Advance Directives

Overview

Definition

The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf.

• Underlying principle: autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles (self-determination)
• Studies have found that use of ADs is associated with decreased use of life-sustaining treatment and increased use of hospice and palliative care services, although the evidence is mixed and structured advance care planning conversations appear more influential than documents alone.

The Patient Self-Determination Act

The Patient Self-Determination Act of 1990 (effective December 1, 1991) states that health care facilities must inform patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship of their rights to:

• Participate in and direct their own health care decisions
• Refuse medical or surgical treatment
• Prepare an AD
• Review information on the institutional policies governing these rights

When to obtain an advance directive

• The best time is often during a routine outpatient visit:
  • Allows time for deliberation in a low-pressure situation
  • Approximately one-third of US adults (about 37%) have completed an AD.
  • Completion is higher among adults ≥ 65 years of age (about 46%) and reaches roughly 70% among older Americans at the time of death.
• Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship should start discussions with patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship regarding ADs as early as possible, while a patient is healthy and has decision-making capacity Decision-making capacity Decision-making capacity describes a patient’s ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence.
• Advance directives should be obtained/updated:
  • On hospital admission
  • Prior to surgery
  • On diagnosis with:
    • A terminal illness 
    • A disease associated with dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders
• Desires regarding life-sustaining treatments are not always stable over time and may change. Therefore, ADs should be revisited and updated periodically.

Common scenarios

Some of the most common scenarios in which ADs are used include:

• Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma
• Vegetative state, now also termed unresponsive wakefulness Unresponsive wakefulness The term “persistent vegetative state,” also called unresponsive wakefulness, describes the condition of individuals with severe anoxic brain injury who have progressed to a state of wakefulness without any meaningful response to their environment. A persistent vegetative state is distinguished from a coma in that individuals in a persistent vegetative state have intermittent sleep-wake cycles. Persistent Vegetative State syndrome
• Severe brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification injury
• Stroke
• Dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders, including advanced Alzheimer disease Alzheimer disease As the most common cause of dementia, Alzheimer disease affects not only many individuals but also their families. Alzheimer disease is a progressive neurodegenerative disease that causes brain atrophy and presents with a decline in memory, cognition, and social skills. Alzheimer Disease
• Critical medical illness affecting decision-making capacity Decision-making capacity Decision-making capacity describes a patient’s ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence

Documentation

• In order for an AD to be honored, it must be prepared before the patient loses medical decision-making capacity Decision-making capacity Decision-making capacity describes a patient’s ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence. 
• Advance directives must be noted in the medical records.
• Often requires assistance from the attending physician; an attorney is generally not required (exact requirements and policies differ between states)

Categories of Advance Directives

There are multiple types of ADs, including living wills, designation of a health care proxy and/or a durable power of attorney, or portable medical orders (POLST).

Living will

• Written document that states what medical treatments the patient desires (and which they prefer to omit or refuse) should the patient become incapacitated 
• May be very general or very specific
• Includes instructions for things such as:
  • Rejecting artificial airways (i.e., intubation Intubation Peritonsillar Abscess) and/or ventilators
  • CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest
  • Use of feeding tubes and/or IV fluids IV fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids for nutrition and hydration
  • Analgesia Analgesia Methods of pain relief that may be used with or in place of analgesics. Anesthesiology: History and Basic Concepts/ pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways relief
  • Use of antibiotics
• The most common statement in a living will reads something similar to, “If I suffer an incurable, irreversible illness, disease, or condition, and my attending physician determines my condition is terminal, I direct that life-sustaining measures that serve only to prolong my dying be withheld or discontinued.”

Health care proxy

• A legal designation in which a patient designates another person (also called a surrogate) to make health care decisions on their behalf if the patient is rendered incapable of making their wishes known
• The health care proxy has the same rights to request or refuse treatment that the individual would have if they were capable of communicating their wishes.
• The health care proxy is someone who should make decisions (to the best of their ability) that are consistent with and based on the patient’s known wishes and values (substituted judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment); when those wishes are unknown, decisions should be based on the patient’s best interests.

