September 23, 2015

My New Advance Health Care Directive: Will It Be Honored?

I'm about to sign off on a revised draft of my will and the advance healthcare directive that accompanies it. I've gone through this drill before, but this time I'm making more of an effort to publicize the directive.

An 86-year-old with Parkinson's, I want any healthcare providers to know that in the event of a life-threatening condition, I want comfort care only... no heroics. Earlier this year in its "The New Old Age" blog, The New York Times reported on the trouble with advance directives. Researchers and medical personnel working with patients near the end of life have grown increasingly disenchanted with advance directives, including living wills and powers of attorney for healthcare.

Frequently, directives never get to the right place at the right time, or they're not referenced when decisions must be made. Even clear, formalized instructions are often overridden when relatives on the scene are unaware of their loved ones' end-of-life stipulations.

This time, rather than have my advance directive filed away in my desk drawer, I'm making sure my immediate family, my housemates, and my attorney for healthcare know its contents. I'll also send copies to my geriatrician and neurologist, the two doctors most likely to be involved should a health crisis arise.

The POLST Form for Emergency Care
Emergency medical personnel operate under standing orders to attempt resuscitation regardless of any specific instructions to the contrary in advance directives. In fact, patients may already be hooked up to breathing machines before they even arrive at the emergency room.

Only a do-not-resuscitate or POLST (Physician Order for Life-Sustaining Treatment) form can prevent that unwanted scenario. Research suggests that these forms do a better job than advance directives of keeping dying people out of hospitals. Completed by healthcare professionals in consultation with patients, the documents can exactly stipulate expected medical responses, from comfort-only measures to full life-prolonging interventions and all the options in between.

POLST documents are designed for people with severe illnesses. They're generally appropriate only for people who are in the final year of life, suffering from an advanced terminal illness or an illness from which there is no expectation of recovery.

Unfortunately, Washington, D.C. currently doesn't have a POLST program.

To see if your state has one, click here.

My Advance Health Care Directive
What follows is the main part of my advance directive. Most directives today are similar, listing healthcare options that address different medical situations. I'll be checking the first option -- the one calling for the least medical intervention -- in each situation.

I've added an unusual provision at the end, which I'll discuss tomorrow.
Page 1 of 6

ADVANCE HEALTH CARE DIRECTIVE
My Durable Power of Attorney for Health Care, Living Will and Other Wishes

THIS DIRECTIVE WILL TAKE EFFECT ONLY IF I BECOME UNABLE TO MAKE OR COMMUNICATE MY OWN HEALTH CARE DECISIONS
The terms used in this directive are defined on the attached Instructions and Definitions.
I, JOHN V. SCHAPPI, write this document as a directive regarding my medical care. I intend to create a power of attorney for health care which shall take effect if I become incapable of making my own health care decisions and shall continue during my incapacity. I hereby revoke any advance directive, health care proxy, power of attorney for health care, and/or living will previously executed by me.

Put the initials of your name in the blank before those choices you want to make.

PART 1. MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE
________ I appoint this person to make decisions about my medical care if there ever comes a time when I cannot make those decisions myself and to make decisions concerning the disposition of my remains and arrangements for funeral and memorial services, if any:
______________
Name Home Phone Work Phone Address
________ If the person above cannot or will not make decisions for me, I appoint this person:
Name Home Phone Work Phone Address 

HIPAA Release Authority. I intend for the person I have appointed to be treated as I would be with respect to my rights regarding the use and disclosure of my individual identifiable health information or other medical records from any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health-care provider, any insurance company and the Medical Information Bureau Inc., or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Page 2 of 6
I want the person I have appointed, my doctors, my family, and others to be guided by the decisions I have made below:

PART 2. MY LIVING WILL
These are my wishes for my future medical care if there ever comes a time when I can’t make these decisions for myself.
A. These are my wishes if I have a terminal condition:

Life-Sustaining Treatments
______ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.
______ I want life-sustaining treatments to prolong my life as long as possible within the limits of generally accepted health care standards.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Artificial Nutrition and Hydration
______ I do not want artificial nutrition and hydration started if it would be the main treatment keeping me alive. If artificial nutrition and hydration is started, I want it stopped.
______ I want artificial nutrition and hydration even if it is the main treatment keeping me alive.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Comfort Care
______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Page 3 of 6
B. These are my wishes if I am ever in a persistent vegetative state:

