special subjects
Advance Directives
Introduction
Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because they communicate preferences before incapacitation occurs. These documents usually address decisions regarding end-of-life care but may also address any aspect of care. For example, increasingly, individuals are completing specialized psychiatric advance directives focused on mental health treatment. Because communicating compassionately and effectively about such end-of-life decisions with patients takes special skill, training is advisable. There are 2 primary types of advance directives: Living will : Expresses preferences for medical treatment and end-of-life care Durable power of attorney for health care : Designates a surrogate decision maker typically referred to as a health care agent or proxy These two types of advance directives are typically combined into a single advance directive document. Every state in the United States recognizes these documents and encourages their use as a simple legal tool by which people can express their wishes and have them honored. However, formal advance directives are not the only means of expressing such wishes. Both common law and constitutional principles direct that any authentic, clear expression of patients' wishes should be honored if within the scope of generally accepted medical standards. An advance directive cannot be completed after a patient becomes too incapacitated to understand the nature and effect of an advance directive or to communicate his or her wishes; and, in most states, the directive does not become effective until after incapacity to make health care decisions has been determined. If no advance directive has been prepared, an Consent and Surrogate Decision Making recognized by state law or appointed by a court is needed to make health care decisions. Ideally, clinicians should obtain a copy of a patient’s living will and durable power of attorney for health care, periodically review the contents with the patient while the patient is still capable, and make it part of the medical record. United States federal law requires hospitals and long-term care settings to document in a prominent part of the patient's medical record whether the individual has an advance directive ( Reference ). Patients should also provide a copy of the durable power of attorney for health care to their appointed agent and to other close family or friends who will likely be involved during serious illness. This helps avert surprise and controversy when difficult decisions have to be made by the agent. The patient’s attorney should hold a copy of all documents. An increasing number of states offer optional electronic registries for recording advance directives. 