WHAT ARE YOUR END OF LIFE WISHES?

A living will is one directive you complete documenting your end of life choices. 

A Do Not Resuscitate (DNR) order is another kind of advance directive documenting your end of life choices.

Here are some common questions and answers about a DNR.

What is the purpose of a DNR?

Why do you need to complete a living will and a DNR?

What happens if the  paramedics do not know you have signed a DNR?

How do you create an out of hospital DNR?

Q.   What is the purpose of a DNR?

A.  A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing.  Unless paramedics or other emergency staff is given other instructions, they will try to resuscitate any patient whose heart has stopped or who has stopped breathing.

FACT: The exact rules for obtaining a DNR and for proving its validity vary widely from state to state.

Once you complete a DNR, make sure your physician and others are aware of your wishes.  Give a copy of your DNR to your primary physician and request that this information is added to your medical records.  If you are in a hospital, make sure a copy of your DNR is included with your medical chart.  Keep a copy of the original DNR form in your estate planning files.

FACT: Generally, doctors and hospitals in all states respect DNR orders.

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Q. Why do you need to complete a living will and a DNR?

A. The directions in your living will are only followed when your doctor believes you are in a terminal state and will not recover from your illness or injury.  The directions in your DNR are effective the moment you sign them and do not require any type of medical condition to be present for the DNR to be effective.

Elderly people sometimes want a DNR if they suffer from chronic illnesses and are concerned that their quality of life will suffer if they require resuscitation.

Q. What happens if the paramedics do not know you have completed a DNR?

A. If the paramedics or other medical personnel cannot locate your DNR, they will make an effort to save your life.

You can help the paramedics make the right treatment choices in several ways:

· Participate in the Vial of Life program.  The Vial of Life program is a nationwide effort to assist emergency personnel administer proper medical treatment for you when you can’t speak for yourself. A Vial of Life sticker is placed on your door.  This sticker tells the paramedic to look for your DNR and other medical information in a vial placed in your refrigerator. Some people recommend storing the DNR in the freezer in a blue freezer bag, as paramedics are trained to look there for DNR documents.

· Some states authorize the use of identification bracelets or tags as a way for you to notify medical personnel that you have signed a DNR.  Although all states authorize the use of a DNR, some states require special paper be used when printing as a means of authentication.

A FAMILY STORY: No DNR Present.

Kathy’s 92-year old mother was at Kathy’s house watching TV when she suddenly said she could not breathe. Kathy called an ambulance.

As they prepared to take her mother to the hospital, Kathy explained to the paramedic that she and her mother had decided not to resuscitate if the situation was such that her quality of life could be impaired.

The paramedic asked to see the DNR form.  Kathy replied the form was at her mother’s house in another state. Kathy could not provide a copy of the DNR signed by her mother to the paramedic.

The paramedic said they were allowed to wait sixty seconds for someone to provide the DNR.  After that, they are required by law to administer all available life saving techniques.

Kathy now keeps a copy of the DNR in her freezer and in her purse.  Her mother wears a DNR bracelet.

Q. How do you complete a DNR?

A. Your physician must complete and sign a DNR on your behalf.  In some states, you must wear a DNR bracelet showing you have a DNR on file.    The DNR state rules identify the name of the form required in your state and other facts you need to create an effective DNR. 

Like all legal documents, you need to complete a DNR before you  have a heart attack or other medical condition that would appear to compromise your mental abilities.   Once your mental capacity has been substantially compromised, it is possible for a physician to determine that you lack sufficient mental capacity to provide informed medical consent.

If the physician considers your mental capacity is diminished, it will be too late for you to instruct the medical staff not to resuscitate you.  These orders must be made when you are healthy.

Who Will Make Health Care Choices for You When You Can’t?

You can complete an advance directive  document often referred to as a durable power of attorney for health care and name a health care agent to make health choices for you if and when you can’t.   This person will make sure your previously written wishes relating to your health care are carried out.    This agent may also request other treatments for you consistent with your broad directives regarding your health care.

