Advanced care planning is a proactive process that prepares individuals for future medical decisions, especially when they may be too ill or incapacitated to communicate their wishes. Modern medicine can prolong life even when quality of life is diminished, making planning ahead necessary to ensure care aligns with personal values and goals. This preparation reduces the burden on family members who might otherwise face the emotional difficulty of making complex medical choices without guidance in a moment of crisis.
Understanding Advanced Care Planning
Advanced Care Planning (ACP) is a dynamic process of communication and reflection on personal values and preferences for future healthcare. This process involves discussions with family, loved ones, and healthcare providers to clarify what an acceptable quality of life looks like to the individual. The goal is to establish a framework for care that respects the patient’s autonomy, even when they cannot speak for themselves. This planning is relevant for every adult, regardless of their current age or health status, because unexpected illness or injury can occur at any time.
The process centers on defining the patient’s goals of care, which might shift as their health condition changes over time. Regular, brief conversations are more effective than a single, one-time discussion about potential end-of-life scenarios. By educating family members and surrogate decision-makers, ACP aims to ensure that clinical care remains consistent with the patient’s expressed wishes and preferences.
Essential Legal Documents Formalizing Care
The wishes clarified through the ACP process are formalized using specific legal instruments, known as advance directives, that only take effect if the patient loses the capacity to make or communicate decisions. The two main documents are the Durable Power of Attorney for Healthcare (DPOAHC) and the Living Will. A DPOAHC, sometimes called a Health Care Proxy or Agent, designates a specific person to make medical decisions on the patient’s behalf. This document has broader authority because the appointed agent can interpret wishes in unforeseen medical situations.
The Living Will, on the other hand, is an instruction directive that explicitly outlines the patient’s preferences regarding specific life-prolonging treatments, often focusing on end-of-life care. It provides a written statement detailing which medical treatments the patient would want or want to avoid under certain conditions, such as a terminal illness or a persistent vegetative state. While a Living Will provides specific instructions, the DPOAHC appoints a person to act as an advocate when those instructions may not perfectly fit the current medical reality.
A different, more actionable type of document exists for those who are already seriously ill or frail: the Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). Unlike a Living Will, which is a legal document, a POLST is a portable medical order signed by a healthcare professional and the patient, or their representative. Because it functions as a medical order, emergency medical services (EMS) personnel are legally bound to follow the instructions on a POLST form immediately, such as a Do Not Resuscitate (DNR) order.
Specific Medical Interventions Covered
The practical decisions addressed within advance care documents typically revolve around life-sustaining treatments that may offer limited benefit or severely compromise a patient’s goals for quality of life. One of the most common interventions is Cardiopulmonary Resuscitation (CPR), which attempts to restart the heart and breathing when they stop. Mechanical ventilation, commonly known as life support, is another decision point, as it involves a machine breathing for the patient and requires intubation. These documents clarify whether a patient wishes to receive these treatments, especially if there is little chance of a meaningful recovery.
Artificial nutrition and hydration, often delivered through a feeding tube, also require specific instruction within the planning documents. The patient must decide if they wish to receive these measures if they are unable to eat or drink naturally due to their condition. Furthermore, the plan should address the use of more aggressive interventions, such as chemotherapy, dialysis, or antibiotics, versus focusing on palliative care, which prioritizes comfort and symptom management. A distinction is made between withholding a treatment, meaning never starting it, and withdrawing a treatment, meaning stopping an intervention that has already begun.
Selecting and Empowering a Healthcare Agent
The selection of a Healthcare Agent, Proxy, or Surrogate is central to advanced care planning, as this person is empowered to make decisions when the patient lacks capacity. The chosen individual should be someone the patient trusts completely, who understands their values, and who is willing to follow the patient’s known wishes even if they personally disagree. The agent’s authority becomes active only when a physician determines the patient is unable to make or communicate their own medical decisions, providing a clear boundary for when control is transferred.
The agent’s primary duty is to exercise “substituted judgment,” meaning they must strive to make choices that the patient would have made if they were still able to speak. This requires the agent to consider the patient’s past conversations, religious beliefs, lifestyle, and written instructions to advocate for their known preferences. The agent has the legal authority to access all private health records necessary to make informed decisions. By using substituted judgment, the agent ensures the patient’s autonomy and dignity are maintained during complex medical situations, acting as a faithful representative rather than an independent decision-maker.