Advance Directives — end of life care

eskimoWhat is quality end-of-life care?  That can be a hard question because it depends on where a person lives, what the society expects, what the society can deliver and religious beliefs.  The Eskimo idea of putting grandma on an iceberg and sending her out with the tide is one view.   This primitive Eskimo practice is not without feeling or philosophy and focuses on the basics.  The family loves grandma, the family is in jeopardy trying to provide care and food,  and death should be painless and peaceful.

A modern society would add respect for a person’s wishes — such as religious views, desire for medical care, burial and distribution of assets.  But, despite the willingness of modern society to follow a person’s end-of-life requests a huge majority do not make end-of-life wishes known leaving family and doctors to just guess.  And, the result is expensive medical care and tremendous anxiety for the family — was that really a cultural advancement?

To try to make it easy for patients to make end-of-life medical care requests doctors have encouraged patients to provide them with “advance directives” — some statement in advance of death about what type and quantity of care is wanted at the end of life.  For many years the “living will” has been the vehicle for those requests.  As people fill out their will regarding property they often will fill out a “living will” with statements about what care they want or don’t want.

The “living will” has had problems because it was often filled out in a lawyer’s office without regard to the actual health of the patient or any understanding of advancing science or the grey area of incurable disease.

In the past 10 years a more rational approach has been growing in the form of “Medical Orders for Scope of Care”.  Which likewise is a legal document but one which is a true medical order issued by a licensed physician and discussed with the patient to match their wishes.  Click on the links to see examples:  IPOST, MOST and POLST.

Laura Landro of the Wall Street Journal wrote her story “Patients’ End-of-Life Wishes Granted, Study Finds” on 6/9/14  about an article in the Journal of the American Geriatrics Society:

Fromme, E. K., Zive, D., Schmidt, T. A., Cook, J. N. B. and Tolle, S. W. (2014), Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. Journal of the American Geriatrics Society. doi: 10.1111/jgs.12889

The essence of the article is that the health care system in Oregon does actually follow the POLST form requests.

There are several legal documents essential for someone approaching end-of-life:

  1. A will or trust.  Make bank accounts “payable on death” to some person.  Make sure securities are designated “transfer on death” to some person.
  2. A living will or MOST form (the latter is probably better)
  3. A power of attorney for health care form
  4. A power of attorney for property form
  5. A HIPPA form to designate who may have access to medical information.
  6. Identification documents: birth certificate, marriage certificate, social security card, state issued ID card (like a drivers license), health insurance card, and military discharge papers  — give copies to your power of attorney.
  7. Make sure the executor of your estate or trustee knows where to find a will,  trust documents,  bank information, life insurance policies, pension  information, funeral arrangements, deeds, and securities.


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