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Understanding Your Options

Understanding your options: living will

If you complete a living will, you will usually specify the type of life-sustaining treatments that you do not wish to receive.4 Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276-85. The goal is that in the future, the health care professionals will not administer the treatments listed in the living will.

Living wills are usually not implemented unless you meet two conditions: 1) You have a terminal illness; and 2) you do not have the ability to make decisions at the time that it is implemented. One of the weaknesses of a living will, however, is that the definition of terminal illness varies from state to state. For example, some states specify that you can only be categorized as having a terminal illness if you have a life expectancy of six months or less, whereas other states may not even provide the definition.4 Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276-85. The implication for this limitation is that even with a living will in place and with specific life-sustaining treatments listed, you may still receive those treatments over the course of several years.

Another limitation is that health care professionals may not be aware that you even have a living will.4 Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276-85. If you have a living will, it is the responsibility of either the patients or the caregivers to make the health care professionals aware of the living will.

Understanding your options: physician orders for life-sustaining treatment

If you complete a Physician Orders for Life-Sustaining Treatment (POLST), you will usually specify the type of life-sustaining treatments that you do not wish to receive, in addition to your desires about resuscitation.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64.

If you complete a POLST, a health care professional will work with you to fill out the form and at completion, both you (or an assigned decision-maker) and the health care professional sign the form. Now everyone at the facility will know your desires as to the type of health care that you do not want to receive. Moreover, some states also have a registry and the information from your completed form can be entered; then, if you go to another hospital within the same state, the information will transfer with you.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64.

POLST is typically used for patients who have a year or less to live.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64. Although POLST programs now exist in most states, they still do not exist in all states.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64. You may want to verify that your state has an established POLST program and if so, complete the forms with your health care professionals.

Understanding your options: do not resuscitate order

You can choose to complete a do not resuscitate order, or DNR, if you do not wish to receive CPR to revive you if your heart stops beating or if your breathing stops. This decision pertains only to CPR and does not affect other treatments, pain management or nutrition.

A DNR order can be added to your hospital or hospice chart by your doctor if you request it, or you may be able to obtain a wallet card, bracelet or other means of notifying health care providers of your wishes outside a hospital setting. Ask a social worker or members of your care team for guidance if you wish to put a DNR order in place.

Understanding your options: medical power of attorney

You may want to consider choosing another person to be your decision-maker.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64. The person you select to be your medical decision-maker can then decide the type of life-sustaining therapy that you can (or cannot) receive in the event that you cannot make a decision for yourself.5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64.

If you decide to take this step, then you should periodically check in with your assigned decision-maker to express your view of desired (and non-desired) medical care, which may evolve and change over time.


References

1 Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). National Cancer Institute. Bethesda, MD.Accessed at http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.

2 Lockhart LK, Ditto PH, Danks JH, Coppola KM, Smucker WD. The stability of older adults' judgments of fates better and worse than death. Death Stud. 2001 Jun;25(4):299-317.

3 Ditto PH, Jacobson JA, Smucker WD, Danks JH, Fagerlin A. Context changes choices: a prospective study of the effects of hospitalization on life-sustaining treatment preferences. Med Decis Making. 2006 Jul-Aug;26(4):313-22.

4 Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009 May;76(5):276-85.

5 Bomba PA, Kemp M, Black JS. POLST: An improvement over traditional advance directives. Cleve Clin J Med. 2012 Jul;79(7):457-64.

6 Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol. 2003 Mar 15;21(6):1133-8.

7 Torpy JM, Burke A, Golub RM. Hospice care. JAMA. 2012 Jul 11;308(2):200.

8 Current Clinical Issues: The debate in hospice care. JOP. 2008;4(3):153-157.

9 Levy MH, Adolph MD, Back A, et al. Palliative care. J Natl Compr Canc Netw. 2012;10:1284-1309.