Advance Care Planning

Understanding Advance Care Planning

What are Advance Directives?
Advance Directives are written, legal documents that allow you to make your healthcare wishes known in case you are unable to communicate. They guide your family and healthcare team through the medical treatments you wish to receive. It does not mean “don’t treat,” but does mean “treat me the way I want to be treated.” Studies show that even close family members often do not know each other’s wishes for end of life choices. Caring spouses often guess incorrectly about what kind of treatment their husband or wife would want.

Pennsylvania recognizes:

• Living Wills
• Durable Power of Attorneys for Healthcare

Advance Directives are important because they:

• Protect your rights
• Help your family to make difficult decisions
• Give your doctor guidelines about your choices for care

In Pennsylvania, Living Wills and Durable Power of Attorneys for Healthcare DO NOT require a lawyer and do not require notarization. Pennsylvania law gives you the right to accept or refuse medical care.

It’s important to understand the difference between these free legal documents that relate to health care concerns, versus the legal documents that relate to financial concerns. This document clarifies the difference between these forms, including the purpose and the process.

Facts about Living Wills:
A Living Will is specific to end-stage medical conditions and describes the kind of treatment you want or do not want if you cannot tell your doctor yourself. Living Wills only apply to patients who have an end-stage medical condition OR are permanently unconscious AND who are incompetent. In other words, it applies only when medical treatment would prolong the dying process or keep you unconscious with no hope of waking. Your Living Will must be signed by you and witnessed by two other adults.

Your treating doctor can only follow your Living Will if:

• He has a copy of your Living Will
• You cannot make decisions for yourself
• You have an end-stage medical condition

Facts about Durable Power of Attorney (DPOA):
In a Durable Power of Attorney for Healthcare, you name another person to make treatment decisions for you anytime you lose the ability to communicate your wishes. This person is a guide for your treatment decisions. The DPOA is a more flexible document that can be used anytime you have treatment needs.

It is important to name someone who knows your wishes and who you trust to follow them. It is a good idea to choose a second or alternate DPOA. The Durable Power of Attorney for Healthcare Form must be signed by you and witnessed by two other adults who are not your named decision makers. It is recommended that Financial Wills and Financial Power of Attorneys be drafted by an attorney. Other names for DPOA include Medical Power of Attorney, Healthcare Agent, Healthcare Proxy, and Surrogate.

Does my doctor have to follow my Advance Directive?
Most healthcare facilities have policies to follow your Advance Directive, as long as it is valid under Pennsylvania law. If your doctor feels that the decisions being made are not in your best interest, he will talk to your decision maker and try to come up with a plan that works for everyone.

Can I change my mind?
You may change or cancel your Advance Directive at any time simply by telling your doctor or other healthcare provider. It is important to tell every healthcare provider and others who have a copy of your Advance Directive, including your hospital. You should include dates of the signatures.

Do I have to write an Advance Directive?
No, it is your decision whether to write one or not. Your treatment and its cost DO NOT depend on whether you have an Advance Directive.

If you do not have an Advance Directive and you cannot make treatment decisions for yourself, your doctor may discuss what treatment you should receive with your family members in the following order:

• Spouse AND adult children from a previous relationship
• Adult children
• Parent
• Adult brother or sister
• Adult grandchild
• Adult friend
• Court (rare cases)

All Adults Need Advance Directives
Most people realize advance care planning is important as we age. However, advance care planning is important for younger people too. If you were ill or injured and unable to speak, who would know what kind of care you would want? Regardless of your age or health condition, it is important to discuss your choices before a health crisis.

The leading cause of death for those under the age of 40 is accidental trauma (such as motor vehicle accidents and drowning). These accidents can result in a state where the brain does not work and the person can’t make decisions. The well-known, publicized cases of Karen Ann Quinlin and Terri Schiavo are examples. They were in their twenties when their life-altering events occurred.

Accidents cannot be predicted in advance. Everyone needs to talk about advance care planning, not just older people. All adults over the age of 18 should discuss their choices with loved ones and complete Advance Directives.

