Planning for the future, particularly for end-of-life, is a critical process. But, it can also seem overwhelming. As we’ve discussed in a previous post, there are multiple areas that you need to consider, including how to talk with your family member and where to begin with planning.
In this post, we’re taking a different angle.
We’re focusing on the most common types of advance care planning and how they differ from each other.
A Traditional Will
What It Is
A will is simply a document that details a person’s wishes after they die. Many people already have one but it is also something that often gets put off, especially by people who are healthy.
Wills are important because they are legal documents. In contrast, verbal requests do not have strength in court and can be overridden in many situations.
Even if the senior has few assets, wills can still be valuable. They make processes easier for the family members left behind and means that people know what the senior wanted. Wills can also decrease the risk of contention among family members (although, this isn’t always the case).
Strengths of a Will
- Relatively easy to setup, especially for people with simple estates and no property.
- A well-recognized part of advance planning, so there is plenty of advice and guidance out there already.
- Many people are already familiar with the need to have a will.
- A will is something that even young and healthy people have. This makes it a less scary and can mean that it is a good place to start.
Limitations of a Will
Wills aren’t dynamic. They need to be updated and many people don’t do so. As a result, a will often doesn’t reflect recent changes. This means that people need to make changes regularly, which can be an unappealing and frustrating process.
Advance Care Directives
What They Are
There are two critical types of form for advanced planning. One of these is an advance care directive (sometimes called a living will). This is a legal document that dictates a patient’s wishes at the end-of-life. The term living will is sometimes used as well.
It can cover multiple key areas, including the use of CPR, a ventilator or artificial nutrition. The directive may also just focus on comfort care, requesting that life-saving measures be avoided.
On a side note, the terminology can get confusing. The term advance care directive often just refers to a living will, which is what we’re considering here. But, sometimes it is also applied to all types of paperwork, including durable power of attorney.
Strengths of Advance Care Directives
People who create an advance care directive are more likely to have their wishes followed than those who do not.
Advance care directives also make it very clear what your wishes are. As such, there is no room for error.
Limitations of Advance Care Directives
In many cases, the patient’s requests simply won’t be seen in time. This often happens because of where the records are stored, along with the rush that occurs when staff are trying to save lives.
The paperwork tends to rely on vague language as well, including phrases that are open for interpretation. Words like ‘terminal’ are an example. The term is useful, but there are many different ways to interpret whether or not a case is terminal.
And finally, medical staff have been taught to err on the side of caution. When they’re not sure, they’re always meant to save lives. For that matter, emergency staff have standing orders to resuscitate, even if this contradicts an advance directive.
Durable Power of Attorney for Healthcare
What It Is
This is a second critical type of form that is critical. It is sometimes considered a type of advance care directive – but you’ll typically need to fill out separate paperwork. The Durable Power of Attorney for Healthcare involves naming someone as a healthcare proxy.
A healthcare proxy is someone who makes healthcare decisions for you, if you are unable to. That person is typically a family member, especially if that family member is also a caregiver. The idea is that they will make decisions based on your wishes. As such, they need to be familiar with what these are, along with your values.
Choosing a healthcare proxy is not an all or nothing decision. Instead, you can decide how much authority the proxy has and which decisions they can make for you. Some people also designate an alternate healthcare proxy. Doing so is a good idea, as life can be unpredictable.
Strengths of Durable Power of Attorney
This approach is more flexible than an advance care directive. The family member is able to respond to events as they occur. In contrast, an advance care directive involves trying to predict what will happen and how you’ll feel about it.
The flexibility is important – as some events aren’t predictable. For example, a car crash or a stroke could have devastating impacts, which may not have been considered when creating the advance care directive.
Another strength is that the family member will often be present in an emergency situation. Staff will typically turn to the family member first, long before they look at a formal written document. This gives healthcare proxy more chances to make your wishes known.
One other benefit is that you don’t need to put your wishes in writing. For some people, this is much easier and less stressful. You simply need to be sure that the proxy is someone who you can trust, who you can openly talk to about what you want and what you feel.
Limitations of Durable Power of Attorney
The main limitation is that a healthcare proxy is a person. They’ll ultimately make their own decisions. Those may align with your values and wishes but that might not be the case every time.