Some states call this document a “health care proxy”.   Some states call your health care agent a “health care surrogate” or an agent.   Some states combine the health care power of attorney form with the living will form in a single document referred to as an advanced health care directive.

Most people also complete a Living will documenting  their end of life wishes.  Their health care agent is obligated to follow those instructions and works with medical staff to follow out the instructions contained in a living will.

Fact: Advanced Health Care Directive.
These states have adopted the use of an advanced health care directive, a single form documenting your end of life choices and your designation of a health care agent: Alabama, Arizona, California, Connecticut, Delaware, District of Columbia, Hawaii, Kentucky, Minnesota, Mississippi, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, Pennsylvania and Virginia.

Here are some questions and answers about a Health Care Power of Attorney.

• Who should you appoint a your health care agent?
• What types of decisions can your health care agent make?
• If you have a power of attorney for your spouse’s financial affairs, does this cover health care decisions as well?
• How long is a health care power of attorney effective?
• How do you revoke a health care power of attorney?
• What if you have not completed a health care power of attorney?
• Should you make both a living will and a health care power of attorney?
• How can you make a health care power of attorney form?

Q. Who should you appoint as your health care agent?

A. Your health care agent  can be be your spouse, an adult child, another relative or a friend.  We have found that your agent should, ideally, be a fighter: a person willing to make sure your wishes are carried out.

Some states do not permit the appointment of a patients physician or other health care provider as a designated agent.

While you can only have one health care agent at a time, you may name a contingent agent in the event that the first person is unable or unwilling to serve.

Don’t appoint someone without first asking if they are willing to serve as your health care agent and be sure you trust them to carry out your health care wishes.

You may your health care agent and your attorney-in-fact to be the same person.   Your health care agent has the authority to make health care choices on your behalf; however, your financial agent has the authority to pay for those choices.

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Q. What types of health care choices can a health care agent make on your behalf?

A. The person you identify as your “agent” when you complete your health care power of attorney will be empowered to give informed consent on your behalf and may make decisions about whether you should undergo medical procedures or elect hospice care.

Your agent will talk with doctors and other health care providers to make sure you get the type of care you documented or discussed with your agent.   When arranging care, a health care agent is legally obligated to follow the treatment expressed by the author of the document.

The more specific you make your instructions regarding your health care choices, the better.  These instructions should address whether your agent has the authority to withhold artificial resuscitation, hydration and nutrition, depending on your circumstance.

In many states, the health care power of attorney is a “statutory form,” meaning the authority granted to your health care agent are specifically described in state law.      In West Virginia and Wisconsin, state statutes give the designated agent the authority to arrange for nursing home placement or home health care.

In some states, you can use the health care power of attorney form to name a funeral agent.

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Q. I have power of attorney over my spouse’s financial affairs.   Does this cover health care decisions as well?

A. In most states, no.   Alaska and Pennsylvania are exceptions, the durable power of attorney statute extends to health care decisions making.

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Q. How long is a health care power of attorney effective?

A. A health care power of attorney, like a living will, becomes effective and is used when the author is incapable of making and communicating decisions.   If you are capable of making and communicating your own decisions, there is not need for your health care agent to be involved.

With one exception, the authority of the health care agent ends at your death when a personal representative, executor or a trustee takes over.  The exception is that a person acting under a health care power of attorney could have been given authority to handle the final arrangements regarding your remains and funeral.

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Q. How can you revoke a durable power of attorney?

A. You can create a revocation form terminating the appointment of your health care agent at any time while you are living.

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Q. What if you have not completed a health care power of attorney?

A. If you are married or have a registered domestic partner, generally your spouse or registered domestic partner has the inherent legal right to make health care choices for you if you are unable to do so, even if you have not completed a health care power of attorney form.

If you have no spouse or registered domestic partner and become unable to manage your own personal health care decisions, someone will request the probate court appoint a conservator who will be in charge of making health care decisions for you.

Your medical choices can be delayed unless you have legally identified a health care agent to make choices for you.

Fact: A single adult child also needs a health care power of attorney.
Parents of injured Virginia Tech students rushed to be at the side of their children.  If a child was over 18 and had not signed a health care power of attorney, they found they did not have the legal authority to make their health care choices.

