4.3 Advance Directives and Goals of Care

Why Advance Care Planning Is an Assessment Domain

Topic 1B7 expects ACM candidates to assess advance directives and engage goals of care. Hospital case managers sit at the intersection of legal documents, bedside values conversations, code status orders, and post-acute placement. Missing or misunderstood directives create moral distress, unwanted interventions, and delayed transitions.

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Core Documents: Living Will and POAHC

Living will

A living will (instructional directive) states the treatments a person would or would not want in future situations—often focusing on life-sustaining treatments if the person is terminally ill, permanently unconscious, or otherwise specified by state law. It guides clinicians and surrogates when the patient cannot speak. Limitations: living wills may be vague for the exact clinical scenario and usually do not appoint a decision maker by themselves.

Durable power of attorney for healthcare (POAHC) / healthcare proxy

A POAHC (also called healthcare power of attorney, healthcare proxy, or healthcare agent designation) names a person to make medical decisions when the patient lacks capacity. Activation triggers and formalities (witnesses, notary) are state-specific. This document answers “who decides?” more reliably than an instructional living will alone.

Best practice for adults: complete both an agent designation and written preferences when possible. Case managers should ask on screening: “Do you have an advance directive? Who would speak for you if you could not speak? Where is the document?” Then retrieve, scan, and flag it in the EHR.

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POLST / MOLST Distinctions

POLST (Physician Orders for Life-Sustaining Treatment) and related forms (MOLST, POST, MOST, depending on state) convert goals into actionable medical orders—commonly covering CPR, medical intervention level, antibiotics, and artificial nutrition. Key distinctions for the exam:

• POLST/MOLST is a medical order set, signed by an authorized clinician (and typically the patient or legal decision maker), intended to be followed across settings (EMS, SNF, hospital, home)
• Advance directives are not physician orders; they express preferences and/or appoint an agent and apply more broadly to adults who may be healthy today
• Intended population — seriously ill or frail patients for whom clinicians would not be surprised by death in the near term; inappropriate as a routine form for healthy young adults
• Complementary, not identical — a patient may have both an advance directive (agent + values) and a POLST that operationalizes current orders; POLST does not eliminate the value of a named healthcare agent
• Portability — orders should travel with the patient; on admission, reconcile POLST with hospital code-status orders per policy so emergency responses match documented wishes

Critical operational pearl: presence of a living will or POLST in the chart does not automatically create inpatient code-status orders. The treating clinician must enter facility orders consistent with current wishes. Case managers help surface documents early—ideally within admission screening—so the team does not discover a DNR preference only during a crisis.

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Patient Self-Determination Act (PSDA)

The Patient Self-Determination Act (federal law, effective in the early 1990s) amended Medicare and Medicaid requirements. Covered providers—including hospitals, SNFs, home health agencies, hospices, and certain other organizations—must:

1. Inform adult patients of their rights under state law to make healthcare decisions, accept or refuse treatment, and formulate advance directives
2. Document in the medical record whether the patient has an advance directive
3. Not discriminate based on whether a patient has executed an advance directive
4. Ensure compliance with state law regarding advance directives (within the provider’s policies and legal limits)
5. Educate staff and the community about advance directives (organizational obligation)

PSDA does not create a single national advance-directive form; state law defines document types, witnessing, and surrogate hierarchies. For ACM items: know that Medicare/Medicaid-participating hospitals must provide information and document directive status—not that every patient must complete a directive before admission.

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Goals of Care: From Values to Plan

Goals-of-care conversations connect what matters to the patient (independence, comfort, time with family, avoiding institutionalization, longevity at all costs) with medical options (ICU-level care, limited interventions, comfort-focused care, trial of therapy with clear stopping rules). Case managers contribute by:

• Screening for existing directives and prior POLST/MOLST
• Coordinating the right participants (patient/agent, attending, palliative care, interpreters)
• Translating goals into disposition reality (home with hospice vs SNF vs continued aggressive hospital care)
• Ensuring the written plan, code status, and post-acute referrals match the agreed goals
• Reassessing when prognosis or functional status changes

Common ACM pitfalls

• Assuming “full code” equals “wants every treatment forever” without clarifying acceptable burdens
• Confusing a financial power of attorney with a healthcare power of attorney
• Filing a living will but never identifying who the agent is for day-to-day decisions during incapacity
• Treating POLST as sufficient advance care planning for a healthy adult without an agent designation
• Failing to send advance directives/POLST with the interfacility transfer packet

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Workflow for Hospital Case Management

1. Ask and retrieve — On assessment, inquire about directives; request copies from patient, family, primary care, or prior facilities
2. Verify authority — Confirm whether an agent is named and whether activation conditions are met
3. Align orders — Prompt the LIP to reconcile code status and treatment limitations with documents and current conversation
4. Support the conversation — For serious illness, involve palliative care early when goals are unclear or conflict is high
5. Propagate across the continuum — Include directives and POLST/MOLST in discharge packets to SNF, IRF, LTACH, home health, and hospice
6. Revisit — Goals change; a directive from years ago may need an updated discussion even if still legally valid

Vignette pattern

A frail patient with advanced COPD arrives from a SNF with a MOLST indicating DNR/DNI and comfort-focused measures. The hospital team should locate and honor the portable orders through appropriate hospital order entry, clarify goals with the patient or lawful decision maker, and avoid defaulting to full resuscitation simply because inpatient orders were not yet written. Simultaneously, confirm whether a healthcare agent is named for decisions beyond the MOLST checkboxes.

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Exam Distinctions to Memorize

• Living will = preferences; POAHC = person; POLST/MOLST = portable orders for the seriously ill
• PSDA = inform + document + non-discrimination in Medicare/Medicaid settings; state law supplies the forms
• Capacitated patients can revise or revoke directives according to state rules; always seek current wishes
• Goals of care operationalize values into treatment intensity and transition plans—documents alone are not a substitute for conversation when clinical context has changed