Advanced Directives

ADVANCED DIRECTIVE
The Safety Net for Tough Healthcare Decisions
For LTC and RCFE Administrators

The purpose of this course is to help students
understand the concept and importance of Advanced
Directives and know the myths associated with the
document.
Course Description

What is an Advance Directive?
An Advance Directive tells the doctor what kind of care
you would like if you become unable to make important
medical decisions for yourself. A situation that could
warrant this is a coma.

Advanced Directive
• An adequate advance directive describes the type
of treatment you would want depending on how sick
you are. The directives may describe what kind of
care you want if you have an illness that you are
unlikely to recover from, or if you are permanently
unconscious.
• Advance directives usually communicate to your
doctor that you don’t want certain kinds of
treatment. They can also state that you want a
certain treatment no matter how ill you are.

What it Means to the Physician?
• As just previously stated, the advance directive tells
the doctor what your wishes are should an illness or
other emergency emerges in your life.
• By following your advance directive, the doctor can
make decisions for your healthcare without
overstepping boundaries and infringing on your
patient rights.

What it Means to Patients &
Families
• Patients with advance directives are able to shield
themselves from unwanted medical procedures.
Their wishes are well defined and legalized to
prevent a family or Physician from interfering with
unwanted care decisions (typically end of life
issues). Therefore, an advance directive adds
dignity and meaningfulness to a patient’s plan of
care.
• Families of patients, are less burdened when a
advance directive is in place. They no longer have
to make difficult healthcare decisions for a loved
one.

Types of Advance Directives
There are various types of Advance Directives. We will
discuss 5 forms of advance directives: (1) PIC form
(Preferred Intensity of Care form), (2) Advanced
Healthcare Directive, (3) General Power of Attorney, (4)
Living Will, and (5) Do Not Resuscitate order. All play
different roles in the arena of Healthcare.

The PIC
(Preferred Intensity of Care Form)
This form is widely seen in Skilled Nursing Facilities and
other medical institutions. The PIC form is used to
communicate to the Physician and Nursing staff a
Patient’s wishes regarding CPR, Tube feeding, IV
usage, Comfort Care and other Nursing measures
should they be required. The form is not intended to be
a permanent record and may be changed at any time,
as many times as the Patient desires.

The PIC
(Preferred Intensity of Care Form)
The form is referred to in the event of a medical
emergency. A typical use for this form can be described
in this scenario:
Mrs. Smith is a resident of a Skilled Nursing Facility.
The medication nurse walks into her room and finds her
non-responsive. She reports this to the charge nurse
who then reviews the PIC form. It reads “Full Code”
meaning CPR must be done. Nursing staff proceeds
with CPR and calls 911 for emergency transport to the
acute Hospital.

Advanced Directives
We should address the term “Full Code” at this point.
Full code simply means that a patient wants everything
done in the event of an emergency. This includes CPR,
transferring to hospital, tube feeding, I.V.s, etc…

The Advanced Healthcare Directive
• The Advanced Healthcare Directive (AHCD) is also
known in the healthcare industry as a Durable
Power of Attorney for Healthcare (DPAHC). This
document states whom you have chosen to make
health care decisions for you.
• It becomes active any time you are unconscious or
unable to make medical decisions.

The Advanced Healthcare Directive
The AHCD form also contains special circumstances
such as options for DNR, life sustaining treatment and
limitations on what the appointed healthcare agent can
decide on for you.
Two things to keep in mind regarding the AHCD:
1. The AHCD may not be a good choice if you
don’t have another person you can trust to
make healthcare decisions for you.
2. The AHCD ONLY becomes effective only
when you lose capacity to make decisions.

General Power of Attorney
• This document is used for financial purposes. It
appoints an agent to gain needed access to bank
accounts and other financial documents. The POA
can also write checks and pay bills on behalf of the
patient.
• In a healthcare setting, this form is often confused
with the AHCD (Advance Healthcare Directive). All
should keep in mind that the POA is for
FINANCIANAL while the AHCD is for
HEALTHCARE.

The Living Will
• A living will is a written legal document, that
describes the kind of medical treatments or life-
sustaining measures you would want if you were
seriously or terminally ill.
• The main difference between the Living Will and the
AHCD is that the Living Will doesn’t let you select
someone to make decisions for you.

