Why Are There So Many Different Kinds of Health Care Directives?
Do you have a durable power of attorney for health care, a living will, a health care proxy, a medical directive, a HIPAA release, a DNR or a MOLST? You may have more than one and they may overlap or serve specific and separate purposes. There are really two reasons that there are so many different kinds of health care directives: first, each state has its own laws on health care decision making and as a result different forms or different titles for the same forms exist around the country; second, different documents have different functions.
So, here’s a short primer on the different health care directives that may be available to you:
Health Care Durable Power of Attorney or Health Care Proxy
Health care durable powers of attorney and proxies are essentially the same thing with different names in different states. They permit you to name an agent to make health care decisions for you when and if you are unable to do so for yourself.
Medical or Health Care Directive
While the health care durable power of attorney or proxy permits you to name an agent, a medical or health care directive provides guidance to the agent about what your wishes would be in various medical situations. These come in many forms, from a general statement about values to long questionnaires about what type of treatment you would want in various circumstances. You may use an existing form or write your own statement.
You may include your directive within your health care proxy or make it a separate document, and there are arguments for and against each approach. Depending on your state, your health care directive may be legally binding or simply non-legal guidance for your agent. However, even in the latter case, if a dispute were to arise about your wishes, a court would give great weight to what you wrote in your health care directive.
A living will is a limited medical or health care directive that states what care you would want if you were terminally ill or in a coma. Living wills were the first type of health care directive that were created when Americans began facing the prospect of being kept alive by machines. In some states, living wills have the force of law, which is less often the case with broader health care directives.
Do Not Resuscitate Order (DNR)
Different from the documents listed above, which you can create yourself or with the assistance of an attorney, a Do Not Resuscitate or DNR order must be signed by a physician or other medical professional. It dictates that medical personnel may not resuscitate a patient whose stops breathing or whose heart stops beating. Traditionally, these have only been operative in hospital or nursing home settings, but many states now authorize them for the patient’s home as well. The problem in such settings is making sure that emergency medical personnel are aware of and accept the DNR order when responding to an emergency call. Usually, they are only used when the individual has a terminal illness. If they’re living at home, they often post the document on their refrigerators. In our practice, we had a client whose mother was resuscitated despite having a DNR order because the EMTs could not read the signature or credentials of the medical professional who signed the order.
Medical Order for Life-Sustaining Treatment (MOLST)
DNR orders are limited to avoiding resuscitation in the event of a cardiac or similar medical event. In this way, they are somewhat analogous to living wills. In recent years, advocates for patient-determined medical care have pioneered more comprehensive medical orders that dictate what care the patient would want in various circumstances. These are developed in concert with the patient’s treating physician, who can provide necessary information about the likely progress of the patient’s illness and the benefits and likely side-effects of various treatments. Together they can develop a course of care while the patient is cognitively able and has the energy to make well-considered decisions. These are called Medical Orders for Life-Sustaining Treatment (MOLST) and have been legally authorized in a small number of states to date.
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