Advance Care Planning: How to Plan for Your Medical Care
When you go to the doctor or have a planned procedure, you are in charge of your healthcare. You get to make the choices and decide what kind of treatment you are getting or not getting. But what happens when you are unable to make decisions for yourself?
We never know when an emergency is going to strike. You may be left physically or mentally unable to speak for yourself and communicate your wishes. Who is left to make those important decisions about your healthcare?
If you plan correctly, the answer is you. You will still be the one making those decisions. When you have an advance care plan and advance directives, your wishes will be known to those taking care of you in the case of a medical emergency or end-of-life care.
What is an advance care plan?
An advance care plan is a plan you come up with on how you would like to be treated in the case of a medical emergency. Advance care planning should be done with those who are closest to you. Your friends and family should know how you want to be treated when you are unable to voice your wishes yourself.
While it is important that your loved ones know this information, it is also important to get it in writing. This is known as an advance directive.
What is an advance directive?
An advance directive is a legal document that tells medical providers taking care of you what your wishes are. An advance directive will only go into effect if you are unable to communicate those wishes yourself.
Types of Advance Directives
There are many different types of advance directives. However, the two most common advance directives are living wills and medical power of attorneys.
Living Will
A living will is a written legal document that details how you want to be treated in the event of a medical emergency or if you are unable to state your wishes yourself. A living will can include what treatments you are willing to do, which you are not willing to do, and under what circumstances you would be willing to do them.
These medical treatments could include:
CPR
CPR is a procedure commonly used when someone's heart stops beating. CPR might not be wanted for a variety of reasons. CPR is an often aggressive procedure using force on a person's chest that could break a rib. It can also include the use of medications and electric shocks. Someone might not want CPR if they are older or have a terminal condition.
Ventilator
A ventilator is used when someone cannot breathe on their own or get enough oxygen into their body. A tube is inserted into the throat either through the mouth or through an incision. Air is forced into the lungs to give the body oxygen.
Feeding Tube
A feeding tube is used if someone cannot eat on their own. A feeding tube is either placed down the nose into the stomach or surgically into the stomach.
Dialysis
Dialysis is often needed if the kidneys are not functioning properly. Dialysis takes over the function of the kidneys. It filters water and toxins from the blood. It is often used if someone is waiting for a kidney transplant. However, some people are not eligible for kidney transplants and will need dialysis for the rest of their life. It takes hours each time and usually needs to be done multiple times a week.
Pain Medication
Some people may opt to avoid pain medication towards the end of their life or only elect for certain types of pain medication. Some pain medications can make a person tired and groggy. People may opt out of pain medications that alter their state of mind so they are awake and alert in their final days.
Surgery
A living will can state that a person does not want surgery under certain circumstances. If there is a medical emergency, a decision must be made on whether surgery could save their life. A living will can state what kind of surgery someone is willing to put their body through and what kind of risks they are willing to take.
Organ Donation
Organ donation is something that is often stated on a driver's license. Loved ones should be aware of whether organ donation is something the patient is willing to do. If someone is unable to be fully revived by medical personnel, a decision may need to be made about organ donation. This is often done if someone is declared medically brain dead. Organ donation could save someone else's life that needs a new heart, kidney, liver, or any other part of the body that can be transplanted. If this is something you are willing to do, you can note it in your living will so your loved ones will know if the time comes.
Palliative Care/Hospice
If someone has a serious illness or injury that is terminal, palliative care or hospice care may be needed. A living will may include under what circumstances you want to change your care from a more aggressive treatment to comfort care. Your living will may include under what circumstances you receive palliative care or hospice care. It may also include what type of care you want while in palliative care or hospice care.
Medical Power of Attorney
A medical power of attorney is someone of your choosing whom you grant the authority to make your medical decisions if you are unable to. This person should be someone you trust to have your best interest at heart. They should also be made aware of your advance care orders and any other orders you have in place. Your medical power of attorney should also be up to date on your current medical diagnoses and procedures.
Having a medical power of attorney can make the decision process much easier in the event of a medical emergency or end-of-life care. It makes it clear who is responsible for making the decisions. If you do not have a medical power of attorney appointed, valuable time could be wasted trying to figure out who is in charge of your care. You would also risk your wishes not being clearly communicated to medical staff.
What if you don't have an advance directive?
If you do not have an advance directive, your state's law determines who is in charge of your medical care. In most states, your medical care would be determined by your spouse. If you are not married, your parents will be in charge of your care or your children's care if they are legal adults.
If you do not have any immediate family, your care could be in the hands of an assigned doctor. Depending on the state, a close friend may get assigned to make decisions about your medical care.
Other Advance Care Orders
There are many different types of advance care orders. Which advance care orders you need depends on the state you live in and your medical situation. These orders tend to be done as you need them and as your medical situation changes. They may even need to be done multiple times if you are transferred to different medical facilities.
Show your family some love and pre-plan!
