An “advance directive” is a legal document that can speak for patients when they are too ill to speak for themselves. By executing an advance directive, you are making your end-of-life wishes known at a time when you can still articulate them. The goal of any advance directive is to define which medical procedures and interventions you would consent to in the event your life depended on them.
Defining Your Goal
The main goal for any advance directive is to define the patient’s personal goals for critical care (care that could extend life if given or end life if withheld). Your goals may change as your disease progresses or regresses. For instance, if you are diagnosed with heart failure, your goals for an advance directive may be different in the early stages than they are as the disease progresses to a terminal stage.
While still practical and desirable, drugs, medical helps and medical devices have the ability to extend life. But there may come a time when quality of life is such that you no longer desire assistive medical helps to extend your life. In the case of heart failure, for instance, this means you will want to specify in your advance directive when to attempt extreme measures (such as defibrillation to restart your heart) and when to move to palliative (hospice) care or case from resuscitation attempts.
Communicating Your Wishes
Many patients today desire to spend their last days in their own home with their loved ones. This too should be addressed in your advance directive. For example, you can specify in your advance directive that you wish your doctor to execute and sign a DNLH order (Do Not Leave Home order) which will prevent family or medical technicians from calling an ambulance or admitting you to the emergency room.
When an Advance Directive is Enforceable
An advance directive is designed for patients designated as terminal who cannot speak on their own behalf. If you are temporarily incapacitated but your prognosis is full recovery, your advance directive would not apply.
Defining the Care You Want
There are different levels of what is called “comfort” or palliative care for terminally ill (end-of-life) patients. Your advance directive should specify which types of care you do want – if any. Here is a list of care options you can specify in your advance directive:
- Pain management.
- Nausea medication.
- Prevention and/or treatment for bedsores.
- Psychological and/or spiritual care (patient, loved ones).
- Palliative care (designed to ease suffering).
- Skin care (including application of body lotion).
- Mouth and eye care (including use of lubricating swabs and moisture drops).
- Open visiting hours for loved ones.
- Stiffness care (massage, gentle physical therapy).
- Specific music requests.
- Specific arrangements to donate organs and/or your body after you pass.
- Specific arrangements for an autopsy after you pass.
Physician-initiated Orders
A handful of requests must be authorized by your treating physician to be honored. Here, as with all parts of an advance directive, it is important to revisit your instructions with your treating doctor every so often to ensure they still reflect your personal wishes.These include the following:
- DNR (Do Not Resuscitate) / AND (Allow Natural Death)./li>
- AVEH (Allow Visitors Extended Hours)./li>
- IAC b.i.d. (Inquire About Comfort twice daily)./li>
- FCCO (Full Comfort Care Only).
- DNI (Do Not Intubate).
- DND (Do Not Defibrillate).
- DNTransfer (Do Not Transfer).
- IAC (Inquire About Comfort).
- NIL (No Intravenous Lines).
- NBD (No Blood Draws).
- NFT (No Feeding Tube).
- NVS (No Vital Signs).
Write Down What You Want
Your advance directive will serve as a guide for your selected advocate, your treating physician and your loved ones to give you only the care you desire should you become incapacitated with a terminal prognosis.
Additional Optional Therapies
These therapies should also be considered for inclusion in your advance directive.
- Antibiotics. Treatment for UTI infections, bedsores, aspiration pneumonia and similar.
- Artificial nutrition. Use of tube-fed nutrition via throat/intestines/vein.
- Chemical code. Permits drug use but not CPR to resuscitate.
- Oxygen mask. Continuous positive airway pressure/Bilevel positive airway pressure (CPAP/BiPAP).
- CPR. Mouth-to-mouth resuscitation.
- Defibrillator/pacemaker. Artificial heartbeat regulation.
- Dialysis. Blood purification via machine.
- DNR. Instructions not to perform cardiopulmonary resuscitation if heart or breathing stops.
- IV fluids. Intravenous fluid delivery.
- TPN. Total parenteral nutrition/hyperalimentation delivers nutrition via needle or catheter.
- Transfusions. Blood, plasma, other products.
- Ventilator. Use of a breathing machine.
