Getting the MOST from your ADVANCE DIRECTIVES

The pendulum in healthcare has clearly swung; “Colorado passes medical aid in dying, joining five other states”. Amazingly, to me, it happened during my relatively short healthcare career. It was 1990 and I was in medical school when congress passed the Patient Self Determination Act (PSDA). That law mandated that healthcare organizations “inform patients of their rights under State law to make decisions concerning their medical care”. Now, just 26 years later, we can legally help patients die. This relatively rapid swing has produced a great deal of discussion, but also confusion – especially about “forms”.

One reason the PSDA was passed was to reduce the cost of futile end of life care. This was obviously a government consideration with the ever-increasing Medicare and Medicaid populations. On a personal level people were beginning to realize that staying alive and living weren’t necessarily the same thing. People were being, “saved” with intensive medical care – like a ventilator – only to languish in a coma.

With passage of PSDA, advance directives, living wills and medical durable power of attorney became the methods for people to tell healthcare providers what they did or did not want “in the end”. All states had their own laws governing these issues. However, for the most part it was legal for adults to write their choices on any piece of paper and have it witnessed or notarized.  These patient choices collectively became known as advance directives and essentially gave patients the right to:

  1. Designate a decision maker if they were incapacitated (i.e. Medical Durable Power of Attorney)
  2. Decide what life support they want in a terminal condition (i.e. Living Will)
  3. Choose to receive or not receive CPR (i.e. Do Not Resuscitate - DNR)

Not surprisingly, people documenting their advance directives at home, didn’t always get what they wanted at the hospital. The causes included unavailable forms, confusion about choices, family members with differing opinions and doctors erring on the side of, “saving” people rather than letting them die. This was in part what prompted the POLST movement (Physicians Orders for Life-Sustaining Treatment) and similar programs like MOLST (Medical Orders for Life-Sustaining Treatment) and MOST (Medical Orders for Scope of Treatment). I collectively refer to these as POLST forms.

The critical difference between advance directives and the POLST forms is the required signatory.  Advance directives are signed by patients (Patient SELF Determination Act) and made legal with witnesses or a notary. The “O” in POLST forms stands for “orders”, signed by a physician. Additionally, advance directives are meant for everyone to identify their choices about end of life care. POLST forms are to be completed as end of life becomes more likely due to age and disease.

To receive end of life care consistent with their wishes, everyone should complete advance directives with the help of their primary care physician (Medicare now reimburses the physician for this discussion). This discussion and the completed forms get the patient and doctor on the same page. The written document can then be shared with family and loved ones, so that everyone is on the same page – in the end. The advance directives become the guide for the patient and physician to complete a POLST form later on, as age and disease bring the end nearer.