Advance directives are legal documents that are completed in advance of the need for major medical decisions to specify which healthcare options are or are not desired, at present or in the future, and to designate an individual(s) who will speak on the patient's behalf if the patient cannot speak for his or herself. Variations in advance directive laws exist by state. Many states now have Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Life-Sustaining Treatment (MOLST), Medical Orders for Scope of Treatment (MOST), Physician Order for Scope of Treatment (POST), Do Not Resuscitate Order/Clinician Orders for Life-Sustaining Treatment (DNR/COLST), Transportable Physician Orders for Patient Preferences (TPOPP), or similar directives that put the salient points of the advance directive in the form of a medical order. For the sake of brevity, the term POLST will apply to all of these variations in the remainder of the article.
Advance directives fall primarily under the medical ethics concept of autonomy or self-determination, but beneficence (do good for the patient), nonmaleficence/non-malfeasance (do no harm), and distributive justice (appropriate distribution of finite resources) are also involved.
Issues of Concern
Types of Advance Directives
Durable Power of Attorney/Healthcare Power of Attorney/Healthcare Surrogate
These documents appoint an individual or individuals as the decision-maker(s) on the patient's behalf if they are incapacitated and unable to express their desires for treatment.
This document is completed with or without the use of an attorney to specify the healthcare desires of the individual. These choices most commonly include cardio-pulmonary resuscitation (CPR) and endotracheal intubation/mechanical ventilation. Refusing these interventions is often documented as Do Not Resuscitate (DNR), Allow Natural Death (AND), and/or Do Not Intubate (DNI). Additional options that can be considered in these documents include percutaneous endoscopic gastrostomy (PEG) tubes (essentially contraindicated in patients with severe dementia) also known as feeding tubes or artificial food and hydration, dialysis, intravenous (IV) fluids, and antibiotics among others. In the vernacular, these options are often lumped together under terms such as heroic measures, extreme measures, or life-saving, life-sustaining, or life-prolonging treatments. Under the patient's right of self-determination, he or she can refuse any form of treatment, even if that treatment would be likely to prolong life. While the patient can refuse any treatment (negative autonomy), patients do not have the right to demand treatments that are not medically indicated, are more likely to cause harm than good, or violate the professional's right of conscience, as positive autonomy is not as broad as negative autonomy.
Do Not Resuscitate Order
This is a written document usually signed by the patient's health care provider that states the patient's wishes to refuse resuscitative efforts. In most states, these written orders are the only advance directives that emergency management service providers are legally obligated to consider. The patient may elect which resuscitative procedures they wish to accept or refuse. Professionals should educate patients and surrogates regarding the fairly poor outcomes of CPR (i.e., generally less than 9% in some studies but worse in the very elderly or those with significant life-limiting illness).
Physician's Orders for Life-Sustaining Treatment (POLST)
The POLST form is a newer advance directive. It exists as an agreement between the doctor and the patient regarding their condition. It summarizes the patient's wishes and records them as medical orders. In states that recognize the POLST form, the medical orders carry throughout the healthcare system in all settings, including the prehospital setting. However, depending upon the area where the patient lives, a POLST could be void if it contradicts a pre-existing living will. In other states, the POLST can replace the living will as it is more fluid and can be adjusted more easily as the patient's condition changes and can be completed by the surrogate rather than the patient. See the National POLST Paradigm for more information, https://polst.org. Depending upon the laws of the various states, some states might require a physician's signature on the form, while others might allow nurse practitioners (ARNP) or physician assistants (PA) to provide the authorizing signature.
It is important to note that advance directives do not exist to deny all care to patients and that, especially with terminally ill patients, comfort care and pain management continue to be provided. Attempts to provide comfort are always appropriate.
At some point, most clinicians encounter patients with a living will which typically provides specific directives about the course of treatment the healthcare provider should follow. In some cases, a living will might forbid financially burdensome medical treatment. It also may express the patient's wishes regarding receiving food and water supplied via feeding tubes or intravenous fluids. The living will is only used if the individual is unable to give informed consent or refusal due to incapacity. A living will may be specific or very general.
More specific living wills include information regarding a patient's desire for services such as antibiotics, hydration, feeding, use of ventilators, and cardiopulmonary resuscitation. Analgesia and comfort measures are almost always provided.
More advance directives include the “durable powers of attorney for health care” and “health care proxy appointment” which allow an individual to appoint someone else to make health care decisions if they are rendered incapable of making their wishes known. The appointed health care proxy or surrogate has the same right to request or refuse treatment as the individual would have had if still capable of making and communicating health care decisions. Newer advance directives are designed to contain enriched content to better assist individuals and their appointed agents, families, and clinicians to understand better and honor their wishes. The American public is becoming increasingly comfortable with having "online" discussions, and the use of telemedicine or patient portals for electronic health records might provide newer and more innovative methods to help make sure these difficult discussions take place.
It is important for clinicians to be familiar with the medical and legal requirements of all forms of advance directives so that they fulfill the wishes of patients and their families. Also, it should be noted that no advance directive can cover all interventions for all conditions in all situations. The document would be so long and complicated that it would be rendered essentially useless in an emergent situation. Therefore, the surrogate should be familiar with the patient and the nuances of care that might be desired under different circumstances. For example, a patient with lung disease might have a "Do Not Intubate" order, but rather than being a concrete decision, the patient's intended meaning is that they do not want to be on life support for an extended period. In these cases, time trials of interventions can be attempted. If the patient fails to respond to the treatment within a set period of time, treatments can be withdrawn or withheld.
Advance directives were developed as a response to the increasing sophistication of medical technology. Numerous studies have documented critical deficits in the care of the dying, finding it to be unnecessarily expensive, prolonged, painful, and emotionally stressful to patients and families. Medicare now requires advance care planning discussions in the "Welcome to Medicare Exam."
Many potential interventions can be done to the patient that are not actually for the patient's benefit. Aggressive medical intervention may leave patients confined to nursing homes or dependant on feeding tubes for survival. Many patients are kept alive in a comatose or permanent vegetative state with a poor quality of life.
The financial burden to individuals and families may be overwhelming. In many instances, a family member must quit work, and many spend their life savings. This occurs despite the fact that 70% to 95% of people would rather refuse aggressive medical treatment than living in an incompetent or poor prognosis state with a diminished quality of life.
The first formal response was the living will. As more patients and families experience the burdens and diminishing benefits of invasive and aggressive medical treatment in poor prognosis states, they have created pressure to devise legal measures to avoid the suffering and costs associated with treatments.
Enhancing Healthcare Team Outcomes
All healthcare workers, whether physicians, nurse practitioners, physician assistants, nurses, social workers/counselors, chaplains, or others; should make it a habit of discussing advance directives with patients on a regular basis. These disciplines bring a variety of skill sets that can work together toward better outcomes. The discussion should be undertaken way before an acute illness strikes which usually leads to conflicts and ambiguity. Many medical and surgical specialty societies recommend discussions of advance directives and goals of care in various clinical practice guidelines. There is a low prevalence of DNR orders and/or advance directives among patients with stage IV cancer in spite of poor overall prognoses; therefore, there is a definite role for oncology specialists and palliative services in having these discussions. To avoid unnecessary or undesired medical treatment and increased healthcare costs, advance directives should be stated on the chart on admission.