The Do Not Resuscitate Order
(DNR)
• The DNR is a form requesting not to have
cardiopulmonary resuscitation (CPR), if your heart
stops or if you stop breathing.
• Unless other instructions are given, the medical
staff will try to help all patients whose heart has
stopped or who have stopped breathing. Therefore,
this document is vital to protecting your medical
treatment wishes.

The Do Not Resuscitate Order
(DNR)
In most cases, the AHCD states a patient’s wishes
regarding CPR. In this case, the DNR order is placed in
your medical chart by your doctor. A DNR order often
accompanies the AHCD.

When Should One Have an
Advanced Directive?
• By creating an advance directive, you are making
your wishes about medical care known before
you’re faced with a serious injury or illness. This will
spare your loved ones the stress of making
decisions about your care while you are
incapacitated.
• Any person 18 years of age or older can prepare an
advance directive.

Advanced Directive?
• People who are seriously or terminally ill are more
likely to have an advance directive. Someone with
terminal cancer might write that she does not want
to be put on a respirator if she stops breathing. This
action can reduce her suffering, increase her peace
of mind and increase her control over her death.
• Even if you are in good health, you may want to
consider writing an advance directive. An accident
or serious illness can happen suddenly, and if you
have an AHCD, your wishes are likely to be
followed.

Advanced Directive?
REMEMBER:
You can only form an advance directive during the time
you have capacity. The document only becomes
effective when you lose capacity to make decisions.
Individuals who do not have capacity are legally unable
to form an AHCD with their signature.

Preparing the Advanced Directive
Advance directives do not have to be complicated legal
documents. They can be short, simple statements about
what you want done or not done if your incapacitated.

Advance directives can be prepared in several ways:
1. Use a form provided by your doctor.
2. Write your wishes down yourself generically.
3. Call your health department or state
department on aging to get a form (i.e.
Ombudsman).
4. Call a lawyer.
5. Use a computer software package for legal
documents.

• If you use computer software, it’s important to follow
your state’s guidelines on preparing an AHCD.
Legalizing the Advance Directive
• Advance directives can be legalized in various ways
and often this depends on the type of institution it is
developed in.

Patients in a LTC facility wishing to form an AHCD, only
the Ombudsman can legalize the document. Individuals
outside of a LTC facility, the AHCD must be notarized
and witnessed by two people other than the primary and
secondary designated decision makers. All other
advance directives must be notarized as well, whether it
be a living will, DNR order or general power of attorney.

Can One Change His or Her
Advanced Directive?
• You may change or cancel an advance directive at
any time, as long as you’re considered of sound
mind to do so. If an individual lacks capacity, the
advance directive cannot be changed and current
wishes must be carried out.
• When changes are made they must be signed and
notarized according to the laws in your state. It’s
also important to let your doctor and family know of
any changes.

When it’s Too Late to Form an
Advanced Directive
We must remember, that the individual creating the
advance directive must be able to decide on a primary
as well as a secondary decision maker. Since,
individuals who lack capacity cannot legally make
decisions any advance directive created by them would
be null and void.

The Alternative Option –
Conservatorship
• For families and friends wishing to obtain an
advance directive pertaining to an incapacitated
individual, the only option is Conservatorship.
• In most cases, a family or close friend can petition
to the court for Conservatorship. If approved, a court
representative will have to personally serve the
incapacitated individual with Conservatorship
papers.
• Conservators are responsible for all health and
financial aspects of the client. Conservators are also
known as “Legal Guardians.”

10 Myths About
Advanced Directives Unveiled
This section addresses popular legal myths regarding
advance directives. It is meant to answer the most
common questions among the elderly and their families.

10 Myths About
Myth #1
Everyone should have a Living Will.
• A living will is not the document most people need.
As an ultimate goal, most people should have an
Advanced Health Care Directive (AHCD) that
names a trusted person as agent.
• The reason for the primary importance of the
agent is simple. Most standardized living will forms
are quite limited in what they can accomplish and
what conditions they cover.

10 Myths About
• For example, most living wills provide instructions
that apply only if the individual is in a terminal
condition or permanently unconscious, yet the
majority of health care decisions that need to be
made for patients lacking capacity concern
questions about day-to-day care, placement options
and treatment options short of “pulling the plug.”
• One caveat: If there is no one close to the individual
whom he or she trust to act as the health agent, then
the AHCD should not be used. In this case, the living
will is safer, despite its limitations.

