Decoding Living Wills/Powers of Attorney/POLST forms
What makes sense? What is the right thing to do?
These important questions about care and treatment contained in advanced directives, living wills, and power of attorney documents are troubling and difficult to answer for many seriously ill people and their families.
"What makes sense?" "What is the right thing to do?" "What would Mom want?" are often answered by the statement: "I just don't know what to do. I don't feel like I have the knowledge or the tools to even begin to answer all the questions they're asking me..."
We are presenting here reflections which will help sort out what makes sense in terms of medical decision-making. The three documents used to document a patient's wishes are the Durable Power of Attorney (also called Attorney in Fact, Health Care Power of Attorney, or health care proxy), the Living Will (or Advanced Directive), and the Physician Orders for Life-Sustaining Treatment, or POLST, form.
1) The Durable Power of Attorney for Health Care, or Health Care Proxy, is considered by many to be the best document for insuring your future health care decisions are honored.
"Durable Power of Attorney" is someone you choose, whom you know and trust, to make health care decisions for you when you are unable to make them for yourself. This can be a trusted spouse, son or daughter, a niece or nephew, a sibling, or close friend, with whom you can discuss your preferences on issues. This sharing of care options can later help your proxy in advocating for your care. (There are legal restrictions on those who cannot be placed in this position, so check your state's regulations on this point.)
You can obtain a Durable Power of Attorney form on-line or at most health care provider offices. You will need to check your local and state laws with regard to required witnesses and other requirements. In some locales, it is not necessary to have a lawyer draft a document for you, though in others that is recommended. Be sure to specify who you would like to be your "attorney in fact." Then take the document to a Notary Public, where it will be witnessed and signed. A notary can be found at most banks.
2) An Advance Directive usually refers to either a Living Will, or a combination of a Living will and a Durable Power of Attorney for Health Care, or a form used by many states called a POLST form (Physician Orders for Life-Sustaining Treatment).
The Living Will document usually has a whole series of questions that are supposed to guide family and health care professionals as to 'what you would want,' if you are, for some reason, unable to make your own decisions. Please see: The problem with Living Wills. Some portions of Living Wills can be helpful tools for communicating wishes about what you want your loved ones to know, how you want to be treated, how comfortable you would like to be, your preferred funeral plans, etc. (The Five Wishes document, which was created originally be Mother Teresa of Calcutta's attorney, is one which has excellent communication and care sections. This form can be found online at www.fivewishes.org.)
The POLST form, completed and signed, is something which can be both helpful and necessary to have in several important circumstances. In some states, the POLST form is the one legal, advanced directive document which all medics and ambulance personnel are required to follow. This form is the only way to be sure that treatment wishes will be honored, if for instance, you, or your loved one, are seriously or terminally ill, and have a "Do Not Resuscitate" (DNR) order, or a full cardio-pulmonary resuscitation (CPR) order, and need to be transported to the hospital.
The POLST form needs to be signed by both the patient and his or her physician, and witnessed and signed by a third party, in most states. The reason is that each state has innumerable Living Will forms. For emergency medical personnel, in the midst of a medical crisis, time is of the essence, and shouldn't be wasted trying to authenticate if the correct form has been filled out and signed. Hospice patients, being cared at home, choose to have a completed POLST form with the DNR or the AND (Allow Natural Death) option checked on the form, and posted either above their bed or in a prominent location, such as the refrigerator, where emergency personnel are likely to see it.
These forms include several sections of end of life decision- making questions, such as: "If I am unconscious, and not expected to recover, I would, or would not, want to be provided with artificial nutrition and hydration." Or "If I am unconscious and not expected to recover, I would, or would not, want CPR." POLST forms also offer questions regarding the use antibiotics and other care choices.
However, while Advance Directives such as POLST forms and Livig Wills can helpful at times, they can also be confusing and potentially even dangerous.
The major problem is that these forms are usually prepared in advance of the actual medical situation to which they will apply. Unfortunately, one cannot know in advance what will be the most desirable choice in any given treatment situation without knowing the surrounding circumstances at the time. (The exception would be the very acceptable use of a POLST form to indicate No CPR for someone who is seriously or terminally ill.) In many other circumstances,the wording can be either too vague to be helpful, or a cause for under or over-treating a patient. When filling out the nutrition and hydration and antibiotic sections of the form, indicate that decisions be made based on the particular medical circumstances at the time as to whether or not these should be used.
2006 Eileen T. Geller. Updated 2009.
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