Advance Healthcare Directive

Advance Health Care Directive is a general term that describes two kinds of legal documents. Statutory Living Wills (question #16) and Durable Power of Attorney for Health Care. These documents provide instructions about future medical care should a person be unable to participate in medical decisions due to serious illness or incapacity. For example, if you suffered a severe stroke and were in a coma, these documents would be used to communicate your wishes to your healthcare providers.

An Advance Health Care Directive is a document that communicates and expresses your healthcare treatment wishes in case a situation develops in which you are unable to communicate. The U.S. Supreme Court decision (Cruzan v. Director, Missouri Department of Health) states that all people have a constitutional right to refuse any medical treatment, including life-prolonging treatment(s). The U.S. Supreme Court’s decision gives you the right to name another person, an agent, to become a deci­sion-maker for healthcare issues in the event that you are unable to communicate and make your own decisions.

An Advance Health Care Directive describes the kind of treatment you want to receive for different levels of illness. For example, the Advance Health Care Directive should describe what kind of care you want if you have a critical illness, a terminal illness or permanent uncon­sciousness. An Advance Health Care Directive usually tells your physician that you do not want certain kinds of treatment when you are this ill.

Most people associate a Durable Power of Attorney with planning their estate. A Durable Power of Attorney for Estate Planning is a legal form designating someone to make financial/legal decisions and financial transactions on your behalf. But for this booklet’s purposes, we are discussing only a Durable Power of Attorney for Health Care. For information about a financial power of attorney, please contact a lawyer.

A Durable Power of Attorney for Health Care is similar to a statutory living will or healthcare directive, but it be­comes active any time you are incapacitated and unable to make medical decisions for yourself. Unlike a living will or other trusting individual, in a Durable Power of Attor­ney for Health Care, you select an agent (a family member, friend or other trusted individual) who will be your medical decision-maker to communicate healthcare decisions that you have not specified in your Advance Health Care Direc­tive. The Durable Power of Attorney for Health Care docu­ment goes into effect only when you lack the ability to make or communicate decisions for yourself, as determined by a physician(s).

An Advance Health Care Directive is similar to a living will, yet it does not focus exclusively on refusing treatment. In an Advance Health Care Directive, you are stating your wishes about future medical decisions in advance. In the event that you become incapacitated due to an illness or injury, the responsibility of making decisions is relieved from family and friends. Your wishes will be honored.

Due to the complexity of illnesses and medical treatment options, situations may arise when it is not clear from your Advance Health Care Directive what your decision or wish may be in regards to your care. To provide for that event, you may name a person you trust to make decisions for you (an agent). This is done in the Durable Power of Attorney for Health Care (Part I and Part Ill of the legal document).

The Advance Health Care Directive only will be used when you cannot make or communicate decisions for yourself. Your Advance Health Care Directive is good until the time of your death unless you cancel it. It is recommended that you review the document annually to make sure it still expresses your wishes. When you do conduct a review, put your ini­tials and the date in the margin to show you are continuing to think out your decisions.

No. It is not necessary to hire a lawyer to fill out an Advance Health Care Directive. If the form in this booklet does not meet your needs, you should consult a lawyer. Although a lawyer is not necessary to complete an Advance Health Care Directive, a Durable Power of Attorney for Health Care requires notarization. Both the Advance Health Care Direc­tive and the Durable Power of Attorney for Health Care are legal documents and you should consult a lawyer if you have questions concerning the legal effect.

A Durable Power of Attorney for Health Care is a legal document in which you appoint someone to make decisions for you if you are unable to do so. The person you appoint to make decisions for you is called an “agent.” This person also is sometimes called an “Attorney in Fact.” It’s important that you choose an agent who knows your goals, values and whom you trust to carry out your decisions. You must appoint a person 18 years of age or older. Usually, a close relative or someone you trust with your life is named as your agent.

It cannot be your physician or an owner, operator or em­ployee of a healthcare facility in which you reside, unless you are related. A Durable Power of Attorney for Health Care does not cover business or financial decisions; it only covers healthcare decisions when you are unable to make decisions for yourself. Be sure to talk with your agent about your wishes in detail and be sure he or she agrees to act on your behalf.

It is your responsibility to notify and provide copies of your Advance Health Care Directive to the agent appointed in your Durable Power of Attorney for Health Care and others such as your physician, family, friends and clergy. Discuss the details of your Advance Health Care Directive with those people and ask your physician to make it part of your perma­nent medical record.

Healthcare providers and your agent must honor your wishes as expressed in your Advance Health Care Directive, as long as the directions you have made are clear and in accord with state law. Any provider who will not honor your Advance Health Care Directive or decisions made by your agent must assist in arranging your transfer to a provider who will honor your Advance Health Care Directive and the decisions of your agent.

