Documents in Advanced Health Directives, and Why They Are More Important Now Than Ever

Amidst an ongoing pandemic, you may have heard some well-meaning declarations urging you to make sure your health care documents are in order. However, there are many kinds of health care documents, and it can be difficult to know what you need and what gaps there may be in any documents you already have prepared. This article is not intended to serve as legal advice, but it may provide an overview of the available types of health care documents so that you are prepared to speak to an attorney about ensuring you have a plan in place that is comprehensive and accurately represents your wishes.

 

The first and most general document is the HIPAA waiver. The Health Insurance Portability and Accountability Act (HIPAA) sets national standards for the protection of personally identifiable health information. Because of this Act, doctors and other health care professionals are limited as to who they may share health information with, including family members of their patients. A HIPAA waiver authorizes doctors, hospitals, and long-term care facilities to disclose protected health information to certain individuals named in the document. A public health emergency does not mean HIPAA no longer applies; while certain jurisdictions have adjusted guidelines to allow doctors to communicate with those involved in the coordination of care, without a waiver in place, communication is not guaranteed. Executing a HIPAA waiver when competent makes clear who you want your doctors and other caretakers to speak to and give advice regarding your care. Without one, family and friends may be unable to receive information from doctors while you are being treated, which can add additional stress and uncertainty to a situation that is already stressful for your loved ones.

 

While many advanced health care directives include a section for HIPAA rights, if this is separated out into a stand-alone document, then not everyone who you may name in a HIPAA waiver needs to be or should be able to make health care decisions on your behalf. In that case, to give someone that power, you should execute a Health Care Power of Attorney (HCPOA). A power of attorney is a document that allows named people to act in your place. Many people are familiar with this kind of document as it relates to finances (authorizing someone to deal with your bank on your behalf, organize to have your bills paid, etc.), but it exists for your healthcare too. A HCPOA names someone who can legally make decisions about your care with health care providers. Depending on what powers you include, this document may authorize them to consent to (or refuse to consent to) your medical treatment, hire or fire medical personnel, make decisions about the best medical facilities for you, visit you when visiting is otherwise restricted, gain access to your medical records, and get court authorization if a hospital or doctor refuses to honor your own wishes or your authority as the authorized representative. A HCPOA does not automatically authorize someone to consent or refuse consent to organ donation, as the document’s authority terminates upon your death. However, in some states as in New Jersey, you may choose to draft the document in a way that covers authority over the disposition of your body. Additionally, you may even choose to have your healthcare representative make end-of-life decisions if you do not want to execute a Living Will (see more on that below) which shifts the responsibility over to one or more doctors. Therefore, the importance of this document is immense. Instead of only relying on doctors who you may have a limited or no relationship with, you can designate someone you trust to carry out your wishes regarding end of life if you are unable to. Although most states allow family members to step in as care coordinators (with an order of preference usually beginning with the spouse), a lack of this document can still be problematic and cause unnecessary tension and stress on the family in deciding the best course of action thereby taking precious time away from coping with your illness.

 

Complementing the two above documents, especially if you have particular intentions on end-of-life decisions, is the Living Will. The Living Will lays out specific directions about types of treatment you want or do not want should you go into a terminal state where there is no meaningful chance of your recovery. It can be as comprehensive or as limited as you want, depending on your preferences of different types of treatment. Typical procedures mentioned in a Living Will might be blood transfusions, CPR, dialysis, use of a respirator, surgery, or palliative care. Particularly amidst the continued spread of the COVID-19 pandemic and as people realize that they may not desire to be put on a respirator should they be hospitalized with this illness (where a number of people who need to be hospitalized end up on respirators), you should consider whether you want to revisit these preferences noted in this document. This is especially important when you may not have communicated your preferences to your HCPOA. Without a Living Will, the person making health care decisions on your behalf will have to guide those decisions. It’s a significant burden that you will be imposing on him or her so you should make thoughtful decisions. You should speak to both your elder care attorney and members of your family to decide the pros and cons of executing a Living Will, and if one should be included in your plan. Having this important discussion ahead of time will allow you to decide whether or not entrusting family with this decision is a good idea.

 

Finally, there is another document called the POLST or Practitioner Orders for Life Sustaining Treatment. Similar to a Living Will, this is also a directive for a specific method of care during the end of life stages; however, a POLST is typically executed somewhat later on than a Living Will might be. They are generally intended for patients who are at risk of a life-threatening clinical event or who may experience a life-threatening clinical event while already under facility care (thus, most facilities have long-term residents sign one upon entry). It is a form made legal with a signature from you (or your agent) and your doctor that is portable between different medical institutions like hospitals and nursing homes, or even to your home, without needing to be changed each time. Every state has its own form, but there is some reciprocity across states. POLST forms are often filled out by a nurse or social worker when someone is admitted to the hospital and the patient is at risk of significant deterioration; this is what makes them so important right now. In June 2020, ventilators have become vitally necessary for many patients suffering from severe cases of COVID-19. At-risk groups such as the elderly or those with underlying medical conditions have difficulty coming off a ventilator, and some people would rather die in dignity than spend weeks or months on a ventilator or other artificial life-extending device. However, if that person does not have proper documentation directing their health providers to follow their wishes—if they don’t tell a doctor or loved one that they don’t want a ventilator—the patient will be put on a ventilator if the situation arises and it is necessary to prolong life.

 

When we consider health care documents from these perspectives, it is clear that a lack of articulated intentions results in stress, confusion, and poor health outcomes (where a positive health outcome is measured by patient satisfaction with care as well as physical health). The creation of advanced health directives is an action taken to protect both yourself and your loved ones from unnecessary grief in the future. Planning for incapacity, no matter the source of the incapacity, is a vital part of any sound estate plan that is unfortunately sometimes overlooked until it is too late. The best thing you can do to prepare yourself and your loved ones is speak to a specialized estate planning attorney to implement your own advanced health directives. Rao Legal Group, LLC (“RLG”) is committed to providing comprehensive estate plans which always include advanced health care directives and financial powers of attorney to help you and your loved ones plan for incapacity. We are only a phone call away.

   
  1. 1. https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html
  2. 2. https://www.nolo.com/legal-encyclopedia/living-will-power-of-attorney-29595.html
  3. 3. https://www.nolo.com/legal-encyclopedia/living-will-power-attorney-medical-issues-29536.html
  4. 4. “Importance of POLST During the COVID-19 Pandemic” webinar given by Goals of Care Coalition of New Jersey