If your adult child is attending college or is not married, your adult child should complete a health care power of attorney designating a parent or another adult as their health care agent.

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Q. Should you make both a living will and a durable power of attorney directive?

A.  Yes.   They serve different purposes.  A living will documents your end of life choices.   A health care power of attorney names an agent to carry out your wishes when you can’t speak or make choices on your own.

A health care power of attorney is obligated by law to carry out wishes documented in your living will.

Because both documents are critical advance directives, some states have combined the forms into a single advance health care directive document.

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Q. How can you make a Durable Health Care Power of Attorney form?

A. You have several choices.

• An attorney can create the form for you.
• If you live in Arizona or California, a legal document assistant can provide power of attorney forms.
• You can do it yourself using forms and software available on the web or on your personal computer.

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WHO DO YOU WANT TO ACCESS YOUR HEALTH CARE RECORDS?

HIPPA is the acronym for the Health Insurance Portability and Accountability Act passed in 2003.  In an effort to protect your privacy, HIPPA restricts the freedom of medical care providers to share medical information about you with anyone, even family members, without your consent.

The provisions of HIPPA give you the right to view information contained in your medical records and to designate other persons with whom your medical information may be shared.

Here are some questions and answers about HIPPA.

Do you need to complete a HIPPA form in order for your spouse or family to see copies of your medical records?

Wht if you have not completed a HIPA form giving someone the legal right to view your medical records?

How can you authorize someone to access your medical records?

Q. Why do you need to complete a HIPPA form in order for your health care agent or family members spouse see copies of your medical records?

A. If you want your medical information shared with someone, you must complete a HIPPA Authorization to Release Information form naming and authorizing the people you will allow to see the records maintained by your physician or hospital.  Access to these records will be important for whomever is in charge of making medical decisions for you.

The list should certainly include your health care agent.  Whether you want your medical information shared with your family is up to you.  If you have old and trusted friends to whom you frequently turn for advice, you may want to name them as well.

Once you sign a HIPPA Authorization to Release Information form, you should give a copy to your family physician.

Although you can add a clause to your Health Care Power of Attorney form giving your health care agent and family access to your personal medical records, it is also wise to sign a separate HIPPA form identifying the people whom you want to have access to your records.

Q. What if you have not completed a HIPPA form giving someone the legal right to view your medical records?

A. Without a written authorization from you to share your medical records, medical professionals and medical facilities face stiff penalties for violating HIPPA.

Without advanced authorization by you, your health care agent will not be able to access the information about you to make an informed decision about the best plan of care for you.

Q   How can you authorize someone to access your medical records?

A. 

WHO WOULD YOU WANT CALLED IN CASE OF EMERGENCY (ICE)?

ICE is a list of persons you want contacted in case of emergency, stored in your cell phone. 

Here are some common questions and answers about ICE.

What is ICE?

How does ICE work?

Q.  What is ICE?

A.  If you are in a car accident or some other event requiring unexpected medical care, the physicians and emergency personnel must find a way to contact someone regarding your medical emergency.  Time is important.  Some medical procedures require authorization from a spouse or a health care agent before treatment can begin.  A shorthand process has been developed to facilitate this communication process, referred to as ICE.  ICE stands for In Case of Emergency.

Q. How Does ICE Work?

A. ICE reflects the list of persons who you want contacted in case of an emergency.  This list of persons and their telephone numbers (and other information) is stored on your cell phone.  The steps are as follows:

• Decide whom you want contacted in case of emergency.
• Enter ICE as the contact name in your cell phone contact list.
• Add the phone number of the person you want called in case of emergency.
• If you want to name more than one person, make an ICE1 and ICE2 entry in your contact list.

FACT: If you are injured in an emergency, paramedics and other emergency responders are trained to examine your cell phone and look under “ICE” to see who ought to be contacted to give your whereabouts and condition.

If you own an Apple Iphone, there are several ICE applications available.  These applications allow you to enter emergency contact information and other types of health information.