Advance Health Care Directives

Life prolonging treatments are procedures to attempt to restore certain functions and maintain an individual’s life. These may include:

• Cardiopulmonary Resuscitation (CPR) – An emergency procedure that attempts to restore and maintain breathing and circulation in someone whose heart or breathing has stopped. This includes chest compressions and/or artificial breathing techniques.
• Mechanical Breathing (ventilator) – A tube is placed through the mouth into the windpipe. The breathing tubes are connected to a machine (a ventilator) that controls breathing.
• Artificial Nutrition and Hydration – A method of providing artificial nutrition/fluids through a tube for someone who cannot eat or drink normally.
• Antibiotics – Medications to combat serious infections in the body.
• Chemotherapy – Medicines to fight cancer administered through pills, injections, or by intravenous infusion.
• Dialysis – Cleansing the body of excess chemicals, minerals, and impurities and removing excess fluids through a machine connected to a patient via a tube in the arm or through the abdomen. Dialysis is used for patients whose kidneys are not functioning normally or adequately. It can be temporary or permanent.

Advance directives (or living wills) are legally recognized documents that are designed to reflect your medical goals and treatment preferences in the event that you are unable to express your wishes personally. It is recommended that all capable adults, regardless of health status, complete an advance directive/living will to let others know their wishes. In New Jersey, these documents allow you to:

• Designate a person (surrogate decision maker/proxy) and give that person the legal authority to make decisions about treatment issues for you if you are unable to make treatment decisions for yourself.
• Let your family and caregivers know your wishes. This is particularly important if you do not want aggressive treatment such as mechanical ventilation or dialysis. You may outline what medical treatments you wish to accept or refuse and the circumstances in which you want those directions implemented, or you may simply write a description of what you want in certain conditions – for example, “If my doctor does not think that I will be able to leave the hospital, I do not want [CPR, dialysis, to be put on a ventilator, or other aggressive treatment].”

If you’ve made an advance directive/living will, you might want to consider completing a POLST form as well.

A POLST form is a set of medical orders that your doctor/advanced practice nurse (APN) develops with you to give you more control over your end-of-life care. It allows for a review and documentation of some key decisions in a standardized format, and encourages frequent review as your health situation evolves. The POLST form includes your goals of care and preferences regarding:

• Cardiopulmonary resuscitation attempts
• Use of intubation and mechanical ventilation for respiratory failure
• Artificially administered nutrition and hydration
• Other specific preferences regarding medical interventions

Unless it is your preference, the use of the POLST form to limit treatment is not appropriate for patients who are medically stable or who have functionally disabling problems but have many years of life expectancy.

The advance directive and POLST work together in advance care planning in New Jersey and most other states. Below are some key differences between the two.

The Advance Directive/Living Will

• Is not a medical order. It requires evaluation by a physician of your diagnosis/prognosis, and your preferences as to treatment. Sometimes, if the advance directive is not specific, treatments are not limited in an emergency situation with only an advance directive. Therefore, unwanted treatments and interventions may be applied.
• Helps you communicate treatment preferences in advance of a serious illness and may designate a proxy to make decisions should you lose the capacity to do so.
• Is recommended for all adults with decision-making capacity to let family, friends and caregivers know their wishes.

POLST

• Is a medical order. It guides the care provided by all health care providers. Because it is a physician’s/practitioner’s order developed with the patient, caregivers must follow its directions.
• Reflects your goals of care and wishes around care near/at the end of life and transforms them into actionable orders that must be followed by all health care professionals.
• Is recommended for those with advanced illness, frailty, or strong preferences about medical interventions in their current state of health.

Using the POLST Form
Completing the POLST form should follow a thorough discussion between you (or your surrogate) and your doctor or advanced practice nurse (APN) based on your individual medical treatment preferences at the time of discussion. The form is organized so that it serves as a template or script for the discussion. You can talk to your doctor or APN about your goals for care within the context of your prognosis and express your specific wishes in the document.

Identifying a Surrogate
You may appoint a health care representative/surrogate decision maker on the POLST form to make decisions for you in the event that you later lose decision-making capacity. If you lose capacity, the health care providers must rely on a surrogate decision maker to help fulfill your medical treatment wishes. The surrogate can be your spouse, legal age child, civil union partner, court-appointed guardian, or another person of your choosing.

Signatures
A POLST form must be signed by a physician or advance practice nurse to be valid. By signing the form, your health care professional assumes full responsibility for the medical orders that are documented, similar to any other medical order in your chart.

Storing the POLST Form
The POLST should be readily accessible in clinical records. In home settings, it should be in a highly visible location that EMS personnel and first responders are likely to see, such as attached to the kitchen refrigerator, by the telephone, by your bed, or on the inside of the front door. You should keep the original copy of the POLST form with you and give a copy to your surrogate.

What if I Change My Mind?
Your health care professional should review and update the POLST form with you as your medical conditions, goals, and treatment preferences change. You may void the POLST form at any time and request different treatment. This can be done by drawing a line through sections A through F and writing “VOID” in large letters on a paper form. If the POLST form is maintained via an electronic medical record kept by the facility, it must be voided in accordance with the institution’s procedures. It should always be dated and signed by you.

Out-of-Hospital DNR Forms
If you have an Out-of-Hospital (OOH) DNR form, it is no longer needed once you and your doctor or APN have completed and signed a POLST form. POLST replaces the OOH DNR Form since all health care providers, including pre-hospital providers like EMS personnel and first responders, must follow the orders on the POLST form.

The goal of palliative care is to manage pain, control symptoms, and improve quality of life for those with a chronic illness or those who are nearing the end of their life. Our Palliative Care team can help when a life-threatening, progressive, or incurable illness presents challenges for patients and their families. We draw on a range of resources and professional expertise and work in partnership with the primary health care team to ensure complete, well-coordinated care.

Since palliative care is focused on relief of pain and suffering, it can be provided at any stage of an illness, regardless of a patient’s life expectancy. In fact, accessing these services as early as possible—even upon the diagnosis of a health condition—can help patients avoid, reduce, or better prepare for difficulties that may result from the illness or treatment. Palliative care is appropriate at any stage of an illness and can be provided at the same time as curative treatment.

Hospice is an organized system of care for patients and families created specifically to help patients expected to have less than six months to live. Care can be delivered at home or in a nursing facility or hospital, depending on the wishes of the patient and family and the modes of treatment needed. Care focuses on pain management and control of symptoms while maintaining dignity and quality life. Hospice also helps family members and caregivers cope with the process of death.

Palliative care and hospice are not about withdrawing care or giving up; rather, these services acknowledge your wishes and choices and assist in advance health care planning.