Front page of North Carolina Medical Orders for Scope of Treatment (MOST) form
Since several different kinds of documents are widely available to record and communicate plans for treatment near the end of life, an obvious question arises, namely, “Which of these documents is best?” that is, “Which document is most likely to achieve its primary purpose of honoring a person’s preferences for end-of-life care?” Not surprisingly, the correct response is: “It depends on a person’s individual circumstances.” Portable physician orders for end-of-life care, for example, will be of greatest value for people who are nearing the end of life, since these orders give clear direction regarding whether to provide or forgo specific life-prolonging treatments. Portable physician orders provide little or no additional benefit for healthy people, because the clear default option for healthy people will be to provide CPR and other life-prolonging treatments in the event of sudden illness or injury.
Of the two types of advance directives, however, I believe that HCPOAs have several distinct advantages over living wills for most people. First, they enable one to select and appoint a trusted relative or friend to make medical treatment decisions on one’s behalf, and such an agent is most likely to make informed, careful choices. Appointing a health care agent enables one to share specific information with one’s agent about one’s medical condition, treatment options, and treatment preferences, and thus allows one’s health care agent to make well informed treatment decisions based on that information. In contrast, living wills authorize a patient’s attending physician, who often has no previous acquaintance with the patient, to interpret and apply the instructions contained in the living will. Moreover, HCPOAs can guide treatment choices in a much broader range of situations than living wills. Living wills usually state general treatment preferences only for a few medical conditions, while HCPOAs enable health care agents to make decisions on behalf of those who have appointed them whenever the people they represent have lost the ability to make decisions for themselves. Because a person who completes an HCPOA gives significant authority and responsibility to his or her health care agent, it is important both to choose one’s agent carefully and to discuss one’s treatment preferences with one’s agent, so that the agent can understand and carry out those preferences.
The benefits of advance care planning (and barriers to achieving them)
Proponents assert that planning in advance for medical treatment near the end of life and completing advance directives can provide significant benefits for people who engage in these practices. What are these promised benefits? First and foremost, advance care planning can give patients greater control over the treatment they receive after they have lost the ability to make treatment choices. It therefore respects and expands the sphere of personal autonomy, and it promotes the goal of providing patient-centered care near the end of life. By enabling people to formulate and communicate clear plans for treatment near the end of life, advance care planning reduces uncertainty about what treatment to provide, and it avoids what is often the default decision under uncertainty, namely, provision of all treatment measures that may prolong life. Clear treatment directions from the person, as stated in a living will or communicated by the person’s health care agent, can also prevent conflict regarding what treatment should be provided. Statutes in many US states provide immunity from liability for physicians who honor advance directives and portable physician orders; these statutes give physicians an additional incentive to respect patients’ end-of-life treatment wishes. Finally, advance care planning can conserve health care resources, by honoring patient wishes to forgo life-prolonging treatment that is often both costly and ineffective.9
To achieve these significant benefits, advance care planning must be organized in systems or programs that inform and guide both the planners and the health care professionals who carry out the plans people make for their treatment near the end of life. Organized programs are essential in order to satisfy the following four necessary conditions for success. First, people must devote the time and effort required to engage in the planning process. Second, they must be able to formulate plans that are clear and clinically relevant. Third, they must communicate their plans so that the plans will be accessible when they are needed. Fourth, health care providers must carry out the plans in the appropriate circumstances.
There are considerable barriers to satisfying these necessary conditions for a successful advance care planning program. A 2007 review of the US medical literature cites estimates that only 18–30 percent of Americans have completed advance directives.10 Some US states and communities have a much higher percentage of residents with advance directives, however. Thanks to a longstanding community-wide advance care planning program in the city of La Crosse, Wisconsin, for example, 90 percent of people who died in that community in 2007–2008 had an advance directive at the time of death.11
If advance directive forms are difficult to understand, and no one is available to provide knowledgeable assistance in completing them, people may abandon the process, or they may prepare forms that do not express their wishes correctly or clearly, and so do not serve their intended purpose. To overcome this barrier, health care systems and communities have trained both professionals and volunteers to serve as advance care planning facilitators. Communities have also championed the use of advance directive forms that give clear instructions and are easy to understand and complete.
Once people prepare advance directives, they must share their directives with others, especially family members and caregivers, so that the documents can be retained and retrieved when they are needed. Medical record systems can be designed or augmented to perform these functions effectively. And, when directives are available, physicians must learn to interpret them accurately and must commit to carry them out faithfully.
Finally, during the US national debate over health care reform legislation in 2009–2010, some politicians accused advance care planning programs of being “death panels” in disguise, designed to deny treatment to vulnerable patients.12 This charge, however, clearly misrepresents the purpose of advance care planning. Rather than imposing treatment decisions on unwilling patients, advance care planning programs are designed to assist people in making their own plans for end-of-life care and to honor the plans people make.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
