Home healthcare clinicians are in an optimal position to help older adults and their caregivers understand and utilize advance directives. However, in order to effectively guide patients through the process, home healthcare clinicians need to be well versed on the subject. Some of the positive effects of advance care planning include the reduction of hospitalization (or shortened hospital stays) and increased use of hospice and/or palliative care due to do not resuscitate and do not hospitalize orders (Brinkman-Stoppelenburg et al., 2014). With an advance directive, a patient's comfort and wishes are more likely to be honored (thus reducing stress and invasive procedures) rather than simply prolonging life at any cost (Brinkman-Stoppelenburg et al.). Additionally, advance directives can improve communication between providers, caregivers, and patients, and significantly reduce healthcare costs by efficiently enforcing the wishes of the individual (Woollen & Bakken, 2016).
Despite the benefits of advance directives, they are frequently not completed due to lack of patient awareness/understanding of them or because of the discomfort of providers in discussing end-of-life care (Woollen & Bakken, 2016). This discomfort may be due to providers' lack of necessary training, not realizing that advance directives are not just for those who are terminally ill, fear of creating patient/caregiver anxiety, or not being reimbursed, or having time to discuss advance directives (Woollen & Bakken). Both patients and clinicians wait for the other party to bring the topic up, leaving this important subject largely undiscussed (Woollen & Bakken). It is important for home healthcare clinicians to initiate a conversation regarding advance directives. Some of the most important end-of-life goals to be addressed during the process of drafting the advance directives are: pain and symptom management, preparation for death, achieving a sense of completion, deciding on treatment preferences, and being treated as a whole person (Benson & Aldrich, 2012).
An advance directive is a general term used to describe living wills and medical powers of attorney (also known as a surrogate/proxy or durable power of attorney) (American Geriatrics Society [AGS], 2015). Living wills help to ensure the patient's wishes are followed regarding using, withholding, or withdrawing life-sustaining treatment when the patient no longer has the ability to make their own decisions (Benson & Aldrich, 2012). Patients and clinicians can visit the National Hospice and Palliative Care Organization Web site at http://www.nhpco.org to obtain the necessary forms to document a living will (AGS, 2015). Although patients do not need lawyers to create an advance directive, they are welcome to utilize one (AGS, 2015).
The medical power of attorney is a person of the patient's choosing who is designated to make healthcare decisions for the patient when they are no longer able to do so on their own (Benson & Aldrich, 2012). Although the living will states the types of treatments a patient does or does not want, the durable power of attorney will have the ability to make decisions beyond the document. Thus, the living will serves as a basic guide for the medical power of attorney to ensure they are honoring the patient's wishes regarding their healthcare (Benson & Aldrich). The goals of a medical power of attorney are to help the person think about planning for future medical decisions; learn the values and goals of the person; and discuss the values of the patient and general treatment preferences with caregivers and providers (AGS, 2016).
A patient can identify a medical power of attorney by writing the name in a living will, or by completing a Durable Power of Attorney for Health Care form that assigns a proxy, which is recognized in all states (AGS, 2016). State living will documents can be downloaded at: http://www.caringinfo.org.
In addition to documenting their wishes in the living will, it is critical that patients have honest and open conversations with their medical power of attorney and healthcare providers regarding their wishes (Benson & Aldrich, 2012). Some issues that should be included in these discussions include (AGS, 2016):
* what illness or permanent disability would be unacceptable to the patient?
* would the patient want medical treatments to prolong life, or just medicines to stay comfortable?
* what should the medical power of attorney think about regarding medical treatments: is comfort important? Is being conscious important? Is being in control important?
* what medical treatments would the patient absolutely not want, be they temporary or permanent?
* what treatments are acceptable on a temporary basis, but not a permanent one?
One method to create an understandable advance directive is an infovisual, where instead of just using written words to communicate a patient's wishes, other means of communication, such as images or videos, are also included with text to more clearly communicate the patient's wishes. This added visualization has been shown to improve patient comprehension, recall, and interest, and causes deeper and better understanding of medication information (Woollen & Bakken, 2016).
Once the living will is documented, it is important that a copy of the advance directive be distributed to healthcare providers, including the home healthcare agency and the local hospital (AGS, 2015). Home healthcare providers may also suggest that the patient carry advance directive information in their wallet. Patients should review their advance directive on a regular basis to ensure it is still aligned with their beliefs and wishes, and update it accordingly (AGS, 2015 ; See Box 1 for resources related to advance directives).
Box 1. Resources
The Centers for Disease Control and Prevention (CDC) offers an advance care planning training course to help those who need more information regarding advance directives to be trained appropriately: http://www.cdc.gov
Advance Care Planning & Advance Directives: http://www.healthinaging.org/public_education/pef/advance_directives.pdf
Advance Care Planning Conversation Guide: http://www.coalitionccc.org/_pdf/Conversation_Guide.pdf
Advance Care Planning: An Introduction for Public Health and Aging Services Professionals, CDC: https://www.cdc.gov/aging/advancecareplanning/care-planning-course.htm
Giving Someone a Power of Attorney for Your Health Care: A Guide with an Easy-to-Use, Legal Form for All Adults: http://www.americanbar.org/content/dam/aba/uncategorized/2011/2011_aging_hcdec_u)
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