- Written by Rochelle A. Shenk Rochelle A. Shenk
Thinking about potential medical issues and end-of-life care can be a bit daunting, but it’s important. There are legal documents, such as an advance healthcare directive, in which one can specify one’s preferences.
“It’s not just for older people; it’s important for all of us no matter what the age to have an advance directive. In my view, it’s part of estate planning, just like a financial power of attorney and a will,” explains David Mills, Esq., Blakey, Yost, Bupp & Rausch LLP, York.
He says that an advance healthcare directive includes both a living will and a healthcare power of attorney, or POA. This comprehensive legal document provides the medical community with a clear path for treatment.
When a patient is admitted for hospital care, asking if he or she has an advance medical directive is as much a part of the admissions process as providing information about healthcare insurance.
A living will specifies treatments that one may want or not want to sustain life when in an end-stage medical condition or in a state of permanent unconsciousness. Treatments include dialysis, mechanical ventilation, surgery, antibiotics, chemotherapy, and radiation treatment.
“This makes your wishes known in the event that you’re in the hospital and are in a coma,” stressed Mills. “The importance of having a living will was demonstrated by the Karen Ann Quinlan case.”
Quinlan was a New Jersey woman who, in the mid-’70s, mixed an anti-anxiety medication with alcohol while on a crash diet and lapsed into a coma and then a persistent vegetative state.
After doctors refused her parents’ request to disconnect her respirator — which her parents considered an extraordinary means of prolonging her life and contended that it caused her pain — they filed suit to have the apparatus removed.
A legal battle ensued and eventually the respirator was removed. The family consented to a feeding tube, and she eventually died in 1985.
Another clause in the living will focuses on using a feeding tube to supply food and hydration. Mills says that this clause is often called the Terri Schiavo clause — named after the landmark end-of-life care case of the 1990s.
Schiavo, a Florida resident, was resuscitated after a cardiac arrest but suffered massive brain damage and was in a coma. Eventually she was diagnosed as being in a persistent vegetative state.
The case pitted her husband, who wanted the feeding tube removed, against her parents, who argued that she was conscious. The legal challenges involved Florida courts, the state’s legislature, then-Gov. Jeb Bush, the U.S. Congress, President George W. Bush, and the U.S. Supreme Court.
In the event of death, the document also includes preferences regarding organ donation. If donation is chosen, limitations about specific organs and tissues and uses for them may be included. It also addresses palliative or comfort care.
Mills says that some preferences may be affected by religious beliefs. He notes that there is a form for those of the Catholic faith that allows the person to state his or her wishes in many areas but indicates that the healthcare agent is to presume in favor of providing nutrition and hydration, including medically assisted nutrition and hydration if they are capable of sustaining the person’s life.
“The decisions in the living will are all very personal decisions — there’s no right or wrong,” Mills says.
Similar to a financial power of attorney, in which one appoints someone as their “agent” to act on their behalf in financial matters, the healthcare power of attorney appoints someone to act on their behalf with regard to health and personal care decisions.
It is invoked if the person can no longer speak for himself or herself. It’s used not only at end of life, but also in the event that someone is unconscious or in a coma. The form allows someone to appoint both a healthcare agent and an alternate.
Mills says that a living will not only specifies one’s wishes for treatment, but it also directs the agent to act either solely in accordance with the preferences as set forth in the living will or to use the preferences as guidance, allowing the healthcare agent to make the final decision.
He encourages people to review the living will and their preferences with both the healthcare agent(s) they have chosen and family members. He also said that like a will, it’s a document that can be changed as one’s preferences change.
Another document some may
consider is a POLST (Pennsylvania Orders for Life-Sustaining Treatment) form, which is intended to give an individual control over end-of-life care and includes a directive for resuscitation or non-resuscitation if the individual has no pulse and is not breathing.
If the patient has a pulse and/or is breathing, the form indicates if he or she wishes to have comfort measures only; limited interventions, such as cardiac monitor and IV fluids; or full treatment.
There are also sections to indicate the patient’s preferences regarding antibiotics and artificially administered hydration and/or nutrition.
This form is usually completed by individuals with chronic progressive illness and/or frailty or by anyone of an advanced age that feels strongly about designating their goals and preferences for care, said Regina Cabezas, social worker for Landis Homes in Lititz.
“POLST is a voluntary form for individuals throughout the Commonwealth of Pennsylvania,” Cabezas said, “and even though it is highly recommended, completion of the form is not required for admission to post-acute care areas or retirement communities, such as Landis Homes.”
At the time it’s completed, any existing advance healthcare directive should be reviewed. The POLST also includes contact information for the healthcare professional preparing it and the individual’s designated emergency contact or healthcare POA.
“I often say that having the POLST takes things ‘up a notch,’ as it moves from the wishes that someone expresses to becoming orders that must be followed,” Cabezas said.
Cabezas stressed that the advance-care planning process “should not be a two-minute task” but instead an honest, thoughtful conversation amongst all involved parties.
“This may make for some difficult and uncomfortable dialogue between the resident and family members, but ultimately it is the individual’s choice and one that ideally their healthcare power of attorney will follow in what can be a very emotionally charged crisis situation,” Cabezas said.
The key element with all of the documents is to ensure that an individual’s wishes for medical treatment measures — in the event they’re in a coma or facing end of life and cannot speak for themselves — are met.