If you have named an agent, only he or she has the legal authority to make healthcare decisions for you. However, your agent may wish to obtain information from your family members to assist him or her in making your healthcare de­cisions. It is a good idea to explain to your family members your healthcare wishes so they will know what to expect.

In an emergency situation, it may be possible and neces­sary for healthcare providers to make a quick judgement of medical treatment versus quality of life. You should assume that treatment will be tried until it proves to be useless. If treatment does not lead to a significant recovery, you should expect that your Advance Health Care Directive will be honored and treatment, which has proven to be useless, will be stopped.

Some people want to refuse cardiopulmonary resuscitation (CPR) because they fear being “trapped” on life support. Your Advance Health Care Directive partly addresses this concern. The Advance Health Care Directive states that if it is uncertain whether or not treatment “will lead to significant recovery,” it only should be tried for a reasonable period of time. If, however, you do not want CPR at all, you need to talk to your physician about a medical order direct­ing emergency workers not to use CPR (No Code or Do Not Resuscitate [DNR] see the next question).

A DNR request is an order written by a physician instruct­ing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) when your heart and breathing stops. A person with a valid DNR order will not be given CPR. Even though the DNR order is written at the request of a person or his or her family, it must be signed by a physician to be valid. An “Outside of Hospital DNR” request is written for individuals who are outside the hospital setting. These are available by contacting CMH Social Services at 417-326-6000 or your primary care provider’s office.

Although both are orders signed by a physician to direct healthcare personnel not to start CPR on a patient whose heart and breathing stops, each are used in different settings. The “no code” applies to a hospital setting and becomes part of the vital information for all healthcare personnel. This way your wishes easily can be recognized in case your heart and breathing stop. The “Outside of Hospital DNR” request is for outside the hospital and primarily is directed to medical staff to honor your wishes not to start CPR when your heart and breathing have stopped.

If you have checked “No CPR” in your Advance Health Care Directive, you also will need to talk to your physician about “DNR” and “No Code” designations.

Yes. You clearly must express this wish in your Advance Health Care Directive.

It is important to describe what an “acceptable quality of life” means in terms of your personal goals and values. There is no single “right” answer to this question. There­fore, this definition needs to be a personal description. Some examples of statement people have made regarding an “acceptable quality of life” include:

I want to have…

• the ability to recognize people.
• the ability to communicate.
• the ability to feed myself.
• the ability to swallow food and fluid.
• the ability to make decisions for myself.
• the ability to relate to my environment.
• the ability to reasonably be free of pain.

No. Your decision to make an Advance Health Care Direc­tive is your right under law. Your signature on an Advance Health Care Directive will not affect your benefits or ability to obtain life or health insurance. Furthermore, an Advance Health Care Directive will not affect your ability to obtain healthcare treatment.

Yes. You may cancel or change your Advance Health Care Directive by telling your agent or physician in writing of your decision to do so. You may change your Advance Health Care Directive by reinitializing and dating the areas of change. If many changes are made to your Advance Health Care Directive, you need to destroy all copies of the old Advance Health Care Directive and complete a new form. Remember to give a new copy to your agent(s), family and physician.

If you do not have an Advance Health Care Directive and you cannot make healthcare decisions because of your phys­ical or mental condition at the time, the decision making power may default to a someone else. In these situations, decisions about your healthcare may or may not reflect your wishes and may be made by someone you would not choose.

A Statutory Living Will was the first type of Advance Health Care Directive. The Statutory Living Will document allows a person to direct that “death prolonging procedures” not be used to keep him or her alive when the person is in a ter­minal condition and is unable to make treatment decisions. A Statutory Living Will is now a part of the Advance Health Care Directive available for download on this page.

A general term that describes two kinds of legal documents: the Advance Health Care Directive and Durable Power of Attorney for Health Care. Together, these documents allow a person to give instructions about future medical care should he or she be unable to participate in medical decisions due to incapacity. Each state regulates the use of advance direc­tive differently. An Advance Health Care Directive is a more comprehensive document than a living will.

A person who you have designated to make decisions for you when you no longer are able to do so. Agent is another name for your Durable Power of Attorney for Health Care.

Artificial nutrition and hydration (or tube feeding) supple­ments or replaces ordinary eating and drinking by giving a chemically balanced mix of nutrients and fluids through a tube placed directly into the stomach, the upper intestine or a vein. Artificial nutrition and hydration can save lives when used until the body heals. Long-term artificial nutrition and hydration may be given to people with serious intestinal disorders that impair their ability to digest food, thereby helping them to enjoy a quality of life that is important to them.

The irreversible loss of all brain function. Most states legally define death to include brain death.

In relation to end-of-life decision-making, a patient has med­ical decision-making capacity if he or she has the ability to understand the medical problem and the risks and benefits of the available treatment options.

