The Savvy Patient

Advance directive lets patient decide end-of-life treatments

Adults have a fundamental right to make decisions about their care

By Dr. Maida Soghikian
February 22, 2011 at 12:01 a.m.

Planning ahead for end-of-life medical decisions can make the final days of a life less stressful for not only the patient, but for families and caregivers as well.

Using legal documents, patients can specify which types of medical treatment they do or don’t want in their final days. A report by the federal Agency for Healthcare Research and Quality show these tools are underutilized, as less than half of the severely or terminally ill patients studied had such documents on record.

These are important documents that help patients maintain autonomy in their health care decisions, even if illness or injury prevents them from communicating.

Advance directives
Advance directives include a patient’s signed description of his or her wishes in the event of a catastrophic medical event. Advance directives have two parts. The individual health care instruction defines what should be done medically when a patient is too ill or injured to personally speak – for example, whether artificial life support measures should be used, or what types of pain relief are preferred. The durable power of attorney for health care enables patients to designate an agent such as an adult relative or friend to make medical decisions when patients are unable.

For patients who haven’t conveyed specific wishes through the individual health care instruction, their agents must try to determine to the best of their knowledge what the patient would have wanted. Caregivers must follow the agent’s decisions unless a requested treatment would be ineffective or harmful.

Physician Orders for Life-Sustaining Treatment
This form complements an advance directive by converting an individual’s wishes regarding life-sustaining treatment and resuscitation into physician orders. This may include whether to give a patient CPR, administer intravenous nutrition, or use life support. Before signing the form, known as a POLST, the physician discusses options and preferences with the patient, so both parties agree about what care will be given. The POLST form, signed by physician and patient, becomes a tool to make these discussions part of the patient’s medical record.

Advance directives and POLST forms work together to ensure patients’ preferences for medical care are followed. At the heart of these documents are the patient’s rights regarding autonomy in health care decisions. California and federal law recognize that adults have a fundamental right to make decisions about their own medical care, including the right to refuse life-sustaining treatment.

While an advance directive expresses the patient’s choices and may be used by caregivers, family and physicians as supportive evidence of the patient’s preferences, it does not have to be followed if deemed to be ambiguous or not in the patient’s best interests. In contrast, the POLST is a physician’s medical order that remains with patients wherever they receive care and must be honored.

Patients 18 and older may obtain these forms from their physicians or health care institutions. Once completed, patients should record them in their medical files, and give copies to their agents and family members. Patients may change or cancel them, provided they can competently communicate their wishes.

Maida Soghikian, M.D., specializes in pulmonary disease and critical care medicine with Scripps Health

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