Post 66: Eeny, Meeny, Miny, Moe, Which Advance Directive Do I Show?
Updated: Jun 1
Patient: I have my will, my living will, my Directive to Physicians, and my durable power of attorney. I have everything! There's nothing more you can recommend, right?
Palliative care physician: Well, actually...yes. Yes, I can and I do.
Patient: What more is there?! I'm drowning in advance directives!
Advance Directives (directives by the patient)
Advance directives are legal documents that list the names of people, usually family or close friends, whom a person trusts to make medical decisions on their behalf if there were ever a time when they physically, mentally, or emotionally were not up to making decisions for themselves.
The most prominent of this type of advance directive is the medical power of attorney (MPOA), also known as the medical durable power of attorney (MDPOA) or healthcare power of attorney (HCPOA) depending on the state. I try my best to make a case for everyone to complete an MPOA in Post 4: Eleven Common Myths About the Medical Power of Attorney (MPOA) and explain what could happen if you do not complete an MPOA form in Post 14: A Medical Emergency With No Medical Power of Attorney (MPOA)! - Two Everyday Scenarios.
Unfortunately, the MPOA form for each state looks different, may be called by a slightly different name, and have slightly different requirements to complete (ex. one state may require witnesses or a notary and another state may not). You can download and print out an MPOA form from your state's public health website.
Certain advance directives, such as the living will or Directive to Physicians, are intended to indicate to family, close friends, and medical providers a person's wishes on how they would want their body to be treated in certain medical situations, such as "in a coma" or "expected to die in six months." I explain why I think the living will and Directive to Physicians are largely ineffective and why they are often neglected even during medical emergencies in Post 32: When the Living Will is Not Helpful.
I also explain in Post 32 that conversations with your MPOA and your family about what is most important to you and what you would accept as "good enough" quality of life are the most valuable guides for your surrogate medical decision makers. At a time when you cannot speak for yourself - perhaps because of a bad car accident or because of a severe stroke - these conversations will give your family and friends much better direction than a series of check marks in a living will.
The Five Wishes pamphlet is an advance directive that serves to start conversations about how a person would envision their end of life care. For this reason, it is potentially more useful than the living will or Directive to Physicians. The Five Wishes pamphlet, available on the Aging with Dignity website: https://agingwithdignity.org/, fulfills legal requirements in almost all fifty states. It consists of five pages, each asking a question:
1. Who would I want as my medical power of attorney (also known as medical durable power of attorney)?
2. What does "life support" mean to me and what kind of medical treatment would I want if I were a) close to death, b) in a coma, or c) had permanent and severe brain damage? What are other conditions in which I would not wish to be kept alive?
3. What are the things that make me feel comfortable and bring me comfort?
4. How would I want people to treat me?
5. What are the wishes I would want my loved ones to know?
If I as a palliative care physician (read Post 1: What Exactly Does a Palliative Care Specialist Do?) had to choose one advance directive to recommend people complete, I would recommend an MPOA form (or MDPOA or HCPOA depending on which state you reside in) that their state will accept. The Five Wishes pamphlet, which includes the MPOA question, and a living will or Directive to Physicians only if they ask the MPOA question are good alternatives.
Portable Medical Orders (orders by the doctor)
There are two types of documents that are often lumped under "advance directives," but are actually medical orders that can follow a person where ever they go. They cannot be completed at the attorney's office because they are not legal documents. They are "doctor's orders," requiring the signature of a physician; in some states, a nurse practitioner or physician assistant can also sign. Because they are "doctor's orders," first responders and paramedics will follow these "doctor's orders" if they see the document at the time of the medical emergency.
One of these documents is called the Out of Hospital Do Not Resuscitate (OOH DNR) or Emergency Medical Services Do Not Resuscitate (EMS DNR) form, depending on the state. This is the document first responders look for in the house, nursing home, or where ever a person happens to be at the time the first responders arrive. If they see a completed OOH DNR form with a doctor's signature - usually on the refrigerator door or bedroom wall - they know to honor the person's wishes for a natural death and to refrain from CPR attempts if they find that the person's heart has stopped (read Post 6: Who Do I Tell if My Mom Does Not Want Resuscitation Attempts? - A Three Step Process).
(If you want to learn more about the realities versus misconceptions about CPR, please read Post 5: CPR on TV versus CPR in Real Life - Three Ways They Differ and Post 51: Three Ways to Perpetuate CPR Myths.)
As with the MPOA form, each state's OOH DNR form looks different from each other, may be called by a slightly different name depending on the state, and can be downloaded and printed out from the state's public health website.
Some states offer a single page document that includes physician's (or in some states, also physician assistant's or nurse practitioner's) orders for certain types of medical care according to a person's wishes. This document has a different name depending on the state:
POST (Physician Orders for Scope of Treatment)
POLST (Physician Orders for Life Sustaining Treatment)
MOST (Medical Order for Scope of Treatment)
MOLST (Medical Orders for Life Sustaining Treatment).
The POST/POLST/MOST/MOLST form includes questions pertaining to MPOA and CPR wishes, as well as other questions such as the level of care one might want in a medical emergency (comfort focus, hospital level, or ICU level) and whether one would allow a feeding tube. This form is intended to follow a person who is frail or significantly declining in health where ever they may end up residing, for example at home or in a nursing home. The purpose of the form is to increase the chances that this person will receive the level of care most in line with their goals (read Post 54: Why Should I Care about My "Goals of Care"?) rather than the "prolong life regardless of what it looks like" medical care that is the default mode in our country.
To summarize, there is a lot of confusion surrounding advance directives, and some advance directives have little effect in the real hospital, clinic, or home setting. I would encourage everyone regardless of age or health to complete an MPOA form. For each major health change, consider having a discussion with family and friends about what is most important to you and what you are fighting for (read Post 7: I Want the Best Care Possible for ME - Part 1 of 2) rather than simply completing an advance directive that requires only checkmarks. If there ever came a time when someone decided that they would want a natural death and for their body to be "left in peace" without CPR attempts if their heart and lungs were to stop, then they should complete an Out of Hospital DNR form or POST/POLST/MOST/MOLST form including a doctor's signature.
I hope this post is helpful in directing your efforts as you contemplate completing advance directives.