Creating an advance care plan explains your wishes to doctors, nurses, and hospice workers if you become medically unresponsive. It lets you remain in control in even the worst scenario, preventing someone else from stepping in and making medical decisions for you.
A POLST form (Physicians Orders for Life-Sustaining Treatment) spells out your desires to your caregivers. It is organized in sections labeled A-D, but workers in the medical field prefer to read it D-A.
To most patients, this appears to be the most important section. However, after considering the previous sections, most find they already know which option they prefer. If they do not want to be kept alive on machines, normally they do not want to be resuscitated.
On TV, resuscitation is painless. Actors press on the chest a few times and the other person wakes up with no side effects. In reality, CPR can seriously injure the ribs. Additionally, a 2007 study in the Journal of Pain and Symptom Management found CPR was only effective 10 percent of the time. However, in elderly patients, it was only effective 0.6 percent of the time. Moreover, elderly people typically survived for only an hour after being resuscitated. There was also evidence they had suffered brain damage.
This does not mean resuscitation is the wrong choice, only that patients should be aware of what it entails before choosing it.
Medical intervention is not the same as medical treatment. This section tells doctors whether they should use machines to keep you alive if you are completely unresponsive (also known as a vegetative state).
Many patients experience confusion choosing between selective treatment and comfort treatment. The difference between the two is slim but meaningful. The first attempts to cure illnesses, while the other tries to make the transition peaceful as possible.
Many people do not understand the term “artificial nutrition.” They think it refers to supplements or meal replacement shakes, like Ensure. Instead, artificial nutrition is given to people when their body is no longer able to process foods. Under these conditions, nutrients are fed to the patient through a tube inserted down their throat or into their stomach.
A study that looked at over 80,000 people found elderly patients who were fed artificially had a shortened lifespan. The tube irritated the throat, which led to secretions and subsequently to pneumonia. In some cases, the patient accidently disturbed or dislocated the tube, which caused further complications. For this reason, patients are only allowed to receive artificial nutrition for a maximum of 30 days.
However, just because a person is not eating does not mean their condition is irreversible. For example, patients with a bowel obstruction might require artificial nutrition, but can resume eating normally once the obstruction has been surgically removed.
There is no right answer to these types of concerns. However, patients should take a moment to weigh the benefits of artificial nutrition against its costs. How likely is it to extend their lifespan?
This section names the person you want to act on your behalf if you are no longer able to make decisions. In most states, the law automatically designates that person as your spouse or closest living blood relative. However, there are situations where the patient’s next of kin is not the person closest to them. Perhaps they have become estranged or are living in another part of the country and were unable to discuss the patient’s wishes. There have even been times when a patient has separated from their spouse, only to have them called back to make end of life decisions because they had not finalized the paperwork. In that case, the doctor would have no choice but to obey the spouse over the objections of the other family members.
Fortunately, scenarios like this are rare. But to avoid confusion and distress, it is best to designate someone ahead of time. If you have explained your wishes to someone who is not your spouse or next of kin, make sure you name them on the POLST otherwise your care plan may not be put into action.
In most cases, the person making decisions about your health is also permitted to make decisions about your finances. However, this does not have to be the case. You can put a separate person in charge of your money, if you feel they would do a better job. This person would be responsible for preserving your resources to guarantee a good end of life, as well as handling mortuary costs.
Creating an advance care plan makes sure doctors honor your wishes even when you cannot communicate with them. If you want to fight, it lets them fight for you. If you want to pass peacefully, it lets them know.
Jose Escobar is the Hospice Executive for Parentis Health. He works with patients and families across Southern California, providing support and education, in order to alleviate the pain and suffering of chronic and terminal illness.