WOTD Round 2 Day 1: Advance Directive

That said, let’s get right into it as always with the definition first. Welcome to WOTD Round 2!  

What's an Advance Directive?

An ADVANCE DIRECTIVE is a legal document, often including a living will, that provides instructions for medical treatment and only goes into effect if you cannot communicate your own wishes.

ACP (advance care planning) is the process that helps adults and their families understand and share their values, goals, and future medical care preferences.

Advance Care Planning: Advance Directives for Health Care | National Institute on Aging

ADVANCE HEALTHCARE DIRECTIVES — AAMG Doctors

From Wikipedia.org: 
An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity.

This isn’t something we necessarily want to think about or talk about but many mistakenly believe that advance care planning is something only senior citizens need to be concerned about. This is absolutely not the case. Accidents and illnesses happen when you least expect it and they don’t care how old you are. 

Taking the time now to develop a plan and get your legal documents in order will make things easier on your family and other caregivers should anything happen that renders you unable to make decisions for yourself. Examples of such situations include being unconscious, in a coma, too ill to communicate your wishes, or when you have chosen someone you trust to make these decisions. “Advance directives provide a way for you to communicate your wishes to your family, friends, and health care professionals, and to avoid confusion later on.”
Advance Directives | Texas Health and Human Services

Speaking from experience as someone with two parents who have/had Alzheimer’s disease, trust me when I say that the last thing  your family needs while they’re grieving what’s happening to you (and ultimately to the entire family) is confusion over trying to figure out what you would want them to do for you. Take that weight off of them and make your plans now. Discuss your plans with your loved ones now. You can ensure that you get the care you want and need and avoid unnecessary suffering, as well as relieving your caregivers of the decision making burden during an already difficult time.

What happens if you do not have an advance directive?

If you do not have an advance directive and you are unable to make decisions on your own, the state laws where you live will determine who may make medical decisions on your behalf. This is typically your spouse, your parents if they are available, or your children if they are adults. 

NOTE:

• If you are unmarried and have not named your partner as your proxy, it’s possible they could be excluded from decision-making
• If you have no family members, some states allow a close friend who is familiar with your values to help
• They may assign a physician to represent your best interests

To learn about the laws in your state, contact your state legal aid office or state bar association.
Advance Care Planning: Advance Directives for Health Care | National Institute on Aging

What are the limits of an Advance Directive?

Advance directives have limitations. A person:

• May not fully understand treatment options or choices they have
• May change their minds and forget to tell others
• Have advance directives that are too vague to guide medical decisions or may not be useful when situations change

Advance Directives | HealthInAging.org

NOTE: each state has its own set of laws governing advance directives.

What types of advance directives do you need?

There are several types/components of advance directives and we’ll talk a little bit about each one. Different sources include different documents/directives.

The top two:

• Living will
• Medical power of attorney (aka durable power of attorney for health care)

The next most common:

• DNR: Do Not Resuscitate
• POLST/MOLST: Provider/Medical Orders for Life-Sustaining Treatment

NOTE: There is a key difference between the advance directive and the POLST: the POLST is a specific type of MEDICAL ORDER while the advance directive is a group of LEGAL DOCUMENTS. We’ll get into more about that later but the thing to remember is that while a POLST can be used WITH an advance directive, it is not a substitute for it.

Details of the elements included in the advance directive

Living Will

Also known as the Directive to Physicians and Family or Surrogates, this form is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known due to illness or injury. Advance Directives | Texas Health and Human Services

You should list many possible end-of-life care decisions in your living will. Talk to your healthcare professional about any questions you may have about the following medical decisions. (Palliative and hospice care, organ and tissue donations, and body donation are three of the most frequently used designations in the living will/advance directive.)

Medical Power of Attorney Designation of Health Care Agent (MPOA)

Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes.

A proxy can be chosen in addition to OR instead of a living will. Having a health care proxy helps you plan for situations that cannot be foreseen, such as a serious car accident or stroke.

Your healthcare proxy

Depending on where you live, the person you choose to make healthcare decisions on your behalf may be called one of the following:

• Healthcare agent
• Healthcare proxy
• Healthcare surrogate
• Healthcare representative
• Healthcare attorney-in-fact
• Patient advocate

Choosing a person to act as your healthcare agent is important. Even if you have other legal papers about your care, you can't anticipate all situations ahead of time, such as emergencies and illnesses. And in some situations, someone will need to decide about your likely care wishes.

Aim to choose a person who:

• Meets your state's requirements for a healthcare agent
• Is not your healthcare professional or a part of your medical care team
• Is willing and able to discuss medical care and end-of-life issues with you
• Can make decisions that follow your wishes and values
• Can speak up for you (advocate for you) if there are disagreements about your care

The person you name may be a spouse, other family member, friend or member of a faith community. You also may choose one or more other people in case the person you chose is unable to fulfill the role.

