An advance directive allows a person to appoint a surrogate (a health-care power of attorney) to make health-care decisions on their behalf in the event they are unable to do so. It will also provide instructions or guidance concerning end-of-life care.
This document goes by different names in different states, including living will and health-care power of attorney, but the intention is always the same.
By contrast, a POLST is a two-sided, bright pink portable medical order that’s specifies treatments a person wishes to receive in emergent and incapacitating situations.
A POLST is appropriate for those with significant illness, frailty or nearing end-of-life. They also are important in emergent situations, which is why some adults undergoing elective surgery are asked to complete one prior to the date of surgery. POLST forms also accompany patients being transported from one venue of care to another, such as from an acute hospital to a skilled nursing facility.
There is a fair amount of detail to a POLST form, but it begins with the most significant choice: attempt resuscitation/CPR or Do Not Resuscitate (DNR). This is the definition of one’s code status.
From there, the form specifies three levels of medical intervention: full treatment, selective treatment or comfort-focused treatment.
Full treatment has the goal of prolonging life by all effective means.
Selective treatment seeks to avoid “burdensome measures” and shifts the focus to comfort. Selective treatment includes IV fluids and medications but avoids aggressive resuscitation, intubation and/or placement in an Intensive Care Unit (ICU). In general, those opting for selective treatment do not wish to be transferred to an acute-care hospital unless comfort needs cannot be met at home.
Comfort-focused treatment is thoroughly focused on preventing pain and suffering at home. Those on comfort care are only transferred if comfort needs cannot be met at one’s residence.
Printed on bright pink paper, the form itself is clear and concise. It allows emergency responders to understand at a glance the wishes of the person they have come to help.
Completing an advance directive is recommended for every adult to ensure that there is someone in place ready and willing to speak up and carry out one’s wishes. Without an advance directive, hospital personnel follow a hierarchy of relationships to determine a decision-maker. For a married adult, the spouse is generally the first person, followed by children and/or parents and moving through other relatives and friends. The process can be quite challenging and may end with appointment of an individual without a close relationship to the patient or a clear understanding of their wishes.
Although most healthy individuals do not relish the thought of grappling with an advance directive and its difficult implications, it is worth working through the discomfort. Palliative care clinicians report numerous instances of adult children stepping into the role of decision-maker for a suddenly incapacitated parent with no clear understanding of the parent’s wishes and, more importantly, at what point to consider stopping lifesaving interventions.
The Western medical system is thoroughly focused on saving and maintaining life and is capable of tremendous heroics. It is, however, every person’s right to determine how much heroics one would choose to receive. If we do not clearly specify our wishes, we leave it to someone else to carry the burden of making unimaginably difficult choices for us. The pain of this experience may haunt our loved ones for the rest of their lives.
“One of the greatest gifts we can give to those who love us and will probably outlive us is our unambiguous, clearly stated wishes in an advance directive,” says a palliative care RN with whom I spoke for this piece. “It prevents potentially years of guilt and second-guessing, which no one wants to leave as a legacy.”
Nathalie Raven Archangel-Montijo holds a rather interesting array of degrees and certifications, including master’s in nursing and traditional Chinese medicine (TCM). She has post-master certification as an adult geriatric primary care nurse practitioner (AGPCNP) and a license to practice acupuncture in California (L.Ac). To round all that out, she is certified in infection prevention and control (CIC) and as an advanced certified Hospice and palliative care nurse (ACHPN).
She also performs in the outlaw country band, Nineteen Hand Horse.