Cardiopulmonary resuscitation (CPR) is a group of treat­ments used when someone’s heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It may consist only of mouth-to-mouth breathing or it may include pressing on the chest to mimic the heart’s function and cause the blood to circulate. Electric shock and medica­tions also are used frequently to stimulate the heart. When used quickly in response to a sudden event like a heart attack or drowning, CPR can be lifesaving. The success rate, however, is extremely low for people who are at the end of a terminal disease process. If you do not wish to receive CPR under certain circumstances, and you are in the hos­pital, your physician must write a “No Code” order on the medical record. If you are at home, the state of Missouri allows for a Do-Not-Resuscitate (DNR) order. This order is written by a physician and directs emergency workers or others outside of a hospital setting not to start CPR.

Chemotherapy is the use of medications to treat cancer. Cancer is a cell that divides quickly and grows out of control. Chemotherapy possibly can kill the cancer cells so that the tumor shrinks or even disappears.

Chemotherapy can be administered in several different ways. Chemotherapy can be given into a vein (IV); by mouth (in the form of a pill, capsule or liquid); topically (the medi­cation is applied to the skin); or can be given into a muscle, under the skin. This is done by an injection.

A DNR order is physician’s written order instructing health­care providers not to attempt cardiopulmonary resuscitation (CPR) when your heart and breathing stops in case of cardiac respiratory arrest. A person with a valid DNR order will not be given CPR under these circumstances. Although the DNR order is written at the request of a person or his or her fami­ly, it must be signed by a physician to be valid. A DNR order typically is written for individuals who are at home and do not want to receive CPR.

Dialysis is a method of removing harmful substances from the blood when the kidneys are unable to do so. Peritoneal dialysis works by placing a very small tube into the abdo­men and attaching a bag of special fluid to flow into the abdomen. This is done by the patient at home. Hemodialysis requires placing a very small tube into the arm and allowing the machine to clean your blood. This is done by going to a dialysis center two or three times a week.

A legal document that allows an individual to appoint someone else to make decisions about his or her medical care if he or she is unable to do so. This type of advance directive also may be called a healthcare proxy, or may be accomplished by the appointment of a healthcare agent. The person appointed may be called a healthcare agent, surro­gate, proxy or attorney-in-fact.

This term is used to describe someone who is unable to communicate decisions. Legally it means a state in which a person is incapable or ineligible. (Incapacity - Lack of physi­cal or intellectual power or of natural or legal qualifications.)

See “Capacity.”

One type of advance directive in which an individual docu­ments his or her wishes about medical treatment should he or she be at the end of life and unable to do so. It also may be called a “directive to physicians,” “healthcare declara­tion” or “medical directive.” The purpose of a living will is to guide family members and physicians in deciding how aggressively to use medical treatments to delay death.

Mechanical ventilation is used to support or replace the function of the lungs. A machine called a ventilator (or res­pirator) forces air into the lungs. The ventilator is attached to a tube inserted into the nose or mouth and down into the windpipe (or trachea). Mechanical ventilation often is used to assist a person through a short-term problem or for pro­longed periods in which irreversible respiratory failure exists due to injuries to the upper spinal cord or a progressive neurological disease. Some people on long-term mechanical ventilation are able to live a quality of life that is important to them. For the dying patient, however, mechanical venti­lation often merely prolongs the dying process until some other body system fails. Mechanical ventilation may supply oxygen but it cannot improve the underlying condition. When discussing end-of-life wishes, make clear to loved ones and your physician whether you want mechanical ventilation if you never regain the ability to breathe on your own or return to a quality of life acceptable to you.

A “No Code” is an order written on a hospital medical record and signed by a physician. This tells all medical per­sonnel that you do not want to have CPR, mechanical venti­lation or medication should your heart or breathing stop.

The emission of energy, rays or waves. In medicine, radio­active therapy is the use of a radioactive substance in the diagnosis or treatment of disease.

A machine used to modify air for breathing or to improve pulmonary ventilation.

Surrogate decision-making laws allow an individual or group of individuals (usually family members) to make decisions about medical treatments for a patient who has lost deci­sion-making capacity and did not prepare an advance direc­tive. A majority of states have passed statutes that permit surrogate decision-making for patients without advance directives.

Any of several devices used in respiratory therapy to provide assisted respiration and positive pressure breathing.

On August 28, 1991, a law went into effect in Missouri that allows a competent adult to designate another person to make healthcare and treatment decisions if and when the adult is unable to do so. The act is known as the durable power of attorney for health care.

The Durable Power of Attorney for Health Care

• must be signed by the patient and notarized;
• becomes effective upon certification of the incapacity of an individual by two licensed physicians (unless the power of attorney document provides for a different number; but in any case, certification by at least one physician is required);
• must provide a specific grant of authority to withhold or withdraw artificially supplied nutrition and hydration if the patient intends the designated person to be able to withhold or withdraw this type of medical treatment; and
• may be revoked by the adult, if competent, at any time and in any manner by which he/she is able to communi­cate his/her intent to revoke.

