Before Your Stay

Forms

(See below for more information)


Advance Directives

Medical Care Decisions - A Summary of Hospital Policy

We recognize that individuals have the right to make decisions concerning their medical care. These decisions should be made after careful consultations with physicians, family members, attorneys, and/or other advisers. The best way to ensure that your wishes regarding medical care are complied with is through specific, ongoing discussions with your physician who orders medical treatment.

In addition, federal law (the Patient Self-Determination Act) requires that we provide you with information on self-determination, including the right to accept or refuse medical treatments. Below is a summary of how we will act to see that your wishes are complied with in accordance with law, your physician's orders, and our mission and philosophy:

1. This information sheet and an information sheet provided by the state of North Carolina will be given to each adult admitted to the hospital. A copy of the Secretary of State's brochure can be downloaded here.

2. A nurse will ask, as part of her information gathering interview with you, whether you have executed a living will, a power of attorney for health care, or any other "advance directives."

3. If you do have an advance directive, we will ask for a copy and will put it in your medical record; we will also give a copy to your physician.

4. If you do not have an advance directive, but want more information or assistance in getting one, we will provide printed materials and try to answer questions you may have (or direct you to an appropriate source for an answer).

5. If you wish to execute an advance directive, we will assist you.

6. We will comply with the directions given in your advance directive in accordance with applicable laws, your physician's orders, and the hospital's mission and philosophy.

It is IMPORTANT to us that you know the following:

1. We will do our best to comply with your wishes concerning medical care (as understood and ordered by your physician) whether or not you have a written advance directive.

2. It is not necessary that you have an advance directive in order to receive treatment at Iredell Memorial. We will give you the same level of compassionate, conscientious care whether you have a written advance directive or not.

3. We (and your physician) need to know whenever you have an advance directive and whether you have changed it or revoked it.

If you have any questions about advance directives or hospital policy, please call extension 3500 or 3501 (Administration) between the hours of 8:30 AM. and 5:00 PM, weekdays.

You also have the right to voice any concerns about our handling of advance directive matters to the North Carolina Division of Facility Services Complaint Section at (800) 662-3004.

Medical Care Decisions & Advance Directives

What You Should Know

This information was developed by the North Carolina Division of Medical Assistance in cooperation with the Department of Human Resources Advisory Panel on Advance Directives in 1991. Revised 1999.

Who decides about my medical care or treatment?
If you are 18 or older, married or legally emancipated and have the capacity to make and communicate health care decisions, you have the right to make decisions about your medical/mental health treatment. You should talk to your doctor or other health care provider about any treatment or procedure so that you understand what will be done and why. You have the right to say yes or no to treatments recommended by your doctor or mental health provider. If you want to control decisions about your health/mental health care even if you become unable to make or to express them yourself, you will need an "advance directive."

What is an advance directive?
An advance directive is a set of directions you give about the health/mental health care you want if you ever lose the ability to make decisions for yourself. North Carolina has three ways for you to make a formal advance directive. One way is called a "living will'; another is called a "health care power of attorney"; and another is called an "advance instruction for mental health treatment."

Do I have to have an advance directive and what happens if I don't?
Making a living will, a health care power of attorney, or an advance instruction for mental health treatment is your choice. If you become unable to make your own decisions, and you have no living will, advance instruction for mental health treatment, or a person named to make medical/mental health decisions for you (health care agent), your doctor or health/mental health care provider will consult with someone close to you about your care.

Living Will

What is a living will?
In North Carolina, a living will is a document that tells others that you want to die a natural death if you are terminally and incurably sick or in a persistent vegetative state (coma or irreversible advanced dementia) from which you will not recover. In a living will, you can direct your doctor not to use heroic treatments that would delay your dying, for example by using a breathing machine ("respirator" or "ventilator"), or to stop such treatments if they have been started. You can also direct your doctor not to begin or to stop giving you food and water through a tube ("artificial nutrition or hydration").

Health Care Power of Attorney

What is a health care power of attorney?
In North Carolina, you can name a person to make medical/mental health care decisions for you if you later become unable to decide yourself. This person is called your "health care agent." In the legal document you name who you want your agent to be. You can say what medical treatments/mental health treatments you would want and what you would not want. Your health care agent then knows what choices you would make.

How should I choose a health care agent?
You should choose an adult you trust and discuss your wishes with the person before you put them in writing.

Advance Instruction for Mental Health Treatment

What is an advance instruction for mental health treatment?
In North Carolina, an advance instruction for mental health treatment is a legal document that tells doctors and health care providers what mental health treatments you would want and what treatments you would not want if you later become unable to decide yourself. The designation of a person to make your mental health care decisions, should you be unable to make them yourself, must be established as part of a valid Health Care Power of Attorney.

Other Questions

How do I make an advance directive?
You must follow several rules when you make a formal living will, health care power of attorney, or an advance instruction for mental health treatment. These rules are to protect you and ensure that your wishes are clear to the doctor or other provider who may be asked to carry them out. A living will, a health care power of attorney, and an advance instruction for mental health treatment must be written and signed by you while you are still able to understand your condition and treatment choices and to make those choices known. Two qualified people must witness all three types of advance directives. The living will and the health care power of attorney also must be notarized. You can also register your form with the Secretary of State if you choose to do so. There is a $10 fee per document.

