3 Topics for Your Health Care Advance Directive

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Of all the difficult topics to discuss in planning for the long term, what you want to happen if you or your parent is seriously ill or has an accident is the one most avoided. Other touchy subjects, such as driving problems and money mismanagement, surface on their own.

But all too often the discussion of what to do if you become seriously ill or incapacitated and cannot speak for yourself only happens in a crisis — the worst time for thoughtful and well-informed conversations.

Nothing will make these profound discussions easy. But you can lay the groundwork in ways that increase your family's chances of being prepared when decisions about treatment and level of care must be made. Here are three ways to organize your thinking, create legal documents, and understand care options.

Adding do not resuscitate (DNR) orders

Do not resuscitate orders are a special kind of advance directive. They tell doctors, nurses, emergency medical technicians, and others that a person has decided not to undergo CPR (cardiopulmonary resuscitation) if his heart stops beating or he stops breathing.

A doctor must sign the DNR order for it to be active. In a hospital or other healthcare facility, staff will start CPR if there is no DNR in the medical record.

Why would anyone not want CPR if it could restore a heartbeat? Certainly this decision is weighty. Success rates for CPR vary, but much depends on the person's overall medical condition. CPR may not be effective for older people with serious chronic conditions. And unlike the portrayals of CPR on television, these interventions can be quite brutal, leading to broken ribs and other injuries, especially for an older person.

Most state laws authorize a doctor to enter a special DNR order that will be honored outside the hospital. This is important because when emergency medical technicians respond to a 911 call at home, they are legally required to start CPR unless there is an out-of-hospital DNR order.

Even with the proper documentation, in the panic of the moment, sometimes DNR orders are ignored. At home the DNR order should be easy to find, not something that has to be hunted down in a crisis. You can post the DNR order on the refrigerator door, for example, or on an easy-to-see bulletin board.

Since a DNR is a doctor's order, you will need to ask your doctor to fill out the form. If he is reluctant to do so, ask why. It may be a good way to start an important conversation about your wishes.

Keeping your advance directive accessible

A carefully completed advance directive is useless if no one knows where it is when you are seriously ill or in an accident. A safe deposit box is great for precious jewelry; for advance directives, not so much.

Discuss your advance directive with your doctor(s), and tell them the name and contact information for the person you have selected as a healthcare proxy. You should provide a copy of the document, which can then go into your medical record.

In a hospital, your regular doctor may not be in charge of your care, so it is essential to have the advance directive as part of your hospital record. When you are admitted to a hospital or other healthcare facility, you will be asked (it's a federal requirement) if you have an advance directive. If this is a planned admission, be sure to bring the document with you.

Your healthcare proxy should have a copy of your advance directive as well as any supporting material that documents your wishes. You should review the advance directive every few years, or more often if your health condition changes. The document should have a relatively recent date. A document created 15 years ago is likely to cause someone to ask, “But what if he or she changed his or her mind?”

You can register your advance directive online at U.S. Living Will Registry. It will then be available to all providers. Be sure to update the registry if you change the document.

Choosing Physician’ Orders for Life-Sustaining Treatment (POLST)

A recent development in advance directives is the Physician Order for Life-Sustaining Treatment (POLST). POLST started in Oregon but has spread to many states. In New York, it is called MOLST (Medical Orders for Life-Sustaining Treatment), and in Iowa, IPOST (Iowa Physicians Orders for Scope of Treatment).

Programs in other states have their own names. See POLST for a state-by-state listing of POLST Paradigm programs.

Although the forms vary by state, the basic idea is that legally completed advance directives, living wills, Five Wishes, even having a healthcare proxy are insufficient to guarantee that your wishes will be followed. You need a medical order signed by a physician. Even though an advance directive is legal, hospitals and nursing homes and clinical staff may be wary of following anything but a physician's order.

POLST is intended for people with serious advanced illness who may be expected to face major treatment decisions within a foreseeable time. The POLST form (with variations) lists medical interventions ranging from comfort care to full treatment, artificially administered nutrition (tube feeding), and a place for additional orders.

The patient (if able) must sign, as must the legally recognized decision maker (if there is one). Obviously, the physician's signature is essential.

The POLST form is intended to be sent with the person whenever he or she is transferred or from one healthcare facility to another. For instance, if a person is transferred from hospital to nursing home, the POLST form describes to the nursing-home staff the treatment plan that should be in place. An EMT can follow a POLST directive if 911 is called.

Although the POLST program addresses a common problem of medical staff failing to follow a person's wishes even when documented in an advance directive, it does not take into account the fuller range of choices recognized in, for example, a living will or Five Wishes. In the most common situations in which POLST is used, the discussion preceding the physician's signing of the order is brief and limited to the items on the checklist.

And hospital staff may not have training or experience in discussing the options with the patient, healthcare proxy, and family. POLST addresses a serious shortcoming in medical practice, but it is not intended to take the place of more traditional advance directives.

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