End of Life Planning Part Two
Okay, you've figured out what form you’re going with for your advance directive. Now you have to figure out what you want and all the different situations you want to address. Let’s start by saying that there’s no way you can possibly address every situation that might occur; however, if you have discussions with your loved ones (and especially the person you pick for your MPOA) about what you do and don’t want, and what’s important to you they will be better able to speak on your behalf if a situation comes up that wasn't addressed in these forms.
Speaking of your medical power of attorney, there are some requirements to keep in mind when picking one. These include (but are not limited to, see your state's specific requirements for more information):
· Is not your doctor or part of your medical care team (this is a good rule of thumb but is also legally restricted in some states)
· Is a mentally competent adult (in some states the age for this is 18, others it is 21)
· Is willing and able to discuss end-of-life care with you
· You trust them to make decisions in accordance with your wishes and beliefs
· You trust them to advocate for you
Another thing to note regarding the MPOA. You can list alternates so there is someone if the primary cannot be reached or declines to act (to help avoid the latter, make sure you discuss this with them and make sure that they are comfortable being named your power of attorney).
Some of the different things you may want to address in your advance directive include:
CPR: cardiopulmonary resuscitation is done in the event that your heart stops. In order to be effective, it requires repeatedly pushing on the chest with a force that can result in broken ribs and/or collapsed lungs. Defibrillation is sometimes grouped in with CPR, and this is the process of using electric shocks to restore a heartbeat.
Intubation: intubation is the use of machines to breath for a patient. The patient has a tube inserted in the trachea (this is the intubation part) and this is then attached to the ventilator, which forces air into the lungs. It is uncomfortable to have this tube in the throat, so sedating medications may be given.
Tracheotomy: if a patient is going to need long term help breathing, a tracheotomy may be done. This procedure involves inserting a tube into the trachea through a hole in the neck. This is more comfortable for the patient and doesn't require the use of sedating medications. It is important to know that someone with a trach will need help talking as air bypasses the vocal cords in this situation.
Artificial nutrition and hydration: in the event that you cannot eat or drink on your own, there are options available to assist. A nasogastric tube (NG) can be inserted down the nose to the stomach, which is typically used for short periods of time. If artificial nutrition is needed for a longer period of time, a percutaneous endoscopic gastronomy (PEG) tube can be placed; in this case, the tube is placed in the abdomen directly into the stomach. In the event that you cannot take in fluids on your own, you can have an IV inserted and get IV fluids.
Hospice care: Some people also call hospice care comfort care, but to me, both palliative care and hospice care can fit under the umbrella of comfort care (stay tuned for a post discussing this further). Right now I’m just addressing hospice care. At the point where there is no chance for cure and/or the patient has made the choice not to do further treatment, a patient may elect for hospice care. This is treatment focused on keeping you comfortable and minimizing suffering (in ways that are consistent with your wishes and values) but no active treatment is occurring. Hospice care is available at home, in care facilities, in assisted living, and in the inpatient setting. There are specific requirements to be able to go into hospice care, mainly that the provider believes the patient has 6 months or less to live.
PLEASE NOTE: when we discuss the cessation of treatment when electing for hospice care, this is in regards to the disease that is expected to cause death but not all treatment will stop. Take the example of someone with cancer, they will stop chemotherapy and any other treatments aimed at curing cancer. However, if they have diabetes, hypertension, etc. they will still get medications for those. Additionally, if they have nausea, pain, or other symptoms they will be given medication to address this. The goal of hospice is not to hasten death but to focus on comfort and quality of life.
Depending on what form you have decided to use and your state’s requirements, you may need to have the forms signed by a witness of a notary. Once everything is in order, you should keep the original forms in a safe place, provide your doctor(s) with a copy, provide your MPOA with a copy, and keep a card in your wallet indicating that you have these forms completed and your MPOA’s info. You should also make sure your loved ones now that these are completed and where to find them if needed.
These documents can always be updated if you change your mind or if situations arise that warrant changes. You may consider reviewing and readdressing these forms in the event of a new medical diagnosis or at least every 10 years to ensure it still aligns with your wishes.
Stay tuned for part three of this series for information on body disposition options!