Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2016 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2018 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2016 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2015 ◽  
Author(s):  
Margaret L. Schwarze
Keyword(s):  
Health Care ◽  
Advance Directives ◽  
Living Will ◽  
Surgical Patients ◽  
Living Wills ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Do Not Resuscitate Orders ◽  
Surrogate Decision ◽  
Binding Mechanisms

Documentation of future wishes for life-supporting therapy includes living wills, do not resuscitate orders, and designations of a durable power of attorney for health care. All are legally binding mechanisms. Because surgeons may need to refer to these documents, this chapter discusses the use of advance directives and living wills in surgical patients, the use of do not resuscitate orders in the operating room, and the activation and use of power of attorney and subsequent surrogate decision-making. A figure shows a living will designating conditions for resuscitation. This review contains 42 references.

Who Decides?

2020 ◽  
pp. 41-48
Author(s):  
Kenneth V. Iserson
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Living Will ◽  
Care Physician ◽  
Power Of Attorney ◽  
Health Care Decisions ◽  
Decision Making Capacity ◽  
State Statutes ◽  
Hospital Policies ◽  
Life Sustaining Treatment

To make a health care decision, individuals (whether it be the patient or an adult surrogate) must have decision-making capacity. Based on the principle of patient autonomy (respect for persons), such adults can make their own health care decisions, even if they contradict what their health care provider recommends. However, if a patient lacks decision-making capacity, his or her previously completed health care directive(s) take effect. These can be a living will, durable power of attorney for health care, Physician Orders for Life-Sustaining Treatment (POLST) form, or a similar document. In a similar manner, if an adult patient wishes to orally designate another adult to make his or her health care decisions (as in the case in this chapter), they may do that. These surrogates’ decisions carry the same weight as and replace any previously named surrogate. When no surrogate has been named, most hospital policies and many state statutes list the general hierarchy of people to be the patient’s surrogates.

In My Best Interest

2016 ◽  
Vol 34 (2) ◽  
pp. 160-165 ◽  
Author(s):  
Patricia A. Mayer ◽  
Bryn Esplin ◽  
Christopher J. Burant ◽  
Brigid M. Wilson ◽  
MaryAnn Lamont Krall ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Medical Center ◽  
Specific Treatment ◽  
Living Will ◽  
Treatment Preferences ◽  
Power Of Attorney ◽  
Best Interest ◽  
Permanent Disability ◽  
Surrogate Decision

Background: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration’s Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. Objective: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. Design/Setting: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. Measurements: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. Results: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. Conclusion: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

On the Edge of Death—To Intervene or Not

2020 ◽  
pp. 33-40
Author(s):  
Alexander Zoretich ◽  
Arvind Venkat
Keyword(s):  
Health Care ◽  
Emergency Department ◽  
Advance Directives ◽  
Medical Condition ◽  
Living Will ◽  
Ethical Challenges ◽  
Power Of Attorney ◽  
Medical Decisions ◽  
Life Sustaining Treatment ◽  
End Stage

Advance directives and actionable medical orders are documents that convey a patient’s wishes regarding medical treatment. Common advance directives are living will and health care power-of-attorney documents. Living wills state what a patient wants if not able to communicate for themselves and having an end-stage medical condition or permanent unconsciousness. Health care powers of attorney state whom a patient would want to make medical decisions on their behalf if not able to communicate for themselves. Both of these documents have minimal application in the emergency department given the time constraints of care in this setting. Actionable medical orders, such as Physician Orders for Life-Sustaining Treatment (POLSTs), have immediate application in the emergency department but carry their own challenges in interpretation by emergency physicians. This chapter reviews the nature of advance directives and actionable medical orders and the legal and ethical challenges posed by their application in the emergency department.

Clinical Issues

2021 ◽  
pp. 34-59
Author(s):  
Timothy E. Quill ◽  
Judith K. Schwarz ◽  
V. J. Periyakoil
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Oral Care ◽  
Oral Intake ◽  
Informed Choice ◽  
Dry Mouth ◽  
Health Care Proxy ◽  
Decision Making Capacity ◽  
Seriously Ill

VSED requires a decisionally capable, seriously ill patient who makes an informed choice to intentionally hasten death because of unacceptable current suffering or fear of imminent future suffering. In addition to being well informed and determined, patients must have access to ongoing caregiving support and a committed clinician partner. The treating clinician must carefully evaluate the reasons for the patient’s request and her decision-making capacity. Most patients who forgo all oral intake, food and liquids, die peacefully from dehydration within ten to fourteen days. Difficult symptoms of thirst and dry mouth can be adequately relieved with good oral care and access to medications to relieve additional distress. Many patients will be reassured by awareness of the option of VSED even if they never actually exercise it. Completion of advance directives (both health care proxy and instructional) as well as MOLST forms are recommended for anyone initiating VSED, as many patients lose decision-making capacity late in the process.

Ethical Issues

2021 ◽  
pp. 176-203
Author(s):  
Dena S. Davis ◽  
Paul T. Menzel
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Moral Distress ◽  
Ethical Issues ◽  
Severe Dementia ◽  
Relevant Change ◽  
Decision Making Capacity ◽  
Behavioral Expression ◽  
Pain And Suffering

The implementation of advance directives to withhold food and water by mouth faces significantly more challenges than VSED by persons with decision-making capacity, though with sufficient care and attention, many of these can be resolved. Reduced awareness may leave the person with little understanding of her directive or no awareness at all. In severe dementia, is behavioral expression of a simple desire for food or drink a relevant change of mind about the directive, or by then does the person no longer have the capacity to make such a change? How relevant is the moral distress that caregivers and health care agents will often experience when implementing the person’s directive, or when they are unable to get it implemented? Patients in severe dementia also may be relatively content, with little pain and suffering—is the deterioration itself, without pain and suffering, a legitimate reason for implementing a VSED directive?

Legal Issues

2021 ◽  
pp. 204-228
Author(s):  
Thaddeus M. Pope
Keyword(s):  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Late Stage ◽  
Legal Issues ◽  
Home State ◽  
Decision Making Capacity ◽  
Food And Drink

This chapter analyzes a patient’s right to have food and drink withheld when they lack decision-making capacity. Authorization for this decision typically comes from the patient’s advance directive. Yet, because the relevant statutory language varies materially from jurisdiction to jurisdiction, so does the permissibility of stopping eating and drinking by advance directive. Individuals may be able to circumvent statutory obstacles by either (1) completing a non-statutory advance directive, or (2) completing an advance directive in a permissive state and having it recognized in their home state. Furthermore, even in permissive jurisdictions, there may be challenges in implementing the directive because some incapacitated individuals in late-stage dementia may make utterances or gestures that suggest they want food and water. Individuals may be able to resolve the contradiction between the wishes of their past self and their present self by including “Ulysses clause” language in their advance directives.

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