Jordan Ellis
Advance care planning (ACP) is a process that helps adults of any age or health stage outline their values, life goals, and preferences for future medical care. This includes conversations with health professionals and the completion of Advance Directives (AD), a set of legal documents that guide critical decisions made on behalf of the patient if they are unable to make them. ACP is particularly relevant in cases of chronic disease, increased life expectancy, and a focus on patient autonomy. It is recommended to begin ACP in early adulthood and periodically review and update Advance Directives throughout one's life as goals and values evolve.
| Characteristics | Values |
|---|---|
| Advance Care Planning | A process that helps adults at any age or stage of health to understand and share their personal values, life goals, and preferences regarding future medical care |
| Advance Directive | A legal document that records an individual's wishes about medical treatment in the future if they are unable to make decisions about their care |
| Health Care Proxy | Someone the individual trusts to make decisions about their health if they can't |
| Physician Order for Life-Sustaining Treatment (POLST) | A form that provides guidance about an individual's medical care that health care professionals can act on immediately in an emergency |
| Do Not Resuscitate (DNR) Order | A document that informs medical staff that an individual does not want CPR or other life-support measures to be attempted if their heartbeat and breathing stop |
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What You'll Learn
- Advance Directives: Legal documents outlining your wishes for future care
- Health Care Proxy: Choosing someone to make decisions on your behalf
- DNR Orders: Directives to medical staff about resuscitation attempts
- POLST/MOLST Forms: Forms for immediate medical guidance in emergencies
- Advance Care Planning: Conversations with health professionals about future care
Advance Directives: Legal documents outlining your wishes for future care
Advance directives are legal documents that outline an individual's wishes for future care and medical treatment. They are used when an individual is unable to communicate their preferences, such as in the event of a serious illness or accident. Advance directives are not just for older adults or those with existing health conditions; anyone can benefit from creating these documents to ensure their wishes are respected in the case of an unforeseen medical emergency.
The process of creating advance directives involves reflecting on one's values, beliefs, and preferences for care. It is a thoughtful and deliberate process that may be guided by resources such as the Conversation Project, which offers online conversation guides and advance care planning documents in multiple languages. These guides can help individuals consider their priorities and shape their directives.
There are two common types of advance directives: living wills and durable power of attorney for healthcare (also known as a health care proxy). A living will outlines the individual's wishes for medical treatment, including any specific treatments they do or do not want. For example, an individual may include a Do Not Resuscitate (DNR) order, indicating that they do not wish to receive CPR or other life-support measures if their heartbeat or breathing stops. A health care proxy, on the other hand, is a designated individual, such as a family member or trusted friend, who is authorized to make medical decisions on the person's behalf if they are unable to do so themselves. This person should be familiar with the individual's values and preferences and can act as their advocate, ensuring their wishes are respected.
It is important to note that advance directives are not static documents. They should be reviewed and updated periodically, especially after significant life events or changes in health status. Additionally, it is recommended to have these directives easily accessible, such as by carrying a card in one's wallet indicating the existence of an advance directive and where it is kept. By preparing these legal documents, individuals can ensure that their wishes for future care are respected, and their loved ones are guided by their instructions during difficult times.
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Health Care Proxy: Choosing someone to make decisions on your behalf
Advance care planning is a process that helps adults at any age or stage of health to prepare for future medical needs, as a serious accident or illness can happen at any time. It involves discussing and preparing for future decisions in the event that you are unable to communicate them yourself.
A health care proxy, also known as a representative, surrogate, or agent, is a person who can make health care decisions for you if you are unable to communicate them yourself. They work closely with your health care team to ensure your care and treatment preferences are followed.
When choosing a health care proxy, it is important to select someone you trust to be assertive and honour your wishes. Some people choose a family member, while others may decide on a trusted friend, lawyer, or neighbour. It is recommended to not choose your healthcare provider or someone working for a government agency financially responsible for your care. You should also be aware of any state requirements or limitations on who can be your proxy. For example, in Alabama and Nebraska, a proxy must be 19 or older.
Before deciding on a proxy, it is a good idea to talk to more than one person about your wishes. Once you have identified someone, ask them if they are willing to take on the responsibility. You can specify how much control your proxy has, including whether they can make a wide range of decisions or only a few specific ones. You can also outline other preferences, such as requiring your proxy to talk with certain family members before making a decision. However, it is important to give your proxy some flexibility to ensure they can provide the best care possible.
To name a health care proxy, you can use an advance directive called a durable power of attorney for health care. You can change your proxy at any time by filling out a new form and letting your family and healthcare team know. It is also a good idea to name a backup agent if your primary proxy is unavailable.
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DNR Orders: Directives to medical staff about resuscitation attempts
Advance care planning is a process that helps adults at any age or stage of health to understand and share their personal values, life goals, and preferences regarding future medical care. It is a process that occurs over a lifetime as goals and values change. Advance directives are a legal document that forms a part of this process. They tell your doctor and family what kind of medical care you would want to receive if you were unable to speak for yourself.
