What is an Advance Directive?
An advance directive is a document that provides direction about what types of medical treatment you want in cases when you cannot speak for yourself. The advance directive is sometimes also called a Living Will or Physician’s Directive or Health Care Directive. A complete advance directive gives both physicians and the person who will be making medical decisions on your behalf detailed instructions on what types of medical conditions warrant what type of medical interventions. Some advance directives will also name a health care agent to make decisions on your behalf. (The naming of an agent is also often done in a separate Health Care Power of Attorney.) In Washington, an Advance Directive must be witnessed by two people or notarized in order to be valid.
Completing an advance directive is appropriate for every adult…young, old, healthy or sick. None of us know what the future holds and an advance directive ensures your wishes will be honored even when you can’t speak for yourself. An advance directive is also a gift to your loved ones. If you are so ill that you cannot make your own medical decisions, you do not want your loved ones agonizing over what type of medical treatment you might want. The guidance you provide ahead of time will ease one burden during a time of crises.
What is a POLST?
POLST is an acronym for Physician Orders for Life Sustaining Treatment. The POLST is a standardized form adopted by Washington law and is easily recognizable by its bright green color. As the name indicates, the POLST is a physician’s order and must be signed by a medical doctor, an ARNP (Accredited Registered Nurse Practitioner) or Certified Physician’s Assistant. Like an Advance Directive, A POLST provides direction on the type of health care decisions you want made when you can’t communicate for yourself, but the directions are much less detailed and nuanced than an advance directive.
The more basic and simplified nature of the POLST is directly related to its purpose of providing medical personnel (including first responders) directions that can be quickly discerned and carried out (or not carried out) during a medical emergency. Because many medical emergencies happen in the home, patients are instructed to hang the POLST on their refrigerator. This standardized and easily found location ensures rapid and accurate treatment by first responders. Because the POLST is intended for people likely to face medical emergencies, not everyone needs to have a POLST. The general guideline in the medical and legal communities is that you should have a POLST if your doctor would not be surprised if you had a life-threatening medical emergency in the next two years.
Although an advance directive and a POLST may contain concordant instructions, because they serve different purposes, they may also contain seemingly contradictory directions. As an example of how the advance directive and POSLT work together, let’s look at the example of Chris Coronary: Chris has a serious heart condition but otherwise enjoys a high quality of life. Chris consulted with an Elder Law attorney when he first discovered his medical condition and completed an advance directive. Chris also completed a health care power of attorney that named his spouse, Rita as his primary agent. On the attorney’s advice, Chris also consulted with his doctor and completed a POLST.
One of the instructions in Chris’ advance directive says that if he suffers a brain injury that does not allow him to have meaningful interaction with his family and friends, he does not want any life sustaining measures. Chris’ POLST, however, says that if he is found unconscious and not breathing, he wants life saving measures taken. One evening, Chris complains to Rita that he’s having chest pains and Rita immediately calls the paramedics. Just before the paramedics arrive, Chris collapses on the kitchen floor. When the paramedics arrive, they see the POLST on the refrigerator and when they determine that Chris is having a heart attack they immediately begin CPR.
The paramedics quickly load Chris into the ambulance and race toward the hospital. On the way, the paramedics manage to restart Chris’ heart. Chris is admitted to the hospital and remains heavily sedated and on a ventilator for the first 24 hours. Rita is beside herself with anxiety about Chris’ condition. She knows that if Chris was unconscious for too long, he will have significant brain injury and she may need to follow his wishes and “pull the plug.” Although Rita knows that will be beyond difficult, she takes some comfort knowing that Chris’ very clear in his directive. When Chris finally starts to come around and is taken off the ventilator, Rita is beyond relieved to find that although he is weak and groggy, his mind seems intact. She tells the doctors to keep Chris’s treatment going, even if that means putting him back on the ventilator for a time.
Siblings but not Twins
In Chris’ case, the POLST and the advance directive contained seemingly contradictory directions. The POLST said to take full life saving measures while the advance directive instructed Rita to “pull the plug.” The POLST’s instructions for full emergency treatment, however, allowed the doctors and Rita to take more time and fully assess Chris’ situation to make decisions that line with Chris’ wishes. The advance directive and the POLST worked together to ensure Chris’ got the medical treatment he wanted even though he couldn’t speak for himself. Chris, however, is just one example. Every situation is unique and all of us should have open discussions about our end of life decisions with an experienced lawyer, a medical provider, and most importantly our loved ones.
As always, thanks for reading!
The Team at the Elder Law Offices of Meyers, Neubeck & Hulford, P.S.
Barry M. Meyers
David M. Neubeck
Sara LC Hulford
DISCLAIMER: The content of this newsletter is: for information purposes only, subject to change by government agencies, should not be relied upon as current, and, does not constitute legal advice. Reading this newsletter does not establish an attorney-client relationship.