The Instruments of Advance Care Planning

Instruments used in Advance Care Planning
(Advance Directives)

  • The Living Will

  • Designation of a Health Care Surrogate

  • Durable Power of Attorney

  • Do Not Resuscitate Order

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The documents used in advance care planning are called "advance directives." They fall into two categories: (1) those that provide instructions regarding medical care and (2) those that designate someone, known as a "proxy" or "surrogate," who is empowered to make decisions for the person who is ill. The health care surrogate instruments deal with health decisions. A Durable Power of Attorney expands decision-making power to other areas.
States have differing laws governing advance directives and forms that are recognized within that state.

Definitions

Living Will: An 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 communicate. The purpose of a living will is to provide guidance to family members and physicians in deciding how aggressively to use medical treatments to delay death. Click on Health Care Advance Directives at this site to view and print the Florida Living Will form. (PDF format.)

Designation of Health Care Surrogate (sometimes called medical power of attorney, health care proxy or health care agent): A 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 communicate. Not all conditions are covered in the Living Will so the designation of a health care surrogate is vital. Go here to view and print the Florida Designation of Health Care Surrogate form. (PDF format)

 

It is recommended that the individual complete both of these documents to ensure that the desired medical care is given when the person can no longer speak for himself or herself.

Durable Power of Attorney is a document that delegates the authority to make health, financial and/or legal decisions on a person's behalf. It goes into effect when a person is unable to make his/her own decisions. If the intent is to designate the person to make health care decisions, it must be specifically stated in writing and must show the person's intent to give specified power if the person is incapacitated. Forms can be purchased at office supply stores and must include the durable provision. The signatures must be notarized.

Do Not Resuscitate Order (DNRO)
Information taken from Do Not Resuscitate, But Do Treat With Care, a brochure issued by the Florida Department of Health, Division of Emergency Medical Services.

The DNRO is a physician's order not to resuscitate if a person goes into cardiac or pulmonary arrest. It is part of the prescribed medical treatment plan and must have a physician's signature. It is also signed by the patient and the health care surrogate or power of attorney. It is the legal document that instructs the hospital or emergency medical service to not resuscitate a person in cardiac or pulmonary failure.

You may get questions and hear concerns about the Do Not Resuscitate order (DNRO). It is often overlooked as one of the advance directives, but it is important. It is usually reserved for someone who is terminally ill, suffering from an end-stage condition, or is in a persistent vegetative state. There have been cases where people who did not want futile life-prolonging measures to be taken have found themselves in an ambulance or in the emergency room resuscitated and even hooked up to life support equipment. The State of Florida has passed laws intended to prevent this from happening.

Pursuant to Florida law, the DNRO is honored in most health care settings, including hospices, adult family care homes, assisted living facilities, emergency departments, nursing homes, home health agencies and hospitals. Florida law provides that health care providers employed in these health care settings may withhold or withdraw cardiopulmonary resuscitation if presented with the DNRO and be immune from criminal prosecution or civil liability. In addition, if the DNRO is presented to an emergency medical technician or paramedic in a setting other than a health care facility, it will still be honored.

The question of whether or not to call 911 if the patient has a DNRO is often raised. 911 can be called at any time to provide the family with back-up and support for the patient. Some families may want the patient to be transported to the hospital so the attending physician will be present. A DNRO only means that, in the event of cardiac or pulmonary arrest, CPR will not be initiated. Comfort care measures, such as oxygen administration, hemorrhage control, and pain management will still be used.

The DNRO form should be kept in a noticeable place such as the head or foot of a bed, or on the refrigerator. It should be readily available in the event of an emergency to ensure that the patient's last wishes will be honored.

Go here to view and print a copy of the DNRO form. (SPECIAL NOTE - The DNRO Form MUST be printed on yellow stock, 8 1/2 x 14, legal size paper.) The DNRO Form 1896 can be obtained by calling 850-245-4440, ext. 2731 or 2742.] Attached to the bottom of the form is a patient identification device that may be removed from the form and laminated, and can be worn on a chain around the neck, or clipped to a key chain or to clothing/bed, etc. so it can travel with the patient. It is equally as valid as the DNRO Form 1896 and can be presented to emergency medical services personnel when they arrive on the scene. The patient identification device is an added option to the form to allow for portability and convenience.

The form can be revoked at any time either orally or in writing, by physical destruction, by failure to present it, or by orally expressing a contrary intent.

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