David Wang, MD
Palliative Medicine Specialist
Scripps

Planning ahead for end-of-life medical care can help bring some peace of mind during a crisis situation. The coronavirus pandemic has reminded us to be ready to have this conversation in case of a serious illness like COVID-19.

While most people who get COVID are able to recover at home, others might require intensive care and extended hospitalization. You don’t have to wait until you’re very sick to express your wishes for health care. In fact, it’s better to have these planning conversations before you have to go to a hospital, nursing home or other health care facility.

You can do this by using an advance directive, which allows you to specify medical treatment you want or don’t want if you become severely ill.

The COVID-19 pandemic has highlighted the importance of advance directives.

“Advance directives are important documents that protect a person’s health care wishes. They help individuals receive their desired medical care even when illness or injury prevents them from communicating,“ says David Wang, MD, a palliative medicine specialist at Scripps. “These documents guide your medical teams in knowing who speaks for you when you cannot speak for yourself.“

These legally recognized tools have been underutilized in the past. According to a 2017 study, only about a quarter of adults in the United States had recorded their end-oflife care wishes in advance directives or Physician Orders for Life-Sustaining Treatment (POLST) forms.

What is an advance directive?

An advance health care directive includes a patient’s wishes in case of a catastrophic medical event, such as from COVID. It has two parts: the individual health care instruction and power of attorney for health care.

What is individual health are instruction?

The individual health care instruction defines what should be done medically when a patient becomes too ill or injured to communicate. It explains the kind of interventions the patient would want or not want, such as being resuscitated or going on a ventilator, or instead allowing a natural death. People can cancel or change these documents at any time.

What is power of attorney for health care?

The power of attorney for health care allows patients to designate an agent to make medical decisions for them when they are unable. An agent may be an adult relative or a friend.

Agents must try to determine what the patient would have wanted if not specified in the individual health care instruction. Medical teams must follow the agent’s decisions unless a requested treatment would be ineffective or harmful.

Physician Orders for Life-Sustaining Treatment (POLST)

The POLST form is used in California and complements an advance directive. It converts a patient’s wishes regarding life-sustaining treatment into legal physician orders, which can be followed by emergency medical first responders.

The provider discusses options and preferences with the patient before the form is signed. The POLST becomes a tool to make these discussions part of the patient’s medical record. At the heart of these documents are the patient’s rights regarding autonomy in health care decisions.

While an advance directive may be used to show a patient’s preferences, it does not have to be followed if deemed to be ambiguous or not in the patient’s best interests. On the other hand, the POLST is a physician’s medical order. It remains with patients wherever they receive care and must be honored.

Patients 18 and older may obtain these forms from their physicians or health care system. Once completed, patients should record them in their medical files, and give copies to their agents and family members. Patients may change or cancel them, provided they can competently communicate their wishes.

“Both advance directives and POLST forms memorialize important decisions that arise from weighty conversations. What is even more important is then courageously sharing these wishes with your loved ones,” Dr. Wang says.

Additional assistance and resources are available at the National Hospice and Palliative Care Organization.

To Your Health is brought to you by the physicians and staff of Scripps. For more information, please visit www.scripsps.org

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