Among the many forms that people are asked to fill out when they are admitted to a care facility is one called the “Degree of Intervention” or “Level of Intervention” form. This form is supposed to act as a guideline for (usually) Nursing staff in the event that an emergency occurs, or when a resident’s health has a turn for the worse and a decision has to be made about how much and how aggressive treatment should be. They are sometimes described as “Advanced Directives.”
Typically Degree, or Level, of Intervention (DOI of LOI) forms have four levels. The levels, described below, vary across jurisdictions and throughout Canada. The “levels” noted below are not standardized. Level 1 in one residence or province may mean “almost no intervention”, while in another location Level 1 may mean “all interventions possible.” If they move from less to more intervention, the levels will typically be as follows:
Level 1: This is usually a level appropriate for when a person is palliative. It indicates that there will be no intervention to attempt to cure someone. They will receive medical attention to keep them comfortable, such as oxygen and pain relief. They will not receive antibiotics or other restorative medications. They will not be transferred to hospital for care and there will be no attempts at cardio-pulmonary resuscitation (CPR).
Level 2: This is similar to level one, except that a person WILL be treated with medications such as antibiotics and receive other treatments to cure, provided that the treatment can be done within the residence. They WILL NOT be transferred to hospital for care and there will be no attempts at cardio-pulmonary resuscitation (CPR).
Level 3: If attempts at care do not succeed in the residence, the person WILL be transferred to hospital for treatment, but would not go to an Intensive Care Unit, or have “extraordinary” measures taken to preserve life. There will be no attempts at cardio-pulmonary resuscitation (CPR).
Level 4: Similar to Level 3, except a person could be cared for in Intensive Care and could have all attempts including CPR, to preserve life.
The Levels of Intervention should be guidelines. They need to be the basis for discussion among family members and the person who would be the recipient of care. All involved should understand exactly what is meant by each level in the residence to which the individual is being admitted.
For instance, there may be a situation where a person has an advanced dementia, but is not palliative. When they were healthy they expressed the wish to be allowed to die peacefully if they reached their current state. So for example, they would not have wanted to be given antibiotics for pneumonia. However, if they were to come down with a urinary tract infection, which can be painful, they would have wished to be treated with antibiotics. Does the family choose level one, or level two?
Ideally (although this writer has never seen it) the Level of Intervention form should be accompanied by a dated notes page which documents the discussion and concerns of resident and family, particulars of any decisions, and with whom the discussion was held.
If the Resident does not have the capacity to understand the form, then family or designated decision makers should sign it. Remember, even though a person may have a dementia or some other impairment, they are often able to express their wishes. A substitute decision maker should choose the level which, from their understanding, the person would have chosen for him or herself. The substitute decision maker should not choose a level based on what he or she wants or what is convenient for him/her.
Generally the Degree of Intervention form is reviewed once a year. However, the level can be changed at any time according to the wishes of the Resident or Family. They are most often changed when a resident’s health or quality of life has deteriorated.
What You Need to Know About DOI Forms
We spoke to Laura Watts, National Director of the Canadian Centre for Elder Law. She had a number of concerns with regards to Degree of Intervention forms in particular and more generally with the use of DOIs as a concept.
Degree of Intervention forms, are often short-hand, tick box forms. As such she feels that they are generally inappropriate for the complicated, important, and communication-based process of advance care planning. Advanced care planning is the way we keep control of what happens to us when we may not be able to give directions ourselves. They are also what can help relieve family members of the guilt inducing and gut wrenching responsibility of making hard decisions for a loved one.
No health care professional, long-term care residence or provider of health care can require a mentally capable adult, or if that person is incapable, their legally appointed substitute decision-maker, to sign a Degree of Intervention form. Refusal cannot be used as a reason to refuse admission. This is illegal in BC, but does exist, problematically, in practice in some places, both in BC and across Canada.
Residents and their supporters should be very careful about signing these forms. If they do decide to use this instrument, they should consider seeking legal advice and have significant discussion about their values, wishes and beliefs, as well as their broader advance care plan, before signing such a document. It is also important to note that a DOI form that is only signed by a physician is also not legal, unless the physician happens to be the now-incapable adult’s legally designated alternative decision maker (e.g. – appointed as an adult’s Representative in a Representation Agreement).
Signing DOI forms can have serious and significant problematic impact for an adult’s previous advance care plan. It may confuse or contradict a previously made document such as a Representation Agreement or the values, wishes and beliefs previously expressed verbally, in writing or otherwise to the adult’s correct legal substitute decision-maker.
Laura adds that LOIs can be used problematically as a way of not engaging with an adult, and can have the effect of infantalizing or de-humanizing the adult in care. No one wants to be known as a “Level 2”. Rather, people in care want to be respected and understood as a whole person.
Our next newsletter will focus on Advanced Care Planning.
Canadian Centre for Elderlaw
The Canadian Centre for Elder Law (“CCEL”) is the national non-profit charitable organization which works to improve the lives of older adults in their relationship with the law. Its goal is to be the best in elder law reform and outreach relating to elder law and elder rights issues. The CCEL is a division of the British Columbia Law Institute.
CCEL has done several different studies, including ones on private care agreements, financial arrangements between older adults and family members, and reverse mortgages.
See the CCEL website http://www.bcli.org/ccel
See also: The Personal Planning and Resource Registry (formerly Representation Agreement Resource Centre) http://www.nidus.ca
Aging With Dignity (Developers of the Five Wishes advanced care planning document): http://agingwithdignity.org
