Advance Directives

Advance Directives Checklist
(Based on the American Medical Association’s Guidance Document: E-2.225, “Optimal Use of Orders Not-to-Intervene and Advance Directives)

Advance care planning can help a patient prepare for end-of-life care. A patient can make choices about the type of care he/she wishes to receive. This planning allows patients to have an acceptable last chapter in their lives. Advance directives should to be more readily available. There should also be better tracking of advance directives. In addition, a uniform approval of form documents that can be honored in all states of the United States is needed. The amount of poor end-of-life decisionmaking is a sign that several steps for improvement need to be taken. These are:

  1. Patients and doctors should use “advisory” and “statutory” documents. Advisory documents aim to correctly represent a patient’s wishes. They are legally binding. Statutory documents protect doctors from malpractice for following a patient’s wishes. Forms should be available that combine these two. If such a form is not available, an advisory document should be added to the state statutory form.
  2. Advisory documents should be based on approved worksheets. This will ensure that a patient’s choices for end-of-life treatment can be fairly and effectively obtained and recorded. It will also ensure that the wishes are relevant to medical decisions.
  3. Doctors should talk directly with the patient and the patient’s proxy about their wishes. These talks should be held before the patient is in the midst of a serious medical problem. This talk and the signing and recording of the document in the medical record should not be left to a junior member of the health care team.
  4. There should be a central place for all documents to be kept. This central area should contain completed advisory documents, state statutory documents and documents that list the patient’s proxy and primary physician. With this central area, documents can be found easily during emergencies and routinely.
  5. Doctor’s should use a range of orders on the Doctor’s Order Sheet to express the patient’s wishes. These orders should address treatments the patient prefers to avoid but which might otherwise be given in an emergency. This will assist other doctors who may not know all of the patient’s wishes. Health care facilities should honor these orders.

Below are orders a doctor may use to convey a patient’s wishes:

  • a Do Not Resuscitate (DNR) order
  • a Full Comfort Care Only (FCCO) order
  • Do Not Intubate (DNI) order
  • Do Not Defibrillate (DND) order
  • Do Not Leave Home (DNLH) order
  • Do Not Transfer (DNTransfer) order
  • No Intravenous Lines (NIL) order
  • No Blood Draws (NBD) order
  • No Feeding Tube (NFT) order
  • No Vital Signs (NVS) order

(One common new order, Do Not Treat (DNT), is not included in this list. It could wrongly convey the message that no care should be given. The patient could then lose the intense care due to a dying person. The FCCO order serves the same purpose without the likely confusion.)

As with DNR orders, all of these orders should be revisited often to make sure they continue to represent the patient’s wishes. Active comfort care orders might include Allow Visitors Extended Hours (AVEH) and Inquire About Comfort (IAC) b.i.d. (twice daily).

Last update: May 23, 2011