Are there forms I can use to make an advance directive?
Yes. There is a living will form, a health care power of attorney form, and an advance instruction for mental health treatment form that you can use. These forms meet all of the rules for a formal advance directive. Using the special form is the best way to make sure that your wishes are carried out. The forms are available at the hospital, by clicking on the links above, and from NC Secretary of State's website.

When does an advance directive go into effect?
A living will goes into effect when you are going to die soon and cannot be cured, or when you are in a persistent vegetative state (coma or irreversible advanced dementia). The powers granted by your health care power of attorney go into effect when your doctor states in writing that you are not able to make or to make known your health care choices. When you make a health care power of attorney, you can name the doctor or mental health provider you would want to make this decision. An advance instruction for mental health treatment goes into effect when it is given to your doctor or mental health provider. The doctor will follow the instructions you have put in the document, except in certain situations, after the doctor determines that you are not able to make and to make known your choices about mental health treatment. After a doctor determines this, your Health Care Power of Attorney may make treatment decisions for you.

What happens if I change my mind?
You can cancel your living will anytime by informing your doctor that you want to cancel it and destroying all the copies of it. You can change your health care power of attorney while you are able to make and make known your decisions by signing another one and telling your doctor and each health care agent you named of the change. You can cancel your advance instruction for mental health treatment while you are able to make and make known your decisions, by telling your doctor or other provider that you want to cancel it. If you registered your form(s) with the Secretary of State, you can also file a request to have them removed from the registration.

Whom should I talk to about an advance directive?
You should talk to those closest to you about an advance directive and your feelings about the health care you would like to receive. Your doctor or health care provider can answer medical questions. A lawyer can answer questions about the law. Some people also discuss the decision with clergy or other trusted advisors.

Where should I keep my advance directive?
Keep a copy in a safe place where your family members can get it. Give copies to your family, your doctor or other health/mental health care provider, your health care agent and any close friends who might be asked about your care should you become unable to make decisions.

What if I have an advance directive from another state?
An advance directive from another state may not meet all of North Carolina's rules. To be sure about this, you may want to make an advance directive in North Carolina too. Or you could have your lawyer review the advance directive from the other state.

Where can I get more information?
You can talk to your provider, stop by Administration at Iredell Memorial Hospital during business hours, or read the frequently asked questions at the Secretary of State's website.

Are there other forms available that will help ensure my health care decisions are known and followed?
Other forms that you may want to be aware of include Authorization to Consent to Health Care for a Minor, Organ Donor Card, Portable Do Not Resuscitate (DNR) Orders, and Medical Orders for Scope of Treatment (MOST). An authorization to consent to health care for a minor is a legal document that allows parents with sole or joint legal custody of a minor (under 18) to authorize another adult to make certain health care decisions for their child or children in their absence.

An Organ Donor Card is a document that allows you to donate your organs. You can become an organ donor by expressing your desire to donate in your will, by authorizing the NC Division of Motor Vehicles to put an organ donor symbol on your driver’s license or identification card, by completing an organ donor card or other document, or by authorizing that a statement or symbol be included on the NC Organ Donor Registry. You also may authorize an agent to make an anatomical gift of organs under a health care power of attorney. To make sure your wishes are honored, you should discuss organ donation with your family, friends, and health care providers so they know and can carry out your wishes. You can get an organ donor card from the North Carolina Department of the Secretary of State Advance Health Care Directive Registry at: http://www.secretary.state.nc.us/ahcdr or click on the link above.

A Portable Do Not Resuscitate (DNR) Order is a medical order that can be followed by emergency medical responders or other health care providers that tells them not to attempt cardiopulmonary resuscitation (CPR) if your heart and breathing stop (cardiopulmonary arrest). Because it is portable, it can be followed in different settings (for example, in your home, in a nursing home, or in a hospital). Since a Portable DNR Order is a physician or medical order it must be signed by your physician (in NC, physician assistants and nurse practitioners also may issue these orders). It is effective when it is completed and signed by your physician (orphysician assistant or nurse practitioner). It can be cancelled by destroying or writing “void”on the original form. Portable DNR Orders must be obtained from your physician. For more information, be sure to talk to your physician or other health care provider.

A Medical Order for Scope of Treatment, called a MOST form, like a Portable DNR Order, is a medical order that can be followed in different settings such as in the home, nursing home, hospital, etc. A MOST form contains instructions for CPR and also addresses other end-of-life treatments that you may or may not want to receive. For example, a MOST can tell emergency medical responders and other health care providers what level of treatment you would like to receive, whether you would like to receive antibiotics, and artificial nutrition and hydration through tubes. While a MOST is a medical order that must be signed by your physician (or physician assistant or nurse practitioner), it also must be signed by you or, if you are not able to make or communicate your health care decisions, by someone who is legally recognized to speak for you. A MOST can be cancelled by destroying the original form or indicating on the form that it is void. A MOST form must be obtained from your physician. For more information, be sure to talk to your physician or other health care provider.