8.2 Advance Directives, Durable Power of Attorney, and Living Wills

8.2 Advance Directives, Durable Power of Attorney, and Living Wills

The Patient Self-Determination Act (PSDA) of 1990

The Patient Self-Determination Act (PSDA) is a landmark federal statute enacted by Congress in 1990 to reinforce patient autonomy in end-of-life decision-making. The PSDA mandates that all healthcare institutions receiving federal Medicare or Medicaid funding—including hospitals, nursing homes, home health agencies, and health maintenance organizations (HMOs)—must comply with specific patient rights requirements upon admission or registration.

Key Institutional Requirements Under the PSDA

1. Written Information Provision: Facilities must provide adult patients with written information regarding their rights under state law to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate Advance Directives.
2. Documentation of Advance Directive Status: Healthcare providers must explicitly document in the patient's Electronic Health Record (EHR) whether or not the patient has executed an advance directive.
3. Nondiscrimination Compliance: Facilities are strictly prohibited from conditioning care delivery or discriminating against patients based on whether or not they have executed an advance directive.
4. Institutional Policy Maintenance: Facilities must maintain written policies regarding advance directives and provide ongoing community and staff education regarding end-of-life autonomy.

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Major Types of Advance Directives

Advance Directives are legal documents executed by a competent individual outlining healthcare preferences or designating a surrogate decision-maker in the event that the individual loses decision-making capacity due to injury, illness, or cognitive decline.

1. Living Wills

Formulated while a patient is fully competent, a Living Will is a written document specifying the patient's explicit instructions regarding life-sustaining medical interventions. Living Wills typically address whether the patient consents to or refuses:

• Mechanical ventilation (respirator support).
• Cardiopulmonary Resuscitation (CPR).
• Artificial nutrition and hydration (nasogastric tubes, IV total parenteral nutrition).
• Renal dialysis and blood transfusions.
• Palliative care and pain management preferences.

Legal Limitation: A Living Will generally takes effect only when the attending physician certifies that the patient is in a terminal condition, end-stage illness, or persistent vegetative state (permanent coma).

2. Durable Power of Attorney for Healthcare (DPOA-HC)

Also known as a Healthcare Proxy or designation of Healthcare Agent, a DPOA-HC is a legal instrument in which a competent adult appoints a trusted individual (attorney-in-fact) to make medical treatment decisions on their behalf if they become temporarily or permanently incapacitated.

General Power of Attorney vs. Healthcare DPOA

It is vital to distinguish between a General Power of Attorney (which grants authority over financial, real estate, and legal business matters) and a Durable Power of Attorney for Healthcare (which applies exclusively to medical decisions). A standard financial POA terminates upon patient incapacity unless designated as "durable," whereas a DPOA-HC is specifically designed to become active upon clinical incapacity.

3. Do Not Resuscitate (DNR) Orders

A Do Not Resuscitate (DNR) order is a specific clinical medical order signed by a licensed physician, nurse practitioner, or physician assistant. It instructs healthcare personnel not to initiate CPR, chest compressions, defibrillation, or endotracheal intubation if the patient experiences cardiac arrest or respiratory failure.

Critical Clinical Distinction: A Living Will is a legal statement of patient wishes, whereas a DNR is an actionable medical order. EMS personnel and hospital staff cannot withhold CPR based solely on a Living Will document; a formal, signed DNR order must be present in the medical chart or presented to emergency responders.

4. POLST / MOLST Orders

Physician Orders for Life-Sustaining Treatment (POLST)—also termed Medical Orders for Life-Sustaining Treatment (MOLST)—represent an advanced approach to translating patient preferences into actionable, standardized medical orders. Designed for patients with serious illness or frailty, a POLST turns advance directive wishes into specific actionable provider orders that travel with the patient across care settings (from home to ambulance to emergency department).

POLST forms are brightly colored (often pink or green) and cover three primary domains:

1. CPR Status: Attempt Resuscitation vs. Do Not Resuscitate.
2. Medical Interventions: Full Treatment vs. Selective Interventions vs. Comfort-Focused Care.
3. Artificially Administered Nutrition: Long-term feeding tube vs. trial period vs. no artificial nutrition.

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Organ Donation and the National Registry (UNOS)

The Uniform Anatomical Gift Act (UAGA) governs organ, tissue, and eye donation in the United States. Competent adults can authorize organ donation upon death through driver's license designations, state donor registries, or advance directive documents.

• United Network for Organ Sharing (UNOS): UNOS is the private, non-profit organization under federal contract that manages the nation's organ transplant system (Organ Procurement and Transplantation Network - OPTN). UNOS maintains the centralized national waitlist, matching donated organs based on medical urgency, tissue matching, blood type, and geographic proximity.
• Medical Assistant Role: MAs must recognize organ donor indicators in patient charts and understand that when a donor patient passes away, hospital protocols require immediate notification of the regional Organ Procurement Organization (OPO).

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Medical Assistant Role in Advance Directive Intake & Verification

During routine patient intake and EHR charting, Medical Assistants perform critical administrative and clinical verification steps regarding advance directives:

1. Systematic Screening: Ask every adult patient during intake: "Do you have an Advance Directive, Living Will, or Durable Power of Attorney for Healthcare?"
2. Document Procurement & Scanning: If the patient has executed directives, request a copy, verify that the document is properly signed and notarized/witnessed according to state law, and scan it into the EHR.
3. Chart Flagging & Alerts: Place an active banner flag or alert in the EHR alerting clinical staff to the presence of an Advance Directive, DPOA-HC proxy contact details, or active DNR order.
4. Provider Notification: Immediately inform the examining provider if a patient presents with conflicting advance directive instructions or wishes to revoke an existing document.