Advance Directives

Advance directives are legal documents that allow a pt to express their preferences on quality of life, medical care and health care decision makers in the event they lose the ability to make their own decisions. Advance care directives remain valid indefinitely. If an advance care directive does not reflect a pt’s wishes, a new document should be executed with a note entered into the EMR reflecting the patient’s current wishes. 

The most common types of advance care directives are:

• Living Will: This document specifies which medical treatments a pt would be willing to pursue and allow an individual to describe preferences about quality of life, specifically for life support, cardiac resuscitation, artificial hydration, and nutrition. A living will must be signed by two witnesses or notarized. It does not require a lawyer.
• Healthcare Power of Attorney (HPOA): This document allows a pt to
  legally designate one to two people to make healthcare decisions if a pt loses capacity. The designated HPOA should make decisions reflective of the pt’s own choices, using substituted judgment. Recognizing that pts may change their wishes on medical care over time, the HPOA may overrule the living will in situations where the choices in the living
  will no longer reflect the pt’s current wishes on health care.
• Physician Order for Scope of Treatment (POST): This is a physician form that specifies which medical interventions should be attempted (CPR, mechanical ventilation, artificial hydration, and nutrition). Additionally, it details under what circumstances a pt would like to be hospitalized and which types of inpatient hospital settings (ICU vs. avoid the ICU) are consistent with their goals. The POST form is valid in the community (including long term care facilities, senior centers, and dialysis units) and in the emergency department. It is preferable but not required for a pt or their surrogate to sign the POST form. Any pt that is DNR or DNR/DNI must have a completed POST form when transferring by ambulance. You can download the form from MedEx or find it here.

How are advance care directives different from code status?

Advance care directives are documents that a patient fills out to describe their wishes on medical care. 

Code status is an order completed by a health care provider. 

It is important to remember to place a new code status order for each admission regardless of whether a living will is on file.

TN Advance Care Planning

The Tennessee Advance Directive for Health Care is a valid legal document that serves both as a living will and POA.

• Outpatient: Discussions on health care decision makers, wishes on medical treatment (particularly CPR), mechanical ventilation and artificial hydration and nutrition should be done periodically with all pts over the age of 18. This conversation should be part of the annual visit, especially for those with chronic health conditions, changes in functional status or a new diagnosis of a serious disease.
• Inpatient: Can ask SW to assist with providing these forms.