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An update on advance directives
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Many misperceptions exist regarding what “advance directives” exactly are, as well as physician order documents for limiting treatment. Although advance directives have not historically had the expected impact of patients’ preferences being honored, they have served as triggers for discussions of patients’ wishes and advance care planning.
A 2009 study by Dow et al of hospitalized cancer patients revealed that most found it important to discuss advance directive issues with a physician and preferred that physician to be their oncologist or primary care physician. Research has also demonstrated the benefit of advance directives for family members as well. In one study of patients who had life-sustaining treatment withdrawn, surviving family members of patients who had written advance directives had significantly lower stress than those who did not.
Advance directives refer to a patient’s directives regarding treatment and/or a proxy decision-maker, and are not limited to patients who are imminently dying. All states have some form of advance directives that are honored as legal documents. An advance directive for treatment is also referred to sometimes as a “living will,” as it applies to the preferences of the patient while they are still living.
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A proxy directive indicates whom the patient would want to make health care decisions, once they lose decision-making capacity; a patient can also make the proxy’s decision-making active, even while they still have capacity. The legal document (or portion of the legal document) that designates this proxy is the durable power of attorney for health care (DPAHC). This distinguishes this proxy from the durable power of attorney for finances, which is a separate document.
A new advance directive
Recently, a new document called Five Wishes was developed as a more expansive tool than the standard advance directives. It is recognized as a legal document in 42 states. The “five wish” categories include the health care proxy, patient treatment preferences, a patient’s desires for comfort at the end of life, how they would like to be cared for, and what they want their loved ones to know. The Five Wishes allows more extensive dialogue about a patient’s values, in addition to the usual treatment directive and proxy directive that compose a standard advance directive.
Physician orders, advance directives
Often, an advance directive regarding treatment will be confused with a do-not-resuscitate (DNR) order. A patient’s preference for resuscitation can be expressed in an advance directive, but a DNR order then makes it a physician order to be followed by health care personnel. All states have a system in place to allow emergency personnel and other health care providers to withhold unwanted resuscitative efforts. For most states, this is a specific out-of-hospital DNR form separate from advance directives. As a single page, an out-of-hospital DNR is more easily located for families and emergency personnel vs. advance directives, which are often filed away.
The POLST paradigm
Although an out-of-hospital DNR form can set the limit for resuscitative efforts, there are an increasing number of states adopting a more comprehensive form, Physician Orders for Life-Sustaining Treatment, which includes not only resuscitation orders, but also orders describing intensity/level of care, the use of antibiotics, and the use of artificial nutrition. Oregon created the POLST form in 1995 in response to research demonstrating that patients’ preferences regarding life-sustaining treatments were still not being followed despite enormous efforts promoting advance directives in the 1990s.
POLST forms are not advance directives, nor do they replace them, but they can help specify a patient’s requests in the form of limited and standardized options rather than advance directives, which have to be interpreted into appropriate physician orders. They will often include the name of the patient’s proxy as well.
The POLST forms are specifically designed for patients with life-limiting illnesses, unlike advance directives, which are for all patients. As a set of physician orders, POLST forms are intended to accompany a patient through transitions of care and are more easily accessed than advance directives. They also are physically eye-catching, printed on bright-colored paper. Although POLST forms do not entirely solve the issues with advance directives, they have made it more likely that a patient’s directives will be followed.
Looking ahead
Although these documents serve to describe and promote patients’ preferences for their health care, their functioning relies on communication of those preferences between physicians and patients. These discussions are challenging for all involved. In upcoming Palliative Care columns, we will be discussing these difficult communications.
Stephanie Harman, MD, is a Palliative Care Physician at Stanford University Medical Center and Director of its Inpatient Palliative Care service.
For more information:
- Bomba, PA. J Natl Compr Canc Netw. 2006;4:819-829.
- Dow LA. J Clin Oncol. 2010;28:299-304.
- Miller RB. J Clin Ethic.s 2009;20:212-219.