Advance Directives in End-of-Life Care


Lyndsey had always been full of life, waiting for the next adventure. She had always said, “A life without being outdoors was no life at all.” But when a random accident left this vivacious 34-year-old with extensive brain damage and in an irreversible coma, a frantic mother, unprepared to say goodbye to her only daughter, insisted Lyndsey remain on life support in case a miracle should happen.

Discussions surrounding end of life care are not just for those seasoned members of our community. The brief story above illustrates the need for everyone to consider what is most important to them.

The circumstances of our end-of-life experience are uncertain; the only guarantee is that it will happen. One way we can be certain our wishes for end-of-life care will be carried out is by completing advance directive documentation. This includes Durable Power of Attorney for Health Care, a Living Will, and a form confirming the Physician Orders for Life-Sustaining Treatment.

While the overall purpose of each document confirms your health care wishes for when you can no longer speak for yourself, each document focuses on different portions of your right to determine the extent of end-of-life care.

  1. Durable Power of Attorney for Health Care
    This form allows you to name a trusted person to handle health care decisions and oversee your medical care with specific suggestions identified by you in writing. Most people assume that a living will is good. And, it is. But it’s not enough.
    A living will is used to declare your desire to not have life-prolonging measure be taken if there’s no hope for recovery—such as in the event of brain damage or terminal illness. This is limited to deathbed concerns only. Also this document is generally completed when a person is already addressing a serious medical condition.
    A durable power of attorney for health care, on the other hand, covers all health care decisions and becomes in force when you are incapable of making decisions. Additionally, you can grant these powers immediately even if you still have the capacity to make decisions. For an individual who is already frail, having a trusted person to advocate for you can relieve this burden from you. Within the document you may set out specific provisions in the Durable Power of Attorney for Health Care telling your agent how you would like them to act in the event that life-prolonging measures are needed. Despite the name, the document does not require an attorney to assist you, but it does have specific instructions on witnessing requirements and options for completing the form.
  1. A Living Will
    As the more recognizable form of end-of-life documentation, a living will is essential in carrying out your medical care preferences for prolonging life, pain management or organ donation. The difference between this and a regular will is that the Living Will guides decisions before your death – a standard “Last Will” guides decisions after your death.
    “In determining your wishes, think about your values, such as the importance to you of being independent and self-sufficient, and what you feel would make your life not worth living,” advises the Mayo Clinic. “Would you want treatment to extend life in any situation? Would you want treatment only if a cure is possible?”
    Then talk about your preferences with your support system to be sure they understand your wishes. Be specific about your feelings toward resuscitation, ventilators or tube feeding. Engaging in conversation about your desires before the need exists will save your loved ones from an overwhelming experience in the future.
  1. Physician Orders for Life-Sustaining Treatment (POLST)
    This POLST form represents your decisions concerning emergency or life-prolonging care. These are actionable medical orders signed by your doctor, physician assistant or nurse practitioner, depending on your location. There is risk and liability for hospitals and medical personnel for not following these orders. At the same time, it releases liability on the part of those following a properly completed POLST form. It also includes requests, specific care and guidelines for emergency medical services and other health care personnel.
    While these forms are similar in the general purpose, the POLST form is unique in that its focus is for people who are currently suffering from a serious illness. The POLST form covers the desired treatment plan for those receiving care as well as expectations for life-sustaining or life-prolonging treatments.

Such documentation takes the guesswork out of what form of care you wish to receive and to what extent you desire your life prolonged. As the Administrator for Supportive Care at 24/7 Care At Home, I firmly believe that completing any or all of these documents is essential to crafting an end-of-life care plan for each individual. Having the knowledge expressed directly from the patient in writing removes the uncertainty of what was desired and what is not. Currently, only 25 percent of Americans have recorded their end-of-life medical wishes in a legal document. This is a problem, as more than half of patients are unable to participate in end-of-life decisions when they need to be made.

The process is very simple. By engaging in meaningful conversations with your physician, other health care providers, and trusted family and friends, and by placing those wishes in writing, you can be sure that your end-of-life experience can be a peaceful celebration of life. It is important to research which forms are legal in your state and if there are specific instructions unique to your state. Most elder law attorneys can guide your decisions. If you are in a hospital or skilled nursing facility, the staff are generally quite familiar with the options as well.

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