Do-not-resuscitate (DNR) orders are a type of advance directive. A DNR order means that you do not want treatments such as cardiopulmonary resuscitation (CPR) to be used on you if your heart or breathing stops. It is a medical order written by a healthcare provider, instructing other providers not to perform CPR if a patient's breathing stops or their heart stops beating. It is specific to CPR and does not include instructions for other treatments such as pain medicine, other medicines, or nutrition.
DNR orders are usually created before an emergency occurs and are added to a patient's medical chart. They can be included in a living will, but it is helpful to have a separate DNR order in your medical file if you go to a hospital. Doctors and hospitals in all states accept DNR orders. They can also be used outside of a hospital setting, alerting emergency medical personnel to your wishes.
It is important to discuss your desires with your healthcare providers and family before an urgent decision is required. You can change your mind about a DNR order at any time and request CPR if necessary. If you do change your mind, it is important to inform your provider, healthcare team, family, and caregivers.
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POLST/MOLST Forms: Forms for immediate medical guidance in emergencies
POLST (Physician Orders for Life-Sustaining Treatment) and MOLST (Medical Orders for Life-Sustaining Treatment) forms are critical components of advanced care planning. Advanced care planning is a process that helps adults at any age or stage of health articulate their personal values, life goals, and preferences regarding future medical care. This is especially important in the context of serious illnesses or accidents, which can occur at any age.
POLST and MOLST forms are designed to provide immediate guidance to healthcare professionals in emergency situations. These forms are typically created when an individual is facing a life-threatening illness or is critically ill and needs to make specific decisions about their medical care. They serve as a supplement to an individual's advance directive, which outlines their wishes for future care if they become seriously ill or unable to communicate their preferences.
The POLST form is a "portable" physician order that summarises an individual's wishes regarding life-sustaining treatment. It is recognised in many states, but the specific process and form can vary. For example, in Washington State, the POLST form allows individuals to express their wishes regarding end-of-life treatment, in alignment with the state's Natural Death Act.
The MOLST form, recognised in New York State, is similar to the POLST form in that it contains specific and actionable medical orders. It is a bright pink document that accompanies a patient across healthcare settings and must be followed by healthcare practitioners when the patient moves from one location to another. The MOLST form is completed after a discussion with the patient, their healthcare agent, or surrogate, taking into account the patient's health status, prognosis, and goals of care.
Both POLST and MOLST forms ensure that an individual's preferences for life-sustaining treatment are respected and followed in emergency situations, providing clear and immediate guidance to healthcare professionals. These forms empower individuals to make critical decisions about their medical care and ensure that their wishes are honoured, even in the most challenging circumstances.
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Advance Care Planning: Conversations with health professionals about future care
Advance Care Planning (ACP) is a process that helps adults of any age or health stage to understand and share their personal values, life goals, and preferences regarding their future medical care. It is a process that occurs over a lifetime as goals and values change. ACP is not just for older people, as serious accidents or illnesses can happen at any age.
ACP involves multiple conversations with health professionals, which may lead to the completion of Advance Directives (AD). These are legal documents that outline your wishes for future care and help clinicians and family members make critical decisions on your behalf if you are unable to. When preparing an Advance Directive, you should consider your wishes for the end of your life, such as the kind of care you would want or not want during a severe illness, and where you would prefer to spend your last days. You should also consider whether you want your life to be preserved for as long as possible and, if not, what kinds of mental or physical conditions would make you think that life-prolonging treatment should not be used.
You can talk about an Advance Directive with an attorney or your healthcare provider, and they can help you prepare the necessary documents. You should also make sure that your Advance Directive is in your medical record. It is recommended that you periodically review your Advance Care Planning documents to ensure that your wishes, as well as names and contact information, are up to date.
In addition to an Advance Directive, you may also want to consider a Do Not Resuscitate (DNR) order, which informs medical staff that you do not want CPR or other life-support measures to be attempted if your heartbeat and breathing stop. This can be helpful to have as part of your medical file if you go to a hospital.
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Frequently asked questions
Advanced care planning (ACP) is a process that helps adults at any age or stage of health communicate their personal values, life goals, and preferences regarding future medical care. It involves multiple conversations with health professionals that may lead to the completion of Advance Directives (AD), a set of legal documents that guide critical medical decisions when the patient is incapable of making them.
An Advance Directive outlines your wishes for future care if you became seriously ill or were near the end of your life. This includes the types of care you would want or not want, where you would prefer to spend your last days, and your wishes regarding life-prolonging treatments and organ donation. You can also name a health care agent or proxy (similar to a durable power of attorney) who will make medical decisions on your behalf if you are unable to do so yourself.
Advanced Care Planning is recommended for all adults, regardless of age or health status, as serious accidents or illnesses can occur at any time. It is a lifelong process that should be reviewed and updated periodically as your goals and values change. While there is no "perfect timing," a recent hospital admission or diagnosis of a serious illness may prompt you to consider future healthcare decisions.
You can discuss creating an Advance Directive with an attorney or your healthcare provider, who can help you prepare the necessary legal documents. You should carefully consider your wishes and the person you want to speak and make decisions on your behalf. It is important to ensure that your Advance Directive is added to your medical record and shared with your healthcare agent, physicians, and loved ones.