For example, some children find it difficult to support comfort only measures, even if they know it was what their parents wanted. In other cases, the proxy may not know enough about your wishes to make an informed decision.
POLST Forms
What They Are
POLST stands for Physician Orders for Life-Sustaining Treatment, although some states have different names and acronyms (like MOLST or POST).
The form specifies whether comfort-only measured are applied, full life-prolonging interventions, or various options in between. A POLST is developed in consultation with a physician, which can mean greater communication.
However, a POLST won’t apply in all situations. The form focuses on patients who are sick and are not expected to recover. This means that they won’t be relevant to many people and situations.
Overall, these forms have a similar function to advance care directives, although they may be more effective in some situations. Which is used will depend on the health of the patient and the perspectives of the people involved.
Strengths of POLST Forms
- Effectiveness. Research shows that POLST is more effective than advance directives at promoting desired outcomes.
- Strength. A POLST can also have more power than an advance directive. For example, a POLST can be used to prevent resuscitation, while an advance directive cannot.
- Involvement with a physician. Developing a POLST involves the physician directly. This means that healthcare staff are much more connected with the process, which can lead to better outcomes.
Weaknesses of POLST Forms
- Limited use. The forms are normally only used for patients with a year or less to live. This makes them irrelevant for many situations.
- Systems are limited. Using POLST forms effectively requires coordination between different healthcare facilities, including hospitals, hospices and nursing homes. Some states are starting to develop such systems but it will be a long time before there are any fully fledged ones in place.
Combined Forms
There are also combined approaches that attempt to make advanced planning easier. These may provide all the forms that are needed at once, often relying on language that is easier to understand.
One example of this is Five Wishes, from Aging with Dignity. This is a popular living will and it does take advantage of everyday words and phrases. There are many languages to choose from and the website is very easy to navigate.
Such approaches are particularly powerful if you want to avoid any confusion with planning and ensure that everyone is on the same page.
But, you’ll need to check the legal guidelines.
As Aging with Dignity points out, the Five Wishes document meets the legal requirements of the District of Colombia and 42 states (you can see which ones in their sample document).
If you don’t live in one of those states, you would need to fill out an official form as well. Even so, Five Wishes is a useful way to help think about what you want. It can even act as a guide in some situations.
End-of-Life Planning
As you can see, there are many different approaches for advance planning. They’re not mutually exclusive either. Instead, there are some situations where people may follow multiple options at the same time.
There are also other approaches and situations that are not on this list.
With so many options out there, it’s critical to get perspectives and feedback from multiple groups of people. This includes family members and healthcare staff. Different people may be able to give you insight into the best directions, along with what is relevant for your situation.
Thankfully, there are many tools that you can turn to. We highlighted some of these in our post on Advance Care Planning.
State-Specific Guidelines
One other consideration is your physical location. States vary in their laws surrounding advance planning and in the documentation that they need. For example:
- Some states have official advance care directive forms that need to be filled out
- Some will require the directive to be witnessed
- In a few cases, you will also need a notarized signature
- There are also differences in where the advance directive is stored and who has access
It’s critical to find out what the requirements are.
Pay attention to where you spend time as well. If you’re often in multiple states, you may want to have forms prepared and ready in each of those locations.
Other Forms
The topics discussed thus far are the main types of advance planning forms. But, there are also some for specific situations. These include:
- Do Not Resuscitate Order (DNR). There are two types of DNR forms. One applies only when you’re in a hospital, the other applies to other situations.
- Organ Donation Form. You can normally select organ donation preferences as part of an advance directive, but this can be done individually as well. Regardless, it is an area worth considering.
Final Thoughts
Advance care planning is complex and honestly, there’s much more that we could say. But, there is a detailed guide at the National Institute of Aging that is worth checking out.
This also provide information about next steps, including who needs to know about any paperwork that you fill out. They also suggest making a card to carry in your wallet that states that you have an advance care directive (or a healthcare proxy) and how this can be accessed. Such a card increases the chance that your wishes will be respected.
More than anything, the best approach is simply to take the time and plan well. Be honest about the topic, even if it scares you.
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