Medical Power of Attorney

[Kitiger, RN]

A relative has asked me to be his agent, giving me Durable Medical Power of Attorney. I am looking for a document that will help him specify what kind of care he would want. So far, the forms that I have found online simply leave a blank space to fill in. I need (he needs) something that makes it easier to write out what he wants.

This is what I've come up with on my own.

Ventilator, when recovery is expected (like surgery):	Yes	No
Ventilator, when recovery is not expected:	Yes	No
CPR:	Yes	No
ICU:	Yes	No
Hospice (comfort care) at home, if possible:	Yes	No
Feeding tube:	Yes	No
Cancer treatments for symptom control (for comfort)	Yes	No
Blood transfusions:	Yes	No

What other areas should I write in? His health is poor, with oxygen-dependent emphysema, diabetes, history of mild stroke, and at least one heart attack. He is roughly 80 years old. He's already told me no CPR or ventilator; I just want it in writing.

[MunoRN, RN]

Does your state use a POLST or MOLST?  Not every states uses the National standardized forms, but even those that don't I'm pretty sure use their own version.

[Kitiger, RN]

4 minutes ago, MunoRN said:

Does your state use a POLST or MOLST?  Not every state uses the National standardized forms, but even those that don't I'm pretty sure use their own version.

My state does participate in POLST. As I understand it, this is not the same as a living will or advance directive. I'll talk to him about POLST, but he would have to get his doctor to do it, correct?

[Kitiger, RN]

For now, I've changed it to this:

Advance Directive Preferences for ________________________________

 

Emergency Surgery (includes ventilator):__________________Yes           No

 

Elective Surgery (includes ventilator) ____________________ Yes            No

 

Ventilator any other time ________________________________ Yes              No

 

CPR: ______________________________________________________Yes              No

                                                                                                                       

Hospital:  _________________________________________________Yes            No

 

ICU: _______________________________________________________Yes           No

 

IV medications and antibiotics: ___________________________ Yes          No

 

Hospice , at home, if possible: _____________________________ Yes       No

 

Feeding tube: ______________________________________________ Yes           No

 

Cancer treatments for symptom control (for comfort)  ________ Yes          No

 

Blood transfusions: _____________________________________Yes         No

 

Full Treatments.

Treatment goal is to have done everything medically appropriate and possible to save your life.       Yes   No

     I’m okay with going to the hospital.

     I’m okay with going to intensive care unit.

     I'm OK with being intubated

     I’m okay with being on a ventilator.

     I’m okay with surgery, IV medicine, and antibiotics

Selective Treatments.

Treatment goal is to treat medical issues that can be reversed.     Yes      No

      I’m okay with going to the hospital.

      I do not want to be in the intensive care unit.

      I do not want to be intubated.

      I do not want to be on a ventilator.        

      I do not want surgery   OR   I do want surgery if needed to treat  medical issues that can be reversed. 

      I’m okay with IV medicine and antibiotics.

 

Comfort-focused.

Treatment goal is to maximize comfort and allow death to happen naturally.           Yes         No

     I do not want to go to the hospital.

     I do not want to be in the intensive care unit.

     I do not want to be intubated.

     I do not want to be on a ventilator.

     I do not want surgery or IV medications

 

 

What do you think? Am I making it too detailed? Or not enough?

[CalicoKitty, BSN, MSN, RN]

I'd probably change breathing machine to something about intubation. Breathing machine may (not sure) exclude CPAP/BiPAP.. 

And some people are fine with "trial periods" of more invasive procedures.

[Kitiger, RN]

Good point. He already has CPAP.

I was able to edit it to state whether or not intubation was OK.

[MunoRN, RN]

1 hour ago, Kitiger said:

My state does participate in POLST. As I understand it, this is not the same as a living will or advance directive. I'll talk to him about POLST, but he would have to get his doctor to do it, correct?

They're not the same, a POLST is far more useful than a living or advanced directives.  

Advanced directives / living will are really only useful in that they typically designated a medical POA, but the specific wishes are no more useful than if they had just communicated to the MPOA what they're wishes are.  Unlike a POLST, where the various medical interventions and level of treatment is discussed with the patient by a Provider, the attorney who fills out the advanced directives has no medical qualifications, so they aren't as directly actionable as if their wishes were documented with a POLST.

[Kitiger, RN]

1 hour ago, MunoRN said:

They're not the same, a POLST is far more useful than a living or advanced directives.  

Advanced directives / living will are really only useful in that they typically designated a medical POA, but the specific wishes are no more useful than if they had just communicated to the MPOA what they're wishes are.  Unlike a POLST, where the various medical interventions and level of treatment is discussed with the patient by a Provider, the attorney who fills out the advanced directives has no medical qualifications, so they aren't as directly actionable as if their wishes were documented with a POLST.

I ran into something like that years ago when my mom was in ER. The hospitalists were trying to convince her to let them sedate her so they could intubate her and put her on a vent. She knew she would never get off a vent and had been adamant that she didn't want a vent. But they kept at her, and the hospitalist told me that I had no say in the matter. I had Medical DPOA, but that was not in effect while she could speak for herself.  We got her pulmonologist's partner in, and he talked to her, and then wrote the orders to say DNR, no intubation, no vent, no more x-rays, etc., and he got her moved to the floor.

[MunoRN, RN]

34 minutes ago, Kitiger said:

I ran into something like that years ago when my mom was in ER. The hospitalists were trying to convince her to let them sedate her so they could intubate her and put her on a vent. She knew she would never get off a vent and had been adamant that she didn't want a vent. But they kept at her, and the hospitalist told me that I had no say in the matter. I had Medical DPOA, but that was not in effect while she could speak for herself.  We got her pulmonologist's partner in, and he talked to her, and then wrote the orders to say DNR, no intubation, no vent, no more x-rays, etc., and he got her moved to the floor.

That's unfortunately not common in the ER.  I worked with one ER doc once that would aggressively ask the patient "do you want to die?" when they told the doc they were DNR or DNI.  Which is of course a loaded question, most people don't want to die so they'd answer, "well, no" which the Doc would take as consent to intubate them, whether they liked it or not.

The nice thing about a POLST is that it's a Physician's durable order, as nurse it's a lot easier to fight off a doctor that's too eager to intubate a DNI patient when there's a POLST on your side.