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Documenting your Wishes with an Advance Directive

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Advance care planning is a process through which you consider your personal values about medical treatment and the care you want to receive at the end of life, discuss those values with your family and others close to you, and complete documents that record those decisions for the future.  It is the best way to help ensure that your values, wishes, and choices will always be known and respected.

The legal tools that document your decisions are called advance directives.  An advance directive is a written or spoken statement you make today to control the health care treatment you will receive in the future. It gives your family and health care providers your directions and decisions about medical care in case you cannot, at some future time, speak for yourself.  In your documents you may name a spokesperson (agent or representative) to make decisions on your behalf.

With the enactment of Act 79 of 2016 Pennsylvania has recently made minor modifications to its laws regarding advance directives. But the essential elements remain the same. Pennsylvania law recognizes a number of forms of advance directive.

living will provides treatment instructions regarding the types of medical treatment and care you want to receive or refuse at the end-of-life. This document is typically used by people to describe the point at which they would no longer desire certain types of life-prolonging medical treatment, but it may also document your desire for continuation of treatment.  A living will is a limited document because it is operative only when you have an end-stage medical condition or are permanently unconscious. As a result, living wills apply to only a small fraction of the decisions caregivers must make.

health care power of attorney appoints a person of your choice to make health-care decisions whenever you are unable to make decisions for yourself. Your spokesperson (agent) can act regardless of whether you are terminally ill or permanently unconscious. You can include your treatment instructions and guidance as to your preferences regarding end-of-life care and other situations that may arise in the document.

An appointment of health care representative designates a person to make health-care decisions for you.  You can make your designation in writing or by personally informing your physician or health care provider of the person or persons you want to act as your representative. You can also specify that certain individuals should be excluded from making decisions concerning your care.

mental health advance directive is a written document that expresses your choices for treatment related to mental health care in the event that mental illness makes you unable to make decisions.

There are also several forms of physician orders that may be used to provide advance treatment instructions.  These documents are a unique form of advance directive because they are actual physician treatment orders.

∙           A do-not-resuscitate (DNR) order is a medical order written by a patient’s attending physician that directs medical personnel to forgo cardiopulmonary resuscitation (CPR) if the patient’s heart or breathing stops. The order, sometimes referred to as a “no code” or “comfort care,” is usually placed on the patient’s chart.  There are several varieties of DNR orders. The traditional DNR order is given by the doctor of a hospital in-patient directing that resuscitation not be performed in the event that the patient’s heart or breathing stops. A second variety of DNR which gives similar instructions for non-institutionalized individuals is the Out of Hospital Do-Not-Resuscitate order.

∙           A POLST order is standardized form containing physician orders detailing the scope of life-sustaining medical treatment to be provided to a patient. POLST stands for physician-order-for-life-sustaining treatment.

Creation of an advance directive is an important step in the advance care planning process.  But you should recognize that it is only one step. Your advance directive will not accurately reflect your preferences unless you have taken time to reflect on what is important to you in life and what gives your life meaning. What kinds of situations do you fear facing in the future? Would you ever want to limit certain types of treatment? Do you want to be sure that you will receive certain types of treatment?  Who is the best person to speak for you if you are ever unable to speak for yourself?

If your family is to understand and follow your wishes, they really need to participate with you in your planning.  Family conversation today can spare your family members from the agony of having to make painful decisions in the future without any meaningful guidance about what you would really want.  Important issues can be considered while there is time for reflection and discussion.

By planning in advance you can provide your family and other care givers with the information they will need to make the most appropriate decisions for you.  They won’t have to guess what you would want.  All too often families are forced to make medical decisions for a loved one during a crisis while under great emotional stress. Studies of close family members show that they do not automatically know each other’s wishes even under the best of conditions. Spouses very often guess wrong about what kind of treatment their husband or wife would want. The more your family knows, they less they will have to guess and disagree and argue.

Effective advance care planning is a blessing you can bestow on yourself and the people closest to you.  A crisis situation may not give you the opportunity to discuss critical issues with your family.  The time to plan is now.