Proxy and Living Will
Have a conversation with your family and health care provider
Choose the right Health Care Agent
Discuss your values, beliefs and what is important to you
Understand life-sustaining treatment
Share copies of your completed advance directives
5. Review and Update
Section Two describes the Medical Orders for Life-Sustaining Treatment (MOLST) Program that
was developed for those who are seriously ill or near the end of their lives to ensure a person’s
end-of-life wishes are followed whether the person is at home, in a nursing home, in a hospital or
in any community setting. In July 2008, Gov. David A. Paterson signed into law a bill that makes
MOLST a permanent, statewide program. The New York State Department of Health’s (DOH)
revised MOLST form (DOH-5003) is included in this booklet, easy to understand and aligns with
the Family Health Care Decisions Act (FHCDA). Both became effective on June 1, 2010. The
FHCDA DOES NOT eliminate the need for open and honest conversations with loved ones about
your wishes and desires for medical care and completion of advance directives.
We are pleased to produce this revised Advance Care Planning booklet on behalf of the
Community-wide End-of-life/Palliative Care Initiative to help individuals “Know Your Choices and
Share Your Wishes.” While advance directives may differ from state to state, the advance care
planning process outlined in this booklet is the same. Additional information to assist in medical
decision-making is available at the community website CompassionAndSupport.org. Complete
your advance directive today!
Sincerely yours,
Patricia A. Bomba, M.D., F.A.C.P.
Leader, Community-wide End-of-life/Palliative Care Initiative
Chair, MOLST Statewide Implementation Team
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Table of Contents
Section 1: For All Adults Age 18 and Older
Community Conversations on Compassionate Care (CCCC) Program
Learn why healthy individuals should complete Advance Directives and follow Five Easy Steps.
Step
1: Learn about Advance Directives
Advance Care Planning: What is it? ............................................................................page 3
New York State Health Care Proxy Form................................................................. Appendix
New York State Living Will Form ............................................................................ Appendix
Information about the Forms.................................................................................page 4, 5
Advance Directives from other States.........................................................................page 5
Step
2: Remove Barriers....................................................................................................page 6
Step
3: Motivate Yourself ..................................................................................................page 6
Step
4: Complete Your Health Care Proxy and Living Will: Put it in writing!
Have a conversation with your family and health care provider....................................page 6
Choose the right Health Care Agent or “Spokesperson” ...............................................page 7
Discuss your values, beliefs and what is important to you ...........................................page 8
Understand life-sustaining treatment..........................................................................page 9
Understand how to make medical decisions..............................................................page 10
Commonly used life-sustaining treatment .................................................................page 10
Share copies of your completed advance directives (Practical Issue) ..........................page 11
Talk to your doctor (Practical Issue).........................................................................page 11
Step
5: Review and Update (Practical Issue).....................................................................page 11
Section 2: For those who are seriously ill or near the end of their lives
Medical Orders for Life-Sustaining Treatment (MOLST) Program
Learn about the MOLST Program that provides actionable medical orders.
What is the MOLST Program? What is the MOLST form? ...........................................page 12
Must all health care professionals follow the medical orders on the MOLST form? .......page 12
Who should have a MOLST form? How is the MOLST form completed? ......................page 12
Who signs the MOLST form? Who makes medical decisions on the MOLST form? .......page 13
Can the MOLST be used for patients with mental illness or developmental disabilities? page 13
What is the difference between a Health Care Proxy/Living Will and the MOLST?....... page 13
What are the benefits of the MOLST Program? .........................................................page 13
Can MOLST be used in other states? What is POLST?...............................................page 13
Medical Orders for Life-Sustaining Treatment (MOLST) Form (DOH-5003) ............... Appendix
Non-Hospital Do Not Resuscitate (DNR) Form…………………………………………………….. Appendix
Checklist for Action
.................................................................................................page 14
Portions of this booklet have been adapted with permission from materials originally published by Partnership for Caring,
Inc., 1620 Eye Street, NW, Suite 202, Washington, DC 20006, 1 (800) 989-9455
Excellus BlueCross BlueShield is responsible for the content.
© 2002 Excellus BlueCross BlueShield, Revised 2010
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