Advance Directives are a means of communicating future significant healthcare choices and decisions at a time when a person is capable of making such decisions.  Advance Directives allow people to better pre-determine the course their healthcare will take by guiding their family/loved ones and healthcare providers in regards to the individual’s goals and wishes for that care. Advance Directives may take various forms including:

• Living will: documented preferences on healthcare and life sustaining treatments.

• Do not resuscitate (DNR): directives that define whether resuscitation, such as cardiopulmonary resuscitation (CPR) or intubation and mechanical ventilation, is desired.

• Power of attorney: defining who will serve as a surrogate decision maker when the individual becomes incapacitated and unable to make their own decisions.

• Physician order: similar to, but more detailed and covering more contingencies than single directive order such as a DNR order.

• Goals of care: care goals may be documented by a physician in consultation with the patient, power of attorney, legal surrogate, or guardian and define the scope of treatment based on the individual’s wishes and desires, with the intent of aligning treatment and resources to patient goals.  These care discussions  would include, but are not limited to, issues including:

  • palliative care versus restorative care

  • re-hospitalization in the setting of advanced disease, including re-evaluation in an emergency department, or use of emergency medical services (EMS, or 911)

  • placement in an intensive care unit

  • use of artificial enteral or parenteral nutrition

  • dialysis

  • intubation or noninvasive ventilators

  • cardiopulmonary resuscitation (CPR)

  • tissue or organ donation

     

Advance Directives are established at a time when an individual is determined to be legally capable of making complex medical decisions. The advance directive document must be legally witnessed for signature. Legal witnesses/signers may not include spouses, heirs, or persons actively involved in the person’s care or treatment due to potential conflict of interest. The spirit of advance directive documents is to give patients the power to better direct and determine their care in advanced disease or at the end of life.  Medical providers and emergency responders are generally required to provide life sustaining treatment, or to “err on the side of life” if advance directives to the contrary are not available. Often, advance directive documents refer to specific conditions, such as:

• Terminal conditions or conditions from which a person will die within short time regardless of medical treatment provided.

• Permanent unconsciousness (e.g., vegetative states), which involve damage to the brain extending to brain death (flat-lined EEG including brainstem function).

   

  Individual states may define when care can or cannot be terminated relative to these conditions and may define the extent to which artificial means of survival must be utilized.

Specific advance directives include:

• The Five Wishes (www.agingwithdignity.org)

  • Identifies and names the healthcare agent

  • Directs treatment options when death is near or in cases of permanent and severe brain injury or permanent coma and defines “comfort measures”

  • Expands upon care wishes including, “How people treat me”

  • Includes a section titled, “What I want my loved ones to know”

• POLST (Physician Orders on Life Sustaining Treatment) (www.polst.org)

  • This is an order set designed to complement, but not replace, traditional state-defined advance directives.Details may varyby state but generally include:

  • CPR

  • Medical interventions

    • Comfort measures only (CMO), or conversely, full treatment

    • Intervention use or limitations (e.g., hospitalization, intravenous fluids, cardiac monitoring, ICU admission)

    • Antibiotic treatment

    • Intubation and mechanical ventilation

    • Artificially administered nutrition

• Honoring Choices (these state specific advance directives vary, with individual state documents able to be accessed online). (www.wismed.org) Directives include:

  • Health care agent authority and limitations and may include decisions regarding:

    • Admission to long-term care

    • Withholding or withdrawing a feeding tube

    • Pregnancy related healthcare decisions

  • Specific condition related instructions regarding:

    • Life prolonging treatments

    • Pain and comfort care and treatments

    • Cardiopulmonary resuscitation

    • Spirituality and/or religious affiliations

    • Upon death determinations includingorgan/tissue donation and autopsy