“The Cruzan Case”

Cruzan vs. Director; Missouri Department of Health

• determined that a state has a right to require “clear and convincing evidence” that a patient would have, if competent, refused treatment; and
• established that there is a constitutional basis for persons to make decisions regarding their own medical care (including the withholding or withdrawing of food and hydration provided by artificial means).

As applied in Missouri, the Jasper County Circuit Court in Cruzan vs. Mounton

• authorized the removal of nutrition and hydration based upon clear and convincing evidence that the patient would have desired the discontinuance of life support measures.

“Clear and convincing evidence” can be established in many ways. Persons can execute a formal document developed by their attorney, can use a statutory declaration form or other printed Advance Directive form, or even can write some­thing out in their own words. Whatever form or format you use, be sure to give a copy to your physician and healthcare provider.

On September 24, 1985, a law went into effect in Missouri that allows a competent adult to sign a declaration permit­ting the withholding of “death-prolonging procedures” if the adult has a terminal condition and is unable to make treat­ment decisions at that time. The act refers to the written authorization as a “Declaration.”

The Declaration:

• must be written, signed, dated and witnessed (unless wholly in the patient’s handwriting);
• is only valid in cases of terminal illness; and
• may not include directives regarding withholding food and water or palliative medical care.

During admission for CMH services you will be asked if you have an existing Advance Health Care Directive. If admitted as a patient, home care client or resident of a long-term care facility, you will be asked to provide a copy for your permanent medical record. However, you are not required to have an Advance Directive, nor does it affect your admission or quality of services.

CMH staff members cannot fulfill directives that are illegal in Missouri, including mercy killing, assisted suicide and withholding or withdrawing life support from a pregnant patient. CMH staff must comply with all legal directives unless they are specifically contrary to CMH policy, in which case staff will cooperate with, or reasonably assist, a result­ing patient transfer to another healthcare provider. A staff physician unwilling to comply with a patient’s legal direc­tive will likewise assist transfer of patient care to another physician.

Alzheimer’s Association, Springfield – 417-886-2199

American Cancer Society National Office – 1-800-227-2345

American Cancer Society, Springfield – 417-881-4668

Cancer Care Inc. – 800-813-4673

Cancer Information Center – 417-885-2273

Carrie J. Babb Cancer Center – 417-326-7200

Cedar County – 417-276-5113

Dade County – 417-637-5326

Dallas County – 417-345-7651

Greene County – 417-895-5677

Hickory County – 417-745-6491

Polk County – 417-326-6241

St. Clair County – 417-646-8165

Cedar County – 417-876-5492

Dade County – 417-637-2345

Dallas County – 417-345-2332

Greene County – 417-864-1658

Hickory County – 417-745-2138

Polk County – 417-326-7250

St. Clair County – 417-646-8332

Citizens Memorial Health Transit Services – 417-777-5165

Logisticare – 866-269-5927

Citizens Memorial Hospital Home Health Services – 417-328-6350

Bolivar Home Medical Equipment – 417-328-6350

Buffalo Home Medical Equipment – 417-345-2244

Hermitage Home Medical Equipment – 417-745-2010

Stockton Home Medical Equipment – 417-276-2401

Citizens Memorial Hospice – 417-326-3585

Missouri Hospice Organization – 573-634-5514

Ash Grove Senior Living Community – 417-751-2575

Butterfield Apartments – 417-326-7648

Colonial Springs Senior Living – 417-345-2888

Community Springs Senior Living – 417-876-2531

Parkview Senior Living Community – 417-326-3000

Butterfield Residential Care Center – 417-328-6380

Ash Grove Healthcare Facility – 417-751-2575

Citizens Memorial Healthcare Facility – 417-326-7648

Colonial Springs Healthcare Center – 417-345-2228

Community Springs Healthcare Facility – 417-876-2531

Lake Stockton Healthcare Facility – 417-276-5126

Alzheimer’s Support Group, Bolivar – 417-328-7310

Alzheimer’s Support Group, Buffalo – 417-345-2228

Alzheimer’s Support Group, Stockton – 417-276-5126

Cancer Support Community Alliance – 417-328-7907

CHEMOcare – 1-844-268-3901

Citizens Memorial Hospice Bereavement Support Group – 417-326-3585

Diabetes Support Group, Bolivar – 417-328-7957

Hereditary Cancer Center – 1-800-648-8133

High Hopes Cancer Support Group – 417-328-7912

Parkinson’s Disease Support Group, Bolivar – 417-328-7059

Smoking Cessation Support Group, Bolivar – 417-328-6574