Advance Directives

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. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Do not resuscitate and do not intubate orders are 2 important types of ADs.

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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 (self-determination)
  • Studies have found that use of ADs decreases use of life-sustaining treatment and increases use of hospice and palliative care services.

The Patient Self-Determination Act

The Patient Self-Determination Act of 1991 states that health care facilities must inform patients 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 70% of older Americans complete ADs prior to their death.
  • Physicians should start discussions with patients regarding ADs as early as possible, while a patient is healthy and competent.
  • Advance directives should be obtained/updated:
    • On hospital admission
    • Prior to surgery
    • On diagnosis with:
      • A terminal illness 
      • A disease associated with dementia
  • 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
  • Persistent vegetative state
  • Severe brain injury
  • Stroke
  • Dementia or advanced Alzheimer’s disease
  • Critical medical illness affecting mental capacity

Documentation

  • In order for an AD to be honored, it must be prepared before the patient loses medical decision-making capacity. 
  • Advance directives must be noted in the medical records.
  • Often requires assistance from the attending physician and an attorney (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 physician’s orders for life-sustaining treatment.

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) and/or ventilators
    • CPR
    • Use of feeding tubes and/or IV fluids for nutrition and hydration
    • Analgesia/pain 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 will.

Durable power of attorney

  • A signed legal document authorizing another person to make medical decisions on the patient’s behalf
  • Unlike the health care proxy, a power of attorney also allows the designated person the ability to execute certain legal documents and activities, including:
    • Make bank transactions
    • Sign social security checks
    • Apply for disability
    • 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).

Physician’s orders for life-sustaining treatment

  • Newer form of AD
  • 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
  • The names for the physician’s orders for life-sustaining treatment and exact policies differ between states.
  • The physician’s orders for life-sustaining treatment could be void if they contradict a preexisting living will.

Do not resuscitate and do not intubate orders

Do not resuscitate (DNR) 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 or intubation for patients 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 doctor
  • Typical DNR/DNI orders prevent health care providers from performing the following procedures:
    • CPR (chest compression)
    • Intubation and mechanical breathing
    • Electrical cardioversion
    • Administering antiarrhythmic or cardiac resuscitation medications (e.g., epinephrine)

Ethics committees

  • Can help in cases where patients left no AD and/or have no health care proxy
  • Provide both legal and moral support to doctors when there are no further treatment options available

Limitations

Suspension of advance directives

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

  • During surgery (which normally requires intubation, IV fluids, etc.)
  • 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 on the durable power of attorney for health care

A person with a DPAHC has certain limitations. 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 or sterilization
  • 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 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

References

  1. House, S. A., Ogilvie, W. A. (2021). Advance directives. StatPearls. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK459133/
  2. Sadock, B. J., Sadock, V. A., Ruiz, P. (2014). End-of-life issues. Chapter 34 of Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 1352–1373.
  3. Silveira, M. J. (2020). Advance care planning and advance directives. In Givens, J. (Ed.). UpToDate. Retrieved June 10, 2021, from https://www.uptodate.com/contents/advance-care-planning-and-advance-directives 
  4. American Bar Association Commission on Law and Aging. (2019). State health care power of attorney statutes: selected characteristics. Retrieved June 10, 2021, from https://www.americanbar.org/content/dam/aba/administrative/law_aging/state-health-care-power-of-attorney-statutes.authcheckdam.pdf 

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