“Organizing your information and clearly documenting your preferences and instructions before your passing is one of the most important acts of service you can perform for your family. This will help your family organize and pay for a funeral; access important information about your bank accounts and other investments; and inventory and distribute your assets in line with your wishes. Ultimately, this will save your family significant time, money, and emotional energy during their period of loss.”
-Adam Zuckerman @buriedinwork
Do Not Resuscitate (DNR)
If you have a DNR order, hospital staff will not attempt to revive you if you stop breathing or your heart stops beating. A DNR is an order that needs to be made at every facility where you receive treatment. If you get transferred to a new facility, you will need to redo the DNR and have it signed by a doctor.
There are a few different types of DNR orders.
DNR-A
This order is meant to keep the patient comfortable but instructs not to interfere in any way with the natural process of death.
DNR-B
This order indicates that the patient wants some medical care but usually avoids extreme measures such as CPR, intubation, or surgery.
Out of Hospital DNR
This order is meant for first responders or medical personnel outside of the hospital. It alerts them not to give life-saving measures if you stop breathing or your heart stops beating outside of the hospital. Since you won't be in a facility, you will need to have the out-of-hospital DNR signed by a doctor. You would then be instructed on how to display the out-of-hospital DNR. This could be a necklace or a bracelet or be displayed somewhere in your home.
Do Not Hospitalize (DNH)
A DNH order is a way to let hospital staff know not to admit you to the hospital for any testing or treatment at the end of life. This is often done when someone has a terminal illness and wants to die naturally at home with little medical intervention.
Do Not Intubate (DNI)
This order indicates you do not want to be intubated and put on a ventilator. Because being intubated can be highly uncomfortable and invasive, many people who have a terminal condition prefer not to be intubated. Intubation can also often mean speaking will be very difficult. Someone may not want to struggle to communicate with their loved ones in their final days. They may opt for less invasive ways to assist with their breathing.
Physician Orders for Life-Sustaining Treatment (POLST)/Medical Orders for Life-Sustaining Treatment (MOLST)
Both orders mean the same thing. The state you live in depends on which one will be used. Unlike a DNR, a POLST or a MOLST is an order that needs to be followed anywhere you go in any setting. They tend to be created only when you are nearing the end of your life. A POLST/MOLST has more specific options for how you would like to be treated towards the end of your life.
Who should have an advance care plan and advance directives?
Everyone. Everyone should have an advance care plan and advance directives. You never know when you are going to be in a situation where you will need an advance care plan. It's better to have an advance care plan and not need one than to need one and not have one.
Even if you are young and healthy, your loved ones should know your advance care plan. They should have an understanding of what type of care you are and are not willing to receive and what quality of life you are willing to have.
Share your end-of-life plans.
“Many Americans fail to inform their families about crucial financial matters such as bank accounts and ongoing debts, which could continue to burden the deceased after their passing. Additionally, many fail to communicate their end-of-life wishes and funeral preferences. This places the burden of these difficult decisions on family members with potentially conflicting views. Lastly, we've observed that many wills and trusts omit instructions for the care of the deceased's pets after their death.”
-Adam Zuckerman
How to get started
1. Learn and understand what advance care planning is.
The first thing to do when creating an advance care plan is to know what an advance care plan is and know your options. If you have read this article, you are already mostly done with this step! Research the laws in your state to know the specific options for where you live.
2. Talk to your loved ones about your values and beliefs.
Determine how you would like to be treated in a medical emergency or in the final stages of your life. Think about your quality of life and what you need to have a good quality of life. Speak with your friends and family and make sure those closest to you know and understand your wishes. Having meaningful conversations with your loved ones is one of the most important parts of advance care planning.
3. Select your medical power of attorney.
Of the people closest to you, choose someone to be your medical power of attorney. Select someone who you know would respect your wishes. Speak with this person and ask if they are willing to be your medical power of attorney. Make sure they know you have selected them so they know in the case of a medical emergency.
4. Put your choices in writing.
Once you have decided on your advance care plan, put these choices in writing. The documents you need to fill out depend on the state in which you live. To find the documents you need based on the state you live in, go to the AARP website and click on your state. It will take you to the exact documents you need for your end-of-life decisions. Companies like Buried In Work offer a complete library of the necessary documents based on your unique needs which can help to streamline the paperwork process.
5. Make copies of your plan and share it with others.
Once you have all of your needed documents, make copies of them and share them with your doctors, your medical power of attorney, and your loved ones. Keep a copy in a safe place and make sure your loved ones know where they are located in case they are needed.
You should review your advance care plan if you have a significant change in your health, such as a new diagnosis. You should also review it if your medical power of attorney is no longer able to make medical decisions or if you get married or divorced. If none of these apply to you, your advance care plan should be updated about every ten years.
Keep your plan updated
Update your advanced care plan for major life events such as a marriage or divorce, or at the very least review your documents every 10 years and edit as necessary.
Written By: Elaina Lilienthal