Glossary

• Advance Directive: A written set of instructions expressing someone’s wishes for medical treatment. It may contain a health care power of attorney, living will or both.
• Amend: Change your advance care directive as long as you are of sound mind. Changes (amendments) must be in writing and signed and dated in the presence of two adult witnesses.
• Antibiotics: A kind of medicine used to treat bacterial infections. Patients with serious medical conditions often develop life-threatening infections. For example, patients with advanced Alzheimer’s are at risk of pneumonia. Antibiotics may help treat the pneumonia, but will not cure the Alzheimer’s or the swallowing problem that may have led to the pneumonia.
• Artificial nutrition and hydration: Treatment that delivers nutrition (food) and/or hydration (water) by a means other than the patient taking food or water in his or her mouth and swallowing. There are two main types of artificial nutrition and hydration:
  • Tube feeding: refers to giving nutrition and/or fluids through a tube placed in the gastrointestinal tract. For short term tube feeding, the tube is passed through the nose into the stomach (nasogastric tube) or the small intestine. For long term tube feeding, the tube is surgically inserted through the abdomen wall directly into the stomach (gastric or “g” tube) or the intestines (jejunal or “j” tube).
  • Intravenous (IV) fluids:refers to fluids (such as water and vitamins, minerals, or other nutrients) given by a very small tube (catheter) inserted in a vein. IV fluids are provided through either a peripheral vein (usually in the lower part of the arm) or a central vein (a larger vein closer to the heart).
• Capacity or Competence: The ability: to understand potential benefits, risks, and alternatives of a decision; to make a decision; to communicate the decision.
• Cardio-pulmonary resuscitation (CPR): Refers to medical procedures used to restart the heartbeat and breathing of a patient whose heart has stopped beating (cardiac arrest). CPR may be blowing air into the patient’s mouth and pressing on the patient’s chest. It may also involve electric shock, insertion of a tube in the patient’s windpipe, injection of medication into the patient’s heart, and extreme cases, open chest heart massage.
• Do-not-resuscitate (DNR): A medical order that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if breathing stops or if the heart stops beating. A DNR order allows a person to choose before an emergency occurs if they want CPR. It is a decision only about CPR.
• End-Stage Medical Condition: An advanced illness or other medical condition that cannot be cured or reversed and will result in your death, even if you receive medical treatment. The most common end-stage medical conditions are advanced stages of: Alzheimer’s disease, Chronic Obstructive Pulmonary Disease (COPD), such as emphysema and chronic bronchitis; Congestive Heart Failure (CHF); malignant neoplasm (cancer).
• Guardian: A person appointed by the court to make certain decisions on behalf of another individual who has been determined by the court to be incapacitated and unable to make those decisions.
• Health Care Agent: A person appointed by another and designated in a health care power of attorney to make that person’s health care decisions. The agent should be someone who has an understanding of the person’s beliefs and values, and is able to authorize, withhold or withdraw medical treatment.
• Health Care Directive: See Advance Directive
• Health Care Power of Attorney: A written document in which a person appoints another to serve as his agent and to make health care decisions.
• Health Care Representative: Someone designated by a patient or authorized by default under Pennsylvania law to make health care decisions. The process is less formal than the appointment of a health care agent in a health care power of attorney.
• Hospice Care: Medical, psychological, and spiritual support provided as a patient approaches end of life. Patients are considered to have less six months of remaining life. The goal is to control pain and other symptoms to help people have peace, comfort, and dignity. Services are also provided to support a patient’s family during the illness and in bereavement.
• Incapacitated or Incompetent: Lacking the ability to understand potential benefits, risks and alternatives of a decision; to make a decision; or to communicate the decision.
• Life-Sustaining Treatment: Medical treatment that prolongs the process of dying for a person with an end-stage medical condition or maintains and individual in a state of permanent unconsciousness.
• Living Will: A written statement of a person’s personal choices regarding life-sustaining treatment and other end of life care. A Living Will becomes effective when a patient is incompetent and has an end stage medical condition or is permanently unconscious.
• Palliative Care: Specialized medical care for people with serious illnesses that focuses on providing patients with relief from the symptoms, pain and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.
• Permanently Unconscious: Totally unconscious and this cannot be reversed or made better. Person is unable to interact with or respond to people and things around them.
• Sound Mind: Is a common requirement for a person signing a legal document, such as a contract, last will and testament, or advance health care directive. You can be of sound mind, even though you are forgetful or make choices different from most people, as long as you are able to understand the meaning and effect of your choices.