Planning Ahead


Modern surgery is remarkably safe and getting safer all the time. Still, complications can happen, even in so-called “minor” operations, while accidents and emergencies can put a person in the hospital when they least expect it.

In the worst-case scenario, an accident or complication can leave a person unable to communicate about his or her care. For that reason, it is incredibly important that patients communicate their wishes ahead of time, to make sure that if they are unable to direct their care, their family or another designated decision maker can know what they would want.

How to Plan Your Advance Directive

An advance directive is the plan that patients put in place to answer questions that their care providers will face if the patient is not able to participate in his or her care (for example, if the patient is put on a breathing machine or had a stroke and can’t communicate). There are some specific parts to an advance directive plan:

Decide who will make decisions for you: If you are not able to make medical decisions for yourself, someone will have to do it for you. Without someone to tell them not to, your doctors are obligated to assume that you would want everything done to prolong your life. But many patients prefer another approach – for example, many patients say that if they would be unconscious on a ventilator for the rest of their lives, they would prefer to have their care focused on their comfort rather than on making them live as long as possible.

If patients don’t have a specific person appointed as their Medical Power of Attorney (MPOA), their medical team will look to their legal next of kin to make those decisions. Generally, the legal next of kin are determined in order with the patient’s spouse being the first person to make decisions, followed by adult children if there is no spouse, then parents if there are no adult children, and on down the line. This system can work well if a patient and his or her spouse have talked about what the patient would want. But it can also break down, with children disagreeing about what the patient would want, or distant relatives being called upon to make decisions for someone they hardly know.

A MPOA takes precedence over the legal next of kin and is charged with deciding what the patient would want if the patient is unable to speak. You can appoint a MPOA with help from an attorney or a hospital social worker.

Write down what care you would like to have: Your MPOA can make decisions for you, but the best way to be sure this person knows what you want is to have a document that outlines your decisions about medical care. These documents are often known as “living wills,” and they spell out whether you would want or not want specific treatments. For example, a living will can say whether you would want to be on a breathing machine for a long time, whether you would want to have a tube placed for feeding if you couldn’t eat for yourself, whether you would want to be an organ donor, and any number of other conditions.

A living will can provide guidelines for your care, but it’s incredibly important to discuss your wishes with your MPOA because the document cannot cover every possible event or decision.  Also, give your MPOA a copy of the living will so he or she will be able to be your representative when needed. Living wills are legal documents you can create with help from an attorney or hospital social worker.

Decide whether you would like to have a breathing tube inserted or have CPR performed: Some people, particularly those with chronic or serious medical conditions, decide that in the event of serious illness or complications they don’t want to have a breathing tube and/or CPR. These are known as “code status” requests, and patients can request that they be “Do Not Resuscitate” or DNR, and/or “Do Not Intubate” or DNI.

Code status is like a sort of mini-living will, covering only the most extreme measures taken to care for patients with serious medical problems. Code status is something that you can talk to your care team about before coming in to the hospital, and which your team can note in your chart or medical record. Of course, many operations require a breathing tube be placed temporarily, so DNR/DNI orders are often suspended temporarily during an operation.

Make Your Wishes Known

Your MPOA, living will, and code status are only useful if your care team knows they exist. Be sure to give your surgical team contact information for your MPOA and a copy of your living will, and bring copies with you to the hospital. Tell your friends and family where to find those documents quickly in case you’re ever in an accident.

Reach Out to Resources for Help

Making a plan for a worst-case scenario can be difficult and scary. But there are plenty of people available to help.

Your healthcare team: Talk to your primary care provider and your surgical team to let them know your wishes and to figure out the best way to make sure that your MPOA is involved in your care and available to your healthcare providers. Remember that just telling your doctors what kind of care you want is not enough to ensure that your wishes are carried out if you are incapacitated, though. It’s vital to have an MPOA who can be your advocate.

Palliative care services: Patients with life-threatening conditions often benefit from a consultation with a palliative care specialist. These doctors and nurses can help patients make plans about advance directives and end-of-life care, and can help speak with family members and MPOAs to be sure that everyone is on the same page. Ask your healthcare team to involve palliative care specialists in your care if you feel they would be helpful.

Social workers: Hospital social workers are skilled at getting the appropriate paperwork together to make sure that your advance directives are properly put together.

Attorneys: MPOA and living will documents are generally drawn up by a lawyer. Consider including a MPOA and living will any time you draft or review a will. Lawyers can also store these documents for you so that they are reliably accessible to your MPOA if the need arises.


More Resources

Here are some good web resources for thinking about, planning, and implementing advance directives:

Living Wills and Advance Directives for Medical DecisionsThis story originally appeared in the  Health Dialog Care Compass Blog.

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