medical decision making

"Agnes" was an elderly woman, and quite ill. She thought she had things in order for when her dying time arrived. Unexpectedly however, she became hospitalized with a life-threatening medical event.  Her Living Will and POLST were clear: if her heart stopped, she did not want to be resuscitated or put on a ventilator.  At her life's end, she wanted to "peacefully go to Jesus."  

Sadly, things didn't turn out exactly as planned.  

Overwrought and understaffed physicians tried their best for her in an emergency situation, not knowing, because they didn't have time to check, that she did not want CPR and did not want to be put on a ventilator.  And so when I came to see her,  she was a tiny woman in a big bed, monitors flashing and alarms beating. It was heartrending.  And yet.

Agnes had, as recommended, filled out a Durable Power of Attorney for Health Care (DPOA), ceding decision making authority to one of her two closest friends.  When they arrived and conferred with her physician, the medical situation was clear: She was not conscious and would not survive.  All the medical equipment in the ICU could not cure her, help her condition improve, or even meaningfully prolong her life.  Her DPOA knew it was time do do as requested: allow her dear friend to go to God.  

And so she did, once the ventilator was removed.  Gently medicated for comfort, with songs sung and friends holding her hands, Agnes left this life, as peacefully as she'd wished, accompanied in her last breaths by hymns sung and love offered.  Those who loved her were comforted they could be with her, thanking her for her grace-filled loveliness of soul, and bidding her adieu.  

Eventually, things worked out as Agnes wished.  It would have been much better for them to work out right away, but before long, the incorrect decisions were remedied, and she passed peacefully. 

Still, most people want to be sure they have the appropriate forms filled out and their health care wishes are respected.  Since it can be confusing to know what one should and should not fill out, and how, here is a brief summary of Health Care Directives.

SUMMARY:  

Many options exist for patients to decide exactly what kind of medical care they will receive and what care they will not receive. From the simplest DNR (Do Not Resuscitate) orders for people who elect not to have CPR or be placed on a ventilator, to POLST forms, to Advance Directives such as Living Wills and Durable Power of Attorney for Health Care, everyone can and should discuss with their family members and their doctor what kind of care and intervention levels they want, so that they do not find themselves receiving care they would not have chosen.

POLST forms (Physician Orders for Life Sustaining Treatment) are documents from each state's medical association, recommended to be used for persons with life-limiting illness. These documents insure that medics, in home or in transport to a hospital, do not provide CPR or other futile care to a person with advanced illness, against his or her will.  A POLST form translates the wishes of patients with advanced illness into physician orders limiting or expanding the kind of care  a person receives. For example, a terminal patient might elect to receive antibiotics and IV fluids but might decline to have CPR go on a ventilator. Please refer to further information POLST forms.

A Do Not Resuscitate (DNR) order is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your doctor that you don't want to be resuscitated or to tell your provider you do wish CPR, and all, or some, life-saving procedures.  All life-saving treatments are called a FULL CODE. In either  case, an order can placed in your electronic medical record.  DNR, FULL CODE, or PARTIAL CODE orders are accepted by doctors and hospitals in all states. 

Note: Since you won't know the circumstances of your acute/unexpected medical situation, it may be best to let your trusted health care proxy (Durable Power of Attorney for Health Care) and your medical providers discern if care in a particular instance is futile or beneficial for you, rather than having a blanket DNR in your medical record.   For example, if you are in your 60's or 70's and have a mild heart attack, from which you are likely to fully recover, or are in a car accident and need life support temporarily in order to fully recover, you don't want to have a DNR preventing your providers from treating you emergently.  Be sure to discuss your wishes with family and medical providers.  

Advance Directives tell a doctor what kind of care a patient would like to have if he or she becomes unable to make medical decisions (in a coma, for example). If someone is admitted to the hospital, the hospital staff will probably talk to them about advance directives. Advance directives include Health Care Directives (Living Wills), Do Not Resuscitate Orders, and Durable Powers of Attorney for Health Care. These have some limited use as they vary from locale to locale.  A durable power of attorney for Health Care is more useful.  

A Durable Power of Attorney for Health Care (DPOA) (Also Called a Medical Power of Attorney or Attorney in Fact or other names) is a legal document which allows you to name a person as your health care agent - someone who is authorized to consent to, stop or refuse most medical treatment for you, if a physician determines that you cannot make these decisions yourself. Once appointed, your health care agent can speak on your behalf anytime you are unable to make your own medical decisions, not only at the end of life.

A Health Care Directive, commonly referred to as a 'Living Will', is a legal document specifying your wishes regarding the care you receive at the end of life should you be unable to communicate them. Health care directives may also be called a directive to a physician, declaration or medical directive. A living will doesn't let you select someone to make decisions for you (unless the document also has an area where a Durable Power of Attorney for Health Care/ or Health Care Power of Attorney can be completed.) 

There are federal and state laws that govern the use of advance directives. The federal law, the Patient Self-Determination Act, requires health care facilities that receive Medicaid and Medicare funds to inform patients of their rights to execute advance directives. All 50 states and the District of Columbia have laws recognizing the use of advance directives. 

As a practical matter, these directives only take effect if you are unable to speak for yourself in the moment.  Since you can't see the future and won't know the particular medical circumstances in which you will find yourself, it might be best to have a trusted friend or loved one (DPOA for health care) and medical providers guide your treatment choices.  Should treatment become burdensome or futile, they can then discern to stop whatever care they deem you would not have wanted. 

While you do not need a lawyer to fill out an advance directive, your advance directive becomes legally valid as soon as you sign it in front of the required witnesses. The laws governing advance directives vary from state to state, so it is important to complete and sign advance directives that comply with your state's law.