Advanced Directives

Advanced directives are essentially a set of legal documents that lays out what medical treatments a person wants or doesn’t want, should they become unable to make their wishes known. Some states have a form known as POLST (Physician’s Orders for Life Sustaining Treatment) or MOLST (Medical Orders for Life Sustaining Treatment), which is a short 5 section form that asks very plainly what the patient or their representative will accept in the event of a cardiac arrest or other life-threatening medical emergency. The questions are intentionally straight forward and include a place for CPR when a person has no pulse and is not breathing, medical interventions when a person has a pulse and/or is breathing, antibiotics, artificially administered nutrition and sometimes artificial hydration. The form must be signed by both the patient or their legal representative and a physician and is in place to ensure that the patient receives the treatment they desire (or lack of) in the event they are unable to make those choices because of a medical emergency. EMTs, Paramedics, Nurses and other medical professionals need these to guide treatment, especially when the form limits treatments. Without it, the medical personnel are required to pursue all aggressive medical treatments to keep a person alive.

Living Wills are another legal document that lay out what treatments a person does or does not want in the event they are unable to speak for themselves due to any medical emergency or condition. These are vastly underused, and in my experience, only the educated middle and upper classes have them in place. A person will need to 1, know what it is and 2, have the means to have one prepared by an attorney and notarized.

A Power of Attorney grants another person to act as your health care agent, health care proxy, health care surrogate, health care representative, heath care attorney-in-fact and as your patient advocate. This is another document that is prepared by an attorney and must be notarized to be legally valid.

There are other orders that can be put in place, like an Out of Hospital DNR, Do Not Hospitalize and others that help to ensure that a person does not receive treatments that they don’t want.

All of these (and the many others not mentioned here) are beautiful in that they give a voice to the patient when the patient is no longer able to speak for themselves. The also relieve pressure on their family, loved ones and otherwise legally responsible persons to make the choices they know the patient wanted when they were thinking clearly and able to execute their autonomy. The problem is that they are not always followed. If one person, any close family relative like a spouse, child or parent, can override those documents and choose full treatment. It can and does happen, and the team of doctors, nurses, respiratory therapists, EMTs and paramedics must follow the most medically aggressive treatments to sustain life if that close family tells them to. Those documents are meaningless when your loved ones disagree and want to keep you alive. I saw it happen more than once in my hospital years and as a home hospice nurse. I saw out of hospital DNRs and Do Not Hospitalize orders blatantly ignored by nursing home staff because they were more concerned with covering their own liability or following their own personal set of ethics. These orders are not enough. Our culture needs to shift. There needs to be more conversations about what hospitalizations look like for the frail, terminally ill and elderly. Acting out of fear or personal ethics should never ever override someone’s wishes. Dilemma or not, it is the choice of the patient.