Speaking from personal experience as my mother’s POA, medical and otherwise, I highly suggest choosing more than one in case the illness/condition goes on as long as Alzheimer's. The first proxy may grow fatigued of the position while they’re also grieving for their loved one, and/or they may develop an issue of their own that renders them incapable of continuing the responsibility. After 10 years of acting as my mother's representative, I was extremely thankful that her MPOA allowed for designating a replacement representative so that my daughter could take over as I deal with my own health issues related to chronic illness.

Additional orders/directives:

You might want to prepare documents to express your wishes about a single medical issue or something else not already covered in your advance directives, such as an emergency. For these types of situations, you can talk with a doctor about establishing the following orders:

Do not resuscitate (DNR) order

• A DNR becomes part of your medical chart to inform medical staff in a hospital or nursing facility that you do not want CPR or other life-support measures to be attempted if your heartbeat and breathing stop.
• Sometimes this document is referred to as a do not attempt resuscitation (DNR) order or an allow natural death (AND) order.
• Even though a living will might state that CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your hospital bed might avoid confusion in an emergency.
• Without a DNR order, medical staff will attempt every effort to restore your breathing and the normal rhythm of your heart.

Out-of-hospital DNR order:

An out-of-hospital DNR alerts emergency medical personnel to your wishes regarding measures to restore your heartbeat or breathing if you are not in a hospital. (This is useful if a person is in a nursing home, memory care facility, etc.)

Do not intubate (DNI) order:

A similar document, a DNI informs medical staff in a hospital or nursing facility that you do not want to be on a ventilator.

Do not hospitalize (DNH) order:

A DNH indicates to long-term care providers, such as nursing home staff, that you prefer not to be sent to a hospital for treatment at the end of life.

Physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST) forms

• These forms provide guidance about your medical care that health care professionals can act on immediately in an emergency. They serve as a medical order in addition to your advance directive.
• Typically, you create a POLST or MOLST when you are near the end of life or critically ill and understand the specific decisions that might need to be made on your behalf.
• These forms may also be called portable medical orders or physician orders for scope of treatment (POST).
• Check with your state department of health to find out if these forms are available where you live.

Advance Care Planning: Advance Directives for Health Care | National Institute on Aging

POLST Program Names

Declaration of Mental Health Treatment

• This directive allows a court to determine when you become incapacitated, and when that declaration becomes effective.
• You may opt not to consent to electro-convulsive therapy or to the use of psychoactive drugs.
• The declaration expires in three years, unless you are incapacitated at that time.

Advance Directives - Texas Hospital Association

FURTHER READING/RESEARCH:

• Advance Care Planning: Advance Directives for Health Care | National Institute on Aging (to find advance directive forms in your state)
• Planning After a Dementia Diagnosis | Alzheimers.gov
• POLST Program Names
• Advance Directives | Texas Health and Human Services
• Advance Directives | HealthInAging.org
• ADVANCE HEALTHCARE DIRECTIVES — AAMG Doctors
• Advance Directives - Texas Hospital Association
• Advanced Directives for Medical Care - Wills & Directives - Guides at Texas State Law Library

Definitions (as included with the Directive to Physicians and Family or Surrogates/Living Will)

“Artificially administered nutrition and hydration"

The provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the gastrointestinal tract.

"Irreversible condition" means a condition, injury, or illness that:

• May be treated, but is never cured or eliminated
• Leaves a person unable to care for or make decisions for the person's own self
• Without life-sustaining treatment provided in accordance with the prevailing standard of medical care, is fatal

Explanation: Many serious illnesses such as cancer, failure of major organs (kidney, heart, liver, or lung), and serious brain diseases such as Alzheimer's dementia may be considered irreversible early on. There is no cure, but the patient may be kept alive for prolonged periods of time if the patient receives life-sustaining treatments. Late in the course of the same illness, the disease may be considered terminal when, even with treatment, the patient is expected to die.

You may wish to consider which burdens of treatment you would be willing to accept in an effort to achieve a particular outcome. This is a very personal decision that you may wish to discuss with your physician, family, or other important persons in your life.

"Life-sustaining treatment"

Treatment that, based on reasonable medical judgment, sustains the life of a patient and without which the patient will die.

Includes:

• Life-sustaining medications
• Artificial life support such as
  • Mechanical breathing machines
  • Kidney dialysis treatment
  • Artificially administered nutrition and hydration

Does NOT include:

• Administration of pain management medication
• Performance of a medical procedure necessary to provide comfort care
• Any other medical care provided to alleviate a patient's pain

"Terminal condition"

An incurable condition caused by injury, disease, or illness that according to reasonable medical judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care.

Explanation: Many serious illnesses may be considered irreversible early in the course of the illness, but they may not be considered terminal until the disease is fairly advanced. In thinking about terminal illness and its treatment, you again may wish to consider the relative benefits and burdens of treatment and discuss your wishes with your physician, family, or other important persons in your life.


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