An advance directive is a legal document addressing your wishes to the health care team regarding end-of-life goals and other terminal medical conditions. The process of laying out your preferences often begins with having a conversation with your loved ones or close friends. The advance directive allows you to document your choices, which your health care providers later use. Your physician can help guide you on the treatment options at the end of life.
It is not uncommon to have patients in the hospital for terminal conditions who failed to establish their wishes beforehand. Moreover, they can no longer specify their choice because the nature of the condition leaves them unable to communicate. The family or medical power of attorney is left to make the best choice on treatment plans.
Examples of end-of-life situations that may or may not be terminal include cardiac and respiratory arrest, stroke, dementia and coma. Treatments include dialysis if your kidneys can no longer function independently and have deteriorated to the extent that dialysis becomes necessary to maintain critical bodily functions. A mechanical ventilator, also identified as a life support machine, can be used if you cannot breathe independently.
In addition to providing oxygen, the machine also delivers breaths. In severe respiratory failure conditions, the lungs cannot give adequate breaths; the ventilator will take over and breathe for you.
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For the ventilator, you would need to be sedated. The wrists will be restrained during ventilation to prevent inadvertent removal of the endotracheal tube, which sits in your airway leading to the lungs.
If you develop anoxia, which is an irreversible, permanent brain change, you will likely be in a coma and not need sedation or restraints. Feeding options will be discussed.
If you suffer cardiac arrest or a severe stroke disabling you from being able to swallow safely, a feeding tube may be offered. Cardiopulmonary resuscitation (CPR) is always mentioned. In CPR, a bystander who recognizes the signs of cardiac and respiratory arrest begins chest compressions. If this happens in the hospital, you will also receive breaths with a bag-mask apparatus, which immediately transitions to a mechanical ventilator. Cardiac and pulmonary arrest happens when your heart and lungs stop functioning, leading to immediate death if not treated.
Except for CPR, these procedures are not just used for terminal medical situations. Sometimes, a patient will need one or more of the above treatments for a temporary period, such as a mechanical ventilator for severe respiratory failure or a feeding tube for nutrition while recovery from a stroke is underway. However, in the advance directive, you are mainly directing your doctor on what to do if you are faced with a terminal condition that has no cure. These procedures are discussed to plan for an end-of-life setting.
A living will is an advanced directive that directs your family and doctors according to your wishes. It is the most common type of advance directive and must be notarized.
A durable power of attorney for health care is a legal document in which the patient designates a surrogate to make medical decisions. The surrogate can also be known as the medical power of attorney (POA).
A medical POA does not imply decision-making on financial matters and is limited to health care decisions only. However, a surrogate may apply for public benefits, such as Medicare and Medicaid, for the patient and request access to financial information regarding the patient’s income, assets and banking records to the extent required to make an application.
The surrogate can be anyone the patient authorizes. You can designate the decision-maker verbally and communicate this to your health care provider.
If you were unable to authorize a surrogate or living will before you became incapacitated and admitted to a hospital, the state allows the physician to choose the best surrogate for you. In Arkansas and many other states, the physicians can determine the decision-maker in the following order: spouse unless legally separated, adult offspring, parent, adult sibling any other relative or any adult who satisfies the legal requirements as specified by state law. When there is no decision-maker, the physician may consult the hospital’s ethics committee.
The medical power of attorney only becomes active once you become incapacitated, which means you are no longer able to understand the risks and benefits of medical treatments and can no longer make informed decisions.
Your physician determines capacity by considering your medical conditions and clinical exam.
Family members who are left having to make decisions for their loved ones have difficulty navigating between the patient’s illness and the grief associated with end-of-life.
By declaring your goals of care, you are enabling your wishes to be met. The advance directive is a good place to start when requesting your preferences.
Help your future self, families and health care team by starting with these important discussions.
Please make this a commitment for 2025!
Dr. Naznin Jamal is a Jefferson Regional Medical Center hospitalist.