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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
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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
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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
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Beginning of life
End of life
Traditional medical treatments
Alternative medical treatments
Organ donation
Resource allocation
Medical research
Questions to ask
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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
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Ordinary vs. Extraordinary
Curative vs. Palliative
Outcomes
One thing leads to the next
Who is decisional
Basic
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Symptomatic medications
Sedation
IV fluids
Comfort measures
More aggressive medical therapies
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Chemotherapies
IV medications
IV feeding
Feeding tube
Procedures/Surgeries
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Low risk surgery
High risk surgery
Central lines
Pacemakers/defibrillators
Cardiac cath/intervention
Endoscopy
Resuscitation
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CPR
Medical resuscitation
Defibrillation
Intubation/ventilation
Mechanical life support
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Dialysis
Life sustaining IV medications
Mechanical ventilation
Artificial heart
Transplants
“Do everything”
“Try it temporarily”
Options
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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.
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An adult age 18 or older is the only person who can make decisions for
that adult.
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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.
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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
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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
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A living will does not apply to any other health care situation
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A living will does not appoint anyone to make health care decisions for anyone
else. It is a directive meant for the physician.
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Living wills must be signed and dated by the patient as well as signed by two
witnesses. Witnesses:
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Must be adults that are not related by blood, marriage or adoption to the
patient,
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Must not have any claim to a portion of the patient’s estate, and
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Must not be directly financially responsible for the patient’s health care.
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A Power of Attorney for Health Care will also cover these situations.
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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.
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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.
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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.
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A POA-HC does not grant power over the principal’s finances. A
separate document, a Power of Attorney for Finances, grants those
rights.
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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!
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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
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Qualified witnesses are disinterested, unrelated, not directly financially
responsible for the principal’s healthcare
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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 
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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.
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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.
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Incapacity can be temporary. A POA-HC can be activated and deactivated many
times. Each activation requires the same determination of incapacity.
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Incapacity vs. Incompetence
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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
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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.
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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
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
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Gives the agent specific or general powers over principal’s finances
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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.
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Can be different or same person as POAHC
If 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.
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Guardians are court-appointed
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Process through the courts is lengthy and expensive
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Person appointed as guardian may or may not be related to or know you and
your wishes
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.
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Plastic, free, signed by the doctor that signed the DNR, OR a metal MedicAlert 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.
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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
Declaration to Physician
(Living Will)
Completing POA HC
Choose POA HC agents
Consider Advance Directives–biblical
principals, quality of life, medical condition
Discuss decisions with POA HC agent; use
questionnaire
Complete document; sign document in
presence of two witnesses not related to you or
our 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 Dimensions
A 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
CPR
Ventilator Support
Kidney Dialysis
Choices to withdraw or withhold life-sustaining
treatment
Feeding tubes, including stomach, nasogastric (placed
down nose), intravenous
Ventilator Support
•Choices related to comfort care
Surgical procedures
Palliation 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 physician
Hospital upon admission
Agents
Lawyer
Any health care facility or agency that you use
Car when traveling
Communicate placement of document in own home