Skip to content

Advanced Directives

Manasa Atyam

Overview

Advance directives are legal documents that allow a patient to express their preferences on quality of life, medical care and health care decision makers in the event they lose the ability to make their own decisions. Advance care directives remain valid indefinitely. If an advance care directive does not reflect a patient’s wishes, a new document should be executed and a note should be entered in to the EMR stating that the current document is no longer valid. The most common types of advance care directives are: - Living Will: This document specifies which medical treatments a patient would be willing to pursue and allow an individual to describe preference about quality of life. Specifically, the living will allow a patient to express their wishes on life support, cardiac resuscitation, artificial hydration, and nutrition. A living will must either be signed by two witnesses or notarized. It does not require a lawyer. - Healthcare Power of Attorney (HPOA): This document allows a patient to legally designate one to two people to make healthcare decisions if a patient loses capacity. The designated HPOA should make decisions reflective of the patient’s own choices, using substituted judgment. Recognizing that patients may change their wishes on medical care over time, the HPOA may trump the living will in situations where the choices in the living will no longer reflect the patient’s current wishes on health care. - Physician Order for Scope of Treatment (POST): This is a physician order that specifies which medical interventions should be attempted (CPR, mechanical ventilation, artificial hydration, and nutrition). Additionally, it details under what circumstances a patient would like to be hospitalized and which types of inpatient hospital settings (ICU vs. avoid the ICU) are consistent with their goals. The POST form is valid in the community (including long term care facilities, senior centers, and dialysis units) and in the emergency department. It is preferable but not required for a patient or their surrogate to sign the POST form. Any patient that is DNR or DNR/DNI must have a completed POST form when transferring by ambulance. You can download the form from MedEx or find them here: https://www.tn.gov/content/dam/tn/health/healthprofboards/hcf/Post_Form.pdf

How are advance care directives different from code status?

Advance care directives are documents that a patient fills out to describe their wishes on medical care. Code status is a physician order completed by a health care provider. It is important to remind patients and families that even if a patient has a completed living will declining CPR/mechanical ventilation, the health care providers will assume the patient desires CPR/mechanical ventilation, unless an appropriate code status order is entered. A new code status order must be entered at each admission. If a patient had a code status order placed when he/she lacked capacity and then regains capacity on admission, code status must be readdressed with the patient.

TN Advance Care Planning

  • The state of Tennessee created a form that combined the contents of a living will and POA: https://www.tn.gov/content/dam/tn/health/documents/Advance_Directive_for_Health_Care.pdf
  • This includes:
    • Agent and when they become effective
    • Defining quality of life
    • Wishes for treatment when quality of life is unacceptable (as defined in previous section), and condition is irreversible
      • CPR
      • Life support (intubation, IVF, pressors)
      • Treatment of new conditions that arise (i.e., antibiotics for new infection)
      • Tube feeding/artificial nutrition
  • Other instructions (free text)
  • Organ donation
  • Signature of person + 2 witnesses (not POA) or notary
  • Outpatient: Discussions on health care decision makers, wishes on medical treatment (particularly CPR), mechanical ventilation and artificial hydration and nutrition should be done periodically with all patients over the age of 18. This conversation should be part of the annual visit, especially for those with chronic health conditions, changes in functional status or a new diagnosis of a serious disease.
  • Inpatient: Can ask SW to assist with providing these forms