Life-Sustaining Treatments
______ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.
______ I want life-sustaining treatments to prolong my life as long as possible within the limits of generally accepted health care standards.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Artificial Nutrition and Hydration
______ I do not want artificial nutrition and hydration started if it would be the main treatment keeping me alive. If artificial nutrition and hydration is started, I want it stopped.
______ I want artificial nutrition and hydration even if it is the main treatment keeping me alive.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Comfort Care
______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.
______ Other wishes: See Other Directions under paragraph D of this Part 2

C. These are my wishes if I ever have an end-stage condition (including Alzheimer’s or
other dementia):

Life-Sustaining Treatments
______ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.
______ I want life-sustaining treatments to prolong my life as long as possible within the limits of generally accepted health care standards.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Page 4 of 6

Artificial Nutrition and Hydration
______ I do not want artificial nutrition and hydration started if it would be the main treatment keeping me alive. If artificial nutrition and hydration is started, I want it stopped.
______ I want artificial nutrition and hydration, even if it is the main treatment keeping me alive.
______ Other wishes: See Other Directions under paragraph D of this Part 2

Comfort Care
______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.
______ Other wishes: See Other Directions under paragraph D of this Part 2

D. Other Directions

Note: This provision is omitted here. It will appear and be discussed in tomorrow's post.


ADVANCE HEALTH CARE DIRECTIVE
Your Durable Power of Attorney for Health Care, Living Will and Other Wishes.

INSTRUCTIONS AND DEFINITIONS
Introduction:
This form is a combined durable power of attorney for health care and living will. With this form, you can:
􀆔 Appoint someone to make medical decisions for you if, in the future, you are unable to make those decisions for yourself. and/or
􀆔 Indicate what medical treatment you do or do not want if, in the future, you are unable to make your wishes known.

Directions:
* Read each section carefully.
* Talk to the person you plan to appoint to make sure that he/she understands your wishes, and is willing to take the responsibility.
* Place the initials of your name in the blank before those choices you want to make.
* Fill in only those choices that you want under Parts 1, 2 and 3. Your advance directive should be valid for whatever part(s) you fill in, as long as it is properly signed.
* Add any special instructions in the blank spaces provided. You can write additional comments on a separate sheet of paper, but you should indicate on the form that there are additional pages to your advance directive.
* Sign the form and have it witnessed.
* Give your doctor, your nurse, the person you appoint to make your medical decisions for you, your family, and anyone else who might be involved in your care, a copy of your advance directive and discuss it with them.
* Understand that you may change or cancel this document at any time.

Terms You Need to Know:

Advance Directive: A written document that tells what a person wants or does not want if he/she, in the future, can’t make his/her wishes known about medical treatment.

Artificial Nutrition and Hydration: When food and water are fed to a person through a tube.

Autopsy: An examination done on a dead body to find the cause of death.

Comfort Care: Care that helps to keep a person comfortable but does not make him/her better. Bathing, turning, keeping a person’s lips moist are types of comfort care.

CPR (Cardiopulmonary Resuscitation): Treatment to try and restart a person’s breathing or heartbeat. CPR may be done by pushing on the chest, by putting a tube down the throat, or by other treatment.

Durable Power of Attorney for Health Care: An advance directive that appoints someone to make medical decisions for a person if, in the future, he/she can’t make his/her own medical decisions.

End-Stage Condition: An advanced, progressive, irreversible condition caused by injury, disease or illness that has caused severe and permanent deterioration indicated by incompetency and complete physical dependency, and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective.

Life-Sustaining Treatment: Any medical treatment that is used to keep a person from dying. A breathing machine and CPR are examples of life-sustaining treatments.

Living Will: An advance directive that tells what medical treatment a person does or does not want if he/she is not able to make his/her wishes known.

Organ and Tissue Donation: When a person permits his/her organs (such as eyes or kidneys) and other parts of the body (such as skin) to be removed after death to be transplanted for use by another person or to be used for experimental purposes.

Persistent Vegetative State: A condition caused by injury, disease or illness:
(1) In which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a learned manner other than reflex activity of muscles and nerves for low level conditioned response; and
(2) From which, after the passage of a medically appropriate period of time, it can be determined, to a reasonable degree of medical certainty, that there can be no recovery.

Terminal Condition: An incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and from which, despite the application of life-sustaining procedures, there can be no recovery. Life-sustaining treatments will only prolong a person’s dying if the person is suffering from a terminal condition.


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