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Advance directives give you a say in your future health care

The practice of medicine involves a lot of paperwork, and not just for doctors.

Even if they’re already stacking piles of co-pay bills, benefits estimate statements and reminder cards for long-past appointments, patients should consider adding a few more documents.

Advance directives, sometimes known as living wills. Durable powers of attorney for health care. Do not resuscitate orders, for Clark County residents, and maybe even a relatively new document called POLST, or physicians orders for life-sustaining treatment, for Nevada residents.

All are documents that let us express our wishes about end-of-life care now, while we can.

Dr. Julie Zacharias-Simpson, a geriatrician and assistant professor at Touro University Nevada College of Osteopathic Medicine, says she regularly speaks with her patients about the importance of drafting a living will, or advance directive, to outline end-of-life treatment wishes.

“It’s important because this is a time to make decisions about what a patient wants done in a crisis mode,” Zacharias-Simpson says. “Do you want to have CPR? Do you want chest compression? Do you want a breathing tube? Do you want a feeding tube?”

Answering such questions now, before a medical crisis hits, is “especially important for the geriatric population, because it could be in the foreseeable future,” she adds.

Advance directives can be a vital, reassuring addition to any adult’s arsenal of medical paperwork. Yet, many of us don’t have them.

Part of the reason is a simple reluctance to talk about our own mortality, says Ellie Powell, clinical nurse ethicist for the Valley Health System.

Lynn Stange, chief compliance officer for Nathan Adelson Hospice, says many people also find it a stressful, difficult task to decide, for example, who’s going to make decisions for you and what (treatments) you want or may not want.

“So what happens is, they don’t activate or implement those (legal) tools,” Stange says. “And, then, an event happens and they have nothing in place.”


As the name implies, advance directives — the term often is used to describe both a specific type of document and as an umbrella term for such documents — record a patient’s health care instructions in advance of a medical crisis that might prevent the patient from making, or voicing, his or her own health care decisions.

The most common advance directive, often called a living will or, in Nevada, simply a “declaration,” lets patients enumerate life-sustaining treatments — artificial breathing, withholding of nutrition or fluids, resuscitation or CPR — they would and would not want to be taken if they are ever diagnosed as terminally ill and can’t speak for themselves.

Powell says the directive would take effect only if you had an incurable or irreversible condition and/or if you can no longer make decisions on your own.


Another similar, but typically more comprehensive document, is the POLST, or physician orders for life-sustaining treatment. Like a living will, it enumerates patients’ end-of-life treatment wishes, and takes effect if patients have serious medical conditions and cannot express their desires firsthand.

However, unlike a living will, which needs simply to be drafted, signed and notarized, a POLST can be drafted only by a physician after a discussion in which the doctor and patient discuss specific end-of-life measures.

“(This document) basically goes over everything,” Zacharias-Simpson says. “You actually go over it with your primary care physician. It’s a physician’s order, so you have to renew it every year.”

POLSTs are usually are done by people who have chronic health conditions, Stange says. “They’re very frail; they may have frequent hospitalizations.”

And, because the POLST is a physician’s order, it will be treated as such by everyone from emergency medical personnel to hospital staff.

Legislation enabling the orders was passed during the 2013 Nevada Legislature, Powell says, and Nevada is one of 17 states that honor such documents. “What it does is to improve the end-of-life experience.”

Like any other advance directive, the orders should be easily accessible. Because emergency medical personnel need to see it, they’re often printed on bright pink paper and patients often keep them on a refrigerator or at their bedside for easy EMT access. And, like other advance directives, they should be made available to physicians, hospital staff and family members.


Another type of advance directive deals with who will be authorized to speak for a patient who can’t. Through a durable power of attorney for health care, an adult can designate a person — a spouse, a parent, a sibling, even a friend — to make health care decisions for the patient if the patient becomes unable to do so.

The durable power of attorney for health care can include instructions about treatments the patients does or doesn’t want to be administered. And, unlike other advance directives, the patient does not have to be diagnosed as terminal or incurable for the document to kick in.

Without a durable power of attorney for health care, a hospital, doctor or medical provider will seek consent from relatives according to a state-designated hierarchy that starts with the patient’s spouse, descends through the patient’s adult children and moves down to the patient’s nearest adult relative.

Trouble is, not all of those people may know exactly which medical procedures the patient may want or avoid. But, Stange says, without a specifically named designee, “somebody’s going to have to decide.”

Because Nevada doesn’t recognize common-law marriage, a durable power of attorney for health care can let longtime live-in partners ensure that their companion will have a voice. Designating someone specific in a durable power of attorney for health care can also help minimize conflicts among family members.

“If there are multiple (family) parties, we like to get a consensus,” Stange says. “But sometimes that does not happen and sometimes there is disagreement about what they think Mom or Dad would want, and that’s really tough.”

Durable powers of attorney for health care can be filed by any adult 18 and older, says Stange, who also recommends that at least one alternate designee be named.

Note, too, that a designee named in a durable power of attorney for finances will not be recognized as a patient’s health care proxy unless that person also is named in a separate durable power of attorney for health care. Stange says patients’ families sometimes mistakenly assume that one automatically carries over to the other.


Another type of advance directive for Clark County residents is a do not resuscitate order, which, Powell says, can be filled out by patients who have chronic, terminal conditions.

With the order, patients express their desire to have emergency medical service personnel withhold resuscitation. The paperwork comes from the Southern Nevada Health District, taken to a physician for filling out and then returned to the district, Powell says.

The patient then receives a card that, she says, paramedics in the field will honor.

The card can be issued only to those who are chronically or terminally ill, Powell adds.

“A lot of people make copies of it and then you can post it on the refrigerator, and you want to make sure … you have it with you in your home and let people know you do have one,” Powell says.

Stange says advance directive documents should be kept easily accessible. Give copies to relevant family members, and ensure your durable power of attorney for health care proxy has a copy of that document. Give copies to your health care providers, too.

To make advance directives even more accessible to health care providers, Nevada’s Secretary of State maintains a Living Will Lockbox service (visit www.livingwilllockbox.com) into which documents can be uploaded and then accessed by hospitals and health care providers when necessary.

Also ensure the documents are kept up to date to reflect your current wishes and the effects of divorce, death and family members’ relocation.

Advance directives can be vital documents and important conversation starters to let patients discuss end-of-life health care wishes with spouses, children and family members.

“I think it’s an important concept to bring these things up,” Zacharias-Simpson says. “It’s important to talk to the families.”

Contact reporter John Przybys at jprzybys@reviewjournal.com or 702-383-0280. Follow @JJPrzybys on Twitter.

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