Advance directives

Advance Directives - The Future is Now

• Legal documents detailing a patient's wishes for medical care if they become incapacitated. Rooted in the Patient Self-Determination Act (PSDA).
• Key Types:
  • Living Will: Dictates desired medical treatments (or their refusal), such as mechanical ventilation or tube feeding, in specific scenarios.
  • Durable Power of Attorney for Healthcare (Healthcare Proxy): Appoints a specific person (agent) to make healthcare decisions if the patient cannot.

⭐ A healthcare proxy is often more flexible than a living will, as it allows the appointed agent to respond to unexpected clinical situations not explicitly covered in a document.

Directive Types - Will vs. Power

• Living Will:

  • A written document detailing wishes for specific medical treatments if incapacitated (e.g., "no mechanical ventilation").
  • Outlines desired or refused interventions.
  • Limited as it cannot anticipate every possible clinical scenario.

• Durable Power of Attorney for Healthcare (DPOA-HC):

  • Also called a healthcare proxy.
  • Appoints a person (agent) to make healthcare decisions if the patient is incapacitated.
  • More flexible than a living will; the proxy can interpret the patient's values in new situations.

• POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment):

  • Actionable medical orders for current treatment, designed for seriously ill or frail patients.
  • Translates patient wishes into direct commands (e.g., DNR, DNI).
  • Stays with the patient across different care settings.

⭐ In a conflict between a living will and a DPOA-HC's decision, the proxy's choice usually prevails. The proxy can interpret the patient's values within the specific clinical context, offering more nuance than a static document.

Surrogacy Hierarchy - The Chain of Consent

When a patient lacks decision-making capacity and has no advance directive, a surrogate is designated based on a legal hierarchy. The surrogate must use substituted judgment-making the decision the patient would have made. If the patient's preferences are unknown, the surrogate must act in the patient's best interest.

⭐ When multiple adult children are surrogates, most states require a majority or consensus agreement. Significant disagreement may necessitate an ethics committee consultation or court intervention.

High‑Yield Points - ⚡ Biggest Takeaways

• Advance directives are legal documents for future medical care, effective only when a patient loses decision-making capacity.
• Includes a living will (specific treatment instructions) and a durable power of attorney for health care (appointing a surrogate).
• A patient with capacity can revoke or change the directive at any time.
• They are distinct from a DNR order, which applies only to resuscitation efforts.
• If no directive exists, decisions fall to next of kin.