More than a million people have died from COVID infections since the pandemic began; many of them did not have advance medical directives indicating how they wanted healthcare decisions to be made if they were unable to express their desires. As a result, families struggled to determine the best approach to end-of-life care for their loved ones.
Advance directives guide the medical team to provide medical care and alleviate the burden on families to decide what types of medical care and treatment the patient would want. The two forms of advance directives that physicians should discuss with families are the Power of Attorney for Health Care and the Declaration to Physicians (the Living Will).
These and other documents discussed in this article are available on the internet and at some retail stores; however, if they are to be used for legal purposes, they must be notarized and properly filed.
A Power of Attorney for Health Care
If patients lose the ability to make their own healthcare decisions, the Power of Attorney for Health Care designates an agent who, in collaboration with the personal physician, can make healthcare decisions for a patient. Additionally, the patient may complete a Power of Health Care addendum, which outlines treatment preferences and desires that will guide the designated healthcare agent’s decision-making.
The healthcare agent can advise the patient’s personal physician, physicians providing medical care, and the hospital staff on what medical treatment the patient wants in all anticipated healthcare end-of-life situations. If the Power of Attorney for Health Care has been completed correctly, in most cases, this advance directive can prevent a court-supervised guardianship or a protective placement proceeding. For this reason, it is often preferable to consult an attorney who can write or review the document as it applies to the individual situation.
The Power of Attorney for Health Care may prevent heated debates between family and healthcare providers and costly guardianship proceedings in court. It is a more robust document than the Declaration to Physicians because it can include an addendum specifying treatment preferences.
The Declaration to Physicians
The Declaration to Physicians describes the life-sustaining medical care to be given to a patient with a terminal condition or who is in a persistent vegetative state. The declaration guides the physicians and healthcare team in deciding whether to withhold or withdraw life-sustaining treatment, such as a feeding tube, if the patient cannot be “cured” and death is imminent; however, the Declaration to Physicians does not give physicians or healthcare providers authority to make healthcare decisions on the patient’s behalf. A court-supervised guardianship and protective placement proceeding are required if the patient is moved to a nursing facility. Such action would be covered under a Power of Attorney for Health Care directive.
When there is no one to assume the healthcare agent role or the agent becomes incapacitated or dies, the Declaration to Physicians is the next best option. If a patient has both types of advance directives, they should be consistent; if there is any conflict, the Power of Attorney for Health Care will prevail.
Concerning life-saving measures, physicians should instruct patients that cardiopulmonary resuscitation (CPR) is an emergency medical procedure designed to restart the heartbeat and breathing. If CPR is administered early and correctly, it may result in adequate blood pressure that allows the vital organs to survive.
If CPR does not revive the patient, the emergency team may initiate advanced cardiac life support (ACLS), which may include shocking the heart, inserting a breathing tube into the trachea, and administering intravenous medications in an attempt to support life.
The patient’s medical condition plays a critical role in determining the success of CPR and ACLS. If the patient’s medical condition warrants a discussion of such procedures, the physician should detail the best approaches.
A do not resuscitate (DNR) order applies to patients who suffer from a terminal medical condition or a medical condition such as severe heart, lung, kidney, or brain disease that makes it highly unlikely CPR would be successful.
To be eligible for a DNR bracelet, patients with the described medical conditions must be at least 18 years of age and not be pregnant.
The patient and the physician must sign an order for a DNR status; when approved, the physician, or representative agent, places the bracelet on the patient’s wrist.
Mentally competent patients can revoke a DNR order by communicating to their family, agent, or physician that they wish to revoke the DNR order and remove the bracelet. Ideally, this action to revoke the DNR order should be a written document entered into the medical record and acknowledged by the family, the agent, and the physician.
Emergency responders are prohibited from performing chest compressions, inserting airways, administering cardiac resuscitation drugs, or applying electric shock therapy on DNR patients. Emergency responders are allowed to clear airways, administer oxygen, position the patient for comfort, provide pain medications, control bleeding, splint injured bones, and provide emotional support.
Why an Advance Directive Is Essential
Advance directives are often prepared under the guidance of an attorney familiar with individuals who wish to make clear their end-of-life wishes to family, friends, and healthcare professionals while mentally competent. These directives prevent conflict among family members and/or physicians about the treatment the patient should receive if incapacitated and offer an advantage to healthcare providers and family members.
Physicians should stress to patients that if they become incapacitated and do not have an advance directive, no one has the legal authority to make their medical decisions. Then decisions left to the physician, spouse, adult children, or court-appointed guardian might generate discord.
So long as they demonstrate their competency as adults, patients have the right to make their own decisions about medical care, including whether to accept or refuse recommended treatment and procedures.
These documents do not become relevant until patients are no longer competent to make rational decisions regarding their healthcare. For that to occur, two physicians or a physician and a psychologist must declare that the patient no longer has the capacity to make healthcare decisions.
Roles and Responsibilities of the Healthcare Team and Family
The patient can appoint a spouse, trusted relative, or close friend to be their healthcare agent; however, an employee or spouse of the employee of the healthcare facility where the patient resides is not eligible to be an agent. The healthcare agent must be at least 18 years old.
The patient’s healthcare agent should meet with the medical team to ensure mutual understanding of the patient’s healthcare status, treatment plan, and chances for recovery. A discussion of end-of-life measures will verify that everyone is on the same page.
A clear articulation of a patient’s wishes will help the agent honor and protect the patient’s wishes. This discussion should cover all potential issues such as using a ventilator, kidney dialysis, artificial nutrition, CPR, pain control, where the patient prefers to die, and whether the patient wants to donate their tissue and organs.
Physicians should play a pivotal role in educating patients on how they want to approach end-of-life situations and how advanced directives will allow their wishes to be carried out. Physicians must understand their fiduciary duty to take an active role in their medical communities by educating patients about the benefits of advanced medical directives to allow for a peaceful and harmonious end of life for patients, medical teams, families, and friends.