10 Myths About
Myth #2
Written Advance Directives Are Not Legal in
Every State.
• Every state recognizes both the agent and living
will type advance directives, although the laws of
each state vary considerably in terminology, the
scope of decision making addressed, restrictions
and the formalities required for making an advance
directive should be the same.

10 Myths About
• A more frequent question raised is whether an
advance directive written in one state will be
recognized in other states. In other words, is the
directive portable across state lines. Many states
expressly recognize out-of-state advance directives
if the directive meets either the legal requirements of
the state where executed or the state where the
treatment decision arises.

10 Myths About
Myth #3
Just telling my doctor what I want is no longer
legally effective.
• While it is better to have a written advance
directive, oral statements remain important both
on their own and as supplements to written
directives.
• Although oral statements may not have the same
legal status as written directives, there are two
important attributes:

10 Myths About
• First, good health care decision making requires
adequate communication among all interested
parties, and oral communication is our most natural
and primary code of communication.
• Second, oral statements constitute important
evidence of one’s wishes and help expand upon,
clarify and reinforce individual preferences.

10 Myths About
Myth #4
An Advance Directive means “Don’t treat”.
• While it is true that most people use advance
directives to avoid being kept alive against their
wishes when death is eminent, it is a mistake to
assume that the existence of an advance directive
means, “Don’t treat”.
• Advance directives are also used to say that the
individual wants all possible treatments within the
range of generally accepted medical standards.

10 Myths About
What is said depends upon one’s particular wishes and
values. Even when an advance directive declines all
life-sustaining treatments, one should always assume
(and insist upon) continuing pain control, comfort care
and respect for one’s dignity.

10 Myths About
Myth #5
When I name an agent in my Advance
Directive,
I give up some control and flexibility.
• An individual gives up no authority or choice by
forming an advance directive. As long as the
patient remains able to make decisions, his or her
consent must be obtained for medical treatment.
• Health care providers cannot legally ignore the
patient in favor of one’s agent or written
instruction.

10 Myths About
There are situations in which a competent patient
abdicates decision making by stating, for example, “Do
whatever my daughter thinks is best”. However, this
form of delegation is effective only from moment to
moment and needs to be rechecked at every significant
decision point. Neither the agent nor a written
instruction can override one’s currently expressed
choice.

10 Myths About
Myth #6
I must use a prescribed Advance Directive form
for my state.
• In most states, you do not have to use a specific
form. About 37 state statutes include forms for
appointing agents or for creating comprehensive
advance directives. In about 18 states, the forms
must be “substantially followed” or certain
information disclosure language must be included
in the form.

10 Myths About
• Any form can and should be personalized to reflect
the individual’s particular values, priorities, and
wishes. If you do not agree with language contained
in an approved form, change the language.
• Above all, it is a mistake to pick up an “official” form
and just sign it unchanged, without first being sure
that it truly reflects one’s specific wishes.

10 Myths About
Myth #7
I need a lawyer to do an Advance Directive.
• No, a lawyer is not needed. Yes, a lawyer is a
helpful resource, but not the only resource, nor
necessarily the best resource for all persons.
Advance directives are not difficult to complete,
but they require a few steps to do well.

10 Myths About
Myth #8
Doctors and other health care providers are not
legally obligated to follow any Advance
Directive.
• It is clear that medical providers cannot treat an
individual against his or her wishes.

10 Myths About
• Consequently, if a physician acts contrary to a
patient’s instruction directive or decision of the
patient’s authorized agent, the physician risks the
same liability he or she would face if the physician
were to ignore a refusal of treatment by a fully
competent patient. Treatment would constitute a
battery.
• There are a few factors that can complicate this
situation:

10 Myths About
• First, the doctor or health facility sometimes are not
aware of the existence of an advance directive. At
times, other medical institutions may not forward
copies of advance directives to the appropriate
record.
• Second, people often do not express their wishes
very clearly or precisely in advance directives.
Therefore, interpretation problems may arise.

10 Myths About
• Third, in most states, if a physician or facility
objects to an advance directive based on reasons of
conscience, state law permits the physician or
facility to refuse to honor it. Facilities must notify the
patient of their policies regarding advance directives
at the time of admission. If a refusal occurs, the
physician and facility should provide assistance in
transferring the patient to a provider that will comply
with the directive.

