As a follow-up to Steve Hartnett’s recent post on advance care planning, “The Importance of Directives,” here are some points from an ABA webinar on this topic earlier this year that are worth keeping in mind. (These are selected bits — email me if you’d like the full presentation from the ABA Commission on Law and Aging.)
1. Advance directive documents, without conversation with clients’ loved ones, have little value; ditto for conversations without documents.
2. Which should come first – advance directive documents or conversations? Answer: it doesn’t matter. Whatever works better for the individual client, as long as both happen.
3. In the presenter’s experience as an attorney, clients can’t really discuss advance care planning with the attorney until after the client has thought about this topic. In other words, the attorney should give the client homework in advance to consider his wishes before discussing together. ABA Commission on Law and Aging has created some tools to help clients (it’s the most popular download); you can find others here.
4. If client isn’t naming someone as HCPOA who would expect to be named, client should talk with this individual while client is still healthy.
5. It’s vital for client to talk with his/her doctor, as well as with loved ones. If necessary, it’s worth making a separate appointment with physician just to discuss this, even if it requires client to pay out-of-pocket.
6. An out of hospital DNR may not be honored, especially by EMTs on the scene. It’s more likely to be honored at the hospital emergency room. Clients may want to call local emergency response organizations to ask if an out of hospital DNR will be honored.
7. DNR is only for cardiac and pulmonary resuscitation. In lay language: it’s only for restarting or supplementing heartbeat or breathing.
8. There are now advance directives specifically for mental health, and also for other illnesses like ESRD (end-stage renal disease).
9. Knowing that advance directives exist and getting access to them when needed can be critical. Availability of advance directives is an ongoing problem – even for attorneys, as a poll during the webinar demonstrated! Advance directives generally don’t get copied and scanned with the hospital medical record. People should do whatever they can to get access to them when needed. One recommendation: clients should email a copy to themselves and store it in their computer’s email, and/or store it in their phone. Other options: registries, smartphone apps.
10. Know the difference between a POLST (Physician’s Orders for Life-Sustaining Treatment) and an advance directive. POLST is a doctor’s order, completed and signed by the physician, addressing the kinds of care that the individual wants. Appropriate for individuals with terminal conditions or chronic, advanced-stage illness. It is legal and acceptable in most but not all states. Email me if you’d like the comparison chart between POLST and an advance directive from the webinar.
11. Lack of uniformity in state laws can present challenges, especially for snow-birds. There is no perfect solution.
a. Best option: have snowbirds execute documents for both states of residence. Additional benefit of this approach: there is value in presenting an advance directive form that is familiar to the medical staff in that state. Have all directives signed on same date to avoid questions of one superseding the other, but recommends not supplying both at the hospital.
b. Alternative: use the ABA’s HCPOA form, which is valid in 45 states (all except IN, NH, OH, TX, WI) — if this form is legal in both states in which client resides. Form was developed in consultation with AARP and AMA. (Note: this form is designed for people to complete independently. Does not include any guidance to HCPOA on the person’s wishes but encourages this conversation.)
12. Family should actively participate in client’s care planning conferences at healthcare facilities – especially if client is in a nursing home. Family and healthcare staff should involve the patient (client) to the extent possible.
13. This is really important work.
Randi J. Siegel, MBA, is the President of DocuBank (docubank.com), the largest advance directives registry in the U.S., which ensures that the emergency information and healthcare directives of its 200,000 enrollees are immediately available 24/7/365. Working with estate planning professionals since 1997, Randi frequently speaks at national estate planning conferences and has appeared on radio and television as an authority on registries. A member of the Center for Advocacy for the Rights and Interests of the Elderly, the International Society of Advance Care Planning, and the Coalition to Transform Advanced Care, she is active in health education and public engagement related to advance care planning and advance directives and serves as Pennsylvania liaison to the National Healthcare Decisions Day initiative. Randi is an ongoing contributor to the Academy blog.
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