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心臟衰竭患者的醫療照護事前指示

心臟衰竭患者的醫療照護事前指示

What medical procedures would you want if you were too ill to speak for yourself? That is the basic question all advance directives address. But it is unanswerable for anyone who is not both a physician and a fortuneteller, who knows what illness you will have and what therapy options you will face.

What is your goal?

The overarching guideline to an advance directive is the patient's goals of care. Goals of care change as heart failure reveals itself, has periods of exacerbation and recovery and eventually becomes terminal.

Drugs, devices and self-management can prolong life and should be optimized. At the same time, you and your cardiologist should hold ongoing conversations about end-stage heart failure and what treatments may be efficacious or futile as your disease progresses. Talk about initiating comfort measures and avoiding unnecessary tests. If you have a defibrillator, talk about when it should be de-activated. Talk about resuscitation and emergency procedures in the event of sudden decline and as preparation for anticipated progressive decline. Talk about hospice.

If the goal of care is to be at home with family, it is not in your best interest to call an ambulance or be admitted to the hospital. Your doctor can sign a Do Not Leave Home (DNLH) order that tells emergency medical technicians you do not want to be taken to the hospital or emergency department. See below for other doctor's orders.

Only in the event of serious illness

Even with an advance directive in place, if you become ill or injured with expectation of a full recovery and return to your regular routine, your advance directive is not pertinent. An advance directive is enforceable only when you are seriously ill and cannot speak for yourself.

Care you do want

Even with an advance directive in place, if you become ill or injured with expectation of a full recovery and return to your regular routine, your advance directive is not pertinent. An advance directive is enforceable only when you are seriously ill and cannot speak for yourself.

Comfort care can include the following, and more:

  • Treatment for pain
  • Treatment for nausea
  • Preventing/addressing bedsores
  • Spiritual care for patient and family
  • Psychological care for patient and family
  • Any care that eases pain and suffering
  • Receiving skin care with body lotions
  • Receiving routine moistening of mouth and eyes when drying occurs
  • Having loved ones be able to visit at any time
  • Receiving gentle massage and passive range-of-motion exercises to prevent stiffness
  • Having favored music played
  • Arrangements to donate your organs after your death
  • Arrangements to undergo an autopsy after your death

Physician orders

Some orders must come from your physician, who uses a specific form recognized by the medical community. A Do Not Resuscitate (DNR) order is probably the most familiar, but there are others used to convey a patient's wishes. For example, active comfort care orders might include Allow Visitors Extended Hours (AVEH) and Inquire About Comfort twice daily (IAC b.i.d.).

Any physician order in your medical or personal files should be re-evaluated periodically. Does it reflect your wishes? Does it reflect your current medical needs?

Physician orders include: 

  • Allow Visitors Extended Hours (AVEH) order
  • Full Comfort Care Only (FCCO) order
  • Do Not Intubate (DNI) order
  • Do Not Defibrillate (DND) order
  • Do Not Leave Home (DNLH) order
  • Do Not Resuscitate (DNR) order, also called an Allow Natural Death (AND) order
  • Do Not Transfer (DNTransfer) order
  • Inquire About Comfort (IAC) order
  • No Intravenous Lines (NIL) order
  • No Blood Draws (NBD) order
  • No Feeding Tube (NFT) order
  • No Vital Signs (NVS) order (Source, found 6-5-2015)

Put your thoughts in writing

As you complete your advance directive, think about the benefits and burdens of these therapies, and put your thoughts in your advance directive. In the event that you cannot speak for yourself, your advance directive will help your healthcare surrogate, your family and your physicians to know what your values are and what choices you have made.

Therapies for Patients and Families

  • Antibiotics—for infections in the urinary tract, due to bedsores, from aspiration pneumonia, or the like
  • Artificial nutrition—nutrients provided via a tube into the stomach, intestine or vein
  • Chemical code—permits the use of drugs, but not cardiopulmonary resuscitation (CPR), for resuscitation
  • Continuous positive airway pressure/Bilevel positive airway pressure (CPAP/BiPAP)—delivery of oxygen through a mask
  • Cardiopulmonary resuscitation—mouth-to-mouth resuscitation
  • Defibrillator or pacemaker—a device implanted in the patient to deliver a therapeutic electric shock to treat irregular heartbeats
  • Dialysis—kidney machine
  • Do Not Resuscitate order—instructions not to perform cardiopulmonary resuscitation if heart or breathing stops
  • Feeding tube—nutrition through a tube down your throat
  • Intravenous (IV) fluids—nutrition via fluid through a vein
  • Total parenteral nutrition (TPN)-nutrition delivered through a needle or catheter placed in a vein. Also referred to as hyperalimentation
  • Transfusions—often of blood or blood products
  • Ventilator—breathing machine
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