10 Myths About
• Fourth, the person who is dying, but living in the
community, may face problems in having an
advance directive followed if a crises occurs and
emergency medical services are called (i.e. “911”).
EMS personnel are generally required to resuscitate
and stabilize patients until they are brought safely to
a hospital.

10 Myths About
Myth #9
If I do not have an Advance Directive, I can
rely
on my family to make my health care decisions
when I am unable to make decisions for myself.
• If an individual does not have an advance directive
naming a health decisions agent, several states
expressly designate default “surrogates,” typically
family members in order of kinship, to make some
or all health care decisions.

10 Myths About
• Even without such statutes, most doctors and health
facilities rely on family involvement in decision
making, as long as there are close family members
available and there is no disagreement.
• Problems can arise because family members may
not know what the patient would want in a given
situation, or they may disagree with one another
about the best course of action.

10 Myths About
Myth #10
Advance Directives are a legal tool for old
people.
• One should never think of this as an “old” people’s
issue. It may be natural to link death and dying
issues with old age, but that is a mistake when it
comes to advance directives.
• Consider that stakes are actually higher for
younger persons in that, if tragedy strikes, they
might be kept alive for decades in a condition they
would not want. An advance directive is an
important tool for all.

Advanced Directives
What follows are question and answer discussions
designed to help students prepare for the final exam:

Advanced Directives
1. The PIC form is a temporary record which may be
changed:
A. True
B. False
True. PIC forms are never set in stone and everyone
or their applicable representative has a right to change
the contents whenever he or she feels it’s necessary.
Remember, PIC forms are different from the “legalized”
Advance Health Care Directive and Living Wills.

Advanced Directives
2. The General Power of Attorney covers financial as
well as medical issues.
A. True
B. False
False. The General Power of Attorney is not designed
to address medical issues. For Healthcare, the
Advance Healthcare Directive must be obtained.

Advanced Directives
3. The term “full code” means:
A. Comfort care
B. All efforts exhausted to save a patient
C. No CPR status
D. CPR only
B. If one chooses full code, he or she is requesting
CPR, Tube Feeding, IV’s, “the whole enchilada.”

Advanced Directives
4. Changing an Advance Directive:
A. Is never possible.
B. Is possible assuming the patient is of
sound mind.
C. Can only be done by a lawyer.
D. Requires court appearances.
B. The patient and only the patient can change an
advance directive, but for this to be a valid change,
there must be a physician's order stating “has capacity”.

Advanced Directives
5. The best time to form an Advance Directive is:
A. When one develops a terminal disease
B. When one enters a Nursing Facility for LTC
C. As soon as one is legally able to do so
D. When a family is in dispute over future
healthcare decisions
C. Advance Directives can be done by individuals as
young as 18. Never wait for a dispute among family or
the development of a terminal disease.

Advanced Directives
6. Without specific instructions, medical staff are trained
to resuscitate any individual who stops breathing.
A. True
B. False
True. Medical staff must by law assume that a patient
is full code unless otherwise specified. Another reason
why an Advance Directive is so important.

Advanced Directives
7. Written Advance Directives are not legal in every
state.
A. True
B. False
False. An Advance Directive written in one State will
be honored by another State. Creating a new Advance
Directive is not necessary.

Advanced Directives
8. When forming an Advance Directive, one should
always:
A. Consult an Attorney.
B. Check with applicable State laws.
C. Name a decision maker who can be trusted.
D. Both B & C
D. Some States regulate the Advance Directive
document differently than others. A trusted decision
maker is essential, this is usually a family member, a
close friend may also qualify.

Advanced Directives
9. Death and Dying should always be linked to old age:
A. True
B. False
False. Death and Dying is a broad concept and covers
any age group including infants, young adults and the
elderly. Another reason why the Advance Directive
should be formed as soon as possible.

Advanced Directives
10. In most States, if a Physician or facility refuses to honor
an Advance Directive based on “conscience,” State law
permits this is:
A. The policy is stated at time of admission.
B. The patient is in agreement.
C. The Physician or facility redo the Advance
Directive with the patient and/or family.
D. State laws never permit this, all must follow
the Advance Directive as written.
A. The facility must note this in their admission agreement,
otherwise they must always default to the patient’s
Advance Directive.

Quiz
You’re Done!!!
To successfully complete this course, please take the
following final examination.
You must pass with a 70% or better to receive your
certificate of completion and granted CEU.

Advanced Directives

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