Durable power of attorney

• A signed legal document authorizing another person to make decisions on the patient’s behalf
• Unlike a health care proxy or DPAHC, which is limited to health care decisions, a general (financial) durable power of attorney also allows the designated person the ability to execute certain legal documents and activities, including:
  • Make bank transactions
  • Manage benefit income
  • Apply for disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment
  • Write checks to pay bills
• In health care, the POA may be referred to more specifically as a durable power of attorney for health care (DPAHC).

Portable medical orders (POLST)

• A portable medical order that complements, but does not replace, an AD; it is intended for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with a serious life-limiting illness or advanced frailty
• Agreement between the doctor and the patient regarding the patient’s condition that records the patient’s wishes as medical orders
• Portable within a state
• As actionable medical orders, POLST forms generally take precedence over an earlier living will
• Conflicts should be resolved in favor of the most recent expression of the patient’s wishes.

Do not resuscitate Do Not Resuscitate Cardiopulmonary Resuscitation (CPR) and do not intubate orders

Do not resuscitate Do Not Resuscitate Cardiopulmonary Resuscitation (CPR) ( DNR DNR Cardiopulmonary Resuscitation (CPR)) and do not intubate (DNI) orders are ADs in the form of a physician’s order that instruct health care personnel not to perform resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome or intubation Intubation Peritonsillar Abscess for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship in critical condition.

• Requested by a patient as part of living will or by the patient’s health care proxy 
• Order must be written by a physician or other authorized clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship (e.g., nurse practitioner or physician assistant), depending on state law
• Typical DNR DNR Cardiopulmonary Resuscitation (CPR)/DNI orders prevent health care providers from performing the following procedures:
  • CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest ( chest compression Chest Compression Crush Syndrome)
  • Intubation Intubation Peritonsillar Abscess and mechanical breathing
  • Electrical cardioversion Cardioversion Atrial Fibrillation
  • Administering antiarrhythmic or cardiac resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome medications (e.g., epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs)

Ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles committees

• Can help in cases where patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship left no AD and/or have no health care proxy
• Provide ethical analysis and recommendations, which are generally advisory rather than legally binding, and do not constitute legal advice

Limitations

Suspension of advance directives

There are particular situations in which an AD may be temporarily suspended or not honored:

• For surgery the American Society of Anesthesiologists, the American College of Surgeons, and AORN require “required reconsideration,” a documented preoperative discussion in which the patient (or surrogate) chooses to suspend the order for a defined period, limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome to specified procedures, or continue the order unchanged.
• Cases in which an AD document is unavailable:
  • Example: emergency situations attended by first responders
  • Until the documented AD is available, the providers must act in the patient’s best interest, according to their experience and knowledge.

Limitations Limitations Conflict of Interest on the durable power of attorney for health care

A person with a DPAHC has certain limitations Limitations Conflict of Interest. These vary by state, but often prevent the DPAHC from refusing or withdrawing:

• Hydration and nutrition to the patient 
• Comfort care measures
• Treatment for a patient who is pregnant and/or procedures involving abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion or sterilization Sterilization Procedures to block or remove all or part of the genital tract for the purpose of rendering individuals sterile, incapable of reproduction. Surgical sterilization procedures are the most commonly used. There are also sterilization procedures involving chemical or physical means. Reproductive Ethical Issues
• Care for a patient who previously consented to receiving that care unless a significant change has occurred in the patient’s condition that causes the treatment to no longer be effective

Who can be a durable power of attorney for health care

This varies by state, but frequently the DPAHC cannot be:

• The attending physician
• A clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship working at the facility (exceptions are typically made for relatives of the patient)
• Officials or administrators (e.g., facility owners, government officials) who are financially responsible for the patient’s care