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End of Life Decisions

My mother is getting older and I am nervous I will not know how to make the right medical decisions for her if the situation arises. What can we do to prepare in case that happens?
April 7, 2017
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Question: My mother is getting older and I am nervous I will not know how to make the right medical decisions for her if the situation arises.  What can we do to prepare in case that happens?

Answer: There are several documents your mom can sign in advance that can assist you if a time should come when you need to make medical decisions for her, including end of life decisions.  A review of these documents will help you to understand the purpose of each.  They include:  a Health Care Proxy, Living Will, Do Not Resuscitate (DNR) and/or Do Not Intubate (DNI), and Medical Orders for Life-Sustaining Treatment (MOLST) form.  As Elder Law practitioners, we usually prepare a Living Will and Health Care Proxy for our clients to sign, although they need not be prepared by a lawyer.  The other documents listed are prepared under the supervision of a physician and are signed by that physician.

A Health Care Proxy is a document in which your mom can name an individual to make her medical decisions if a doctor deems her unable to make these decisions for herself.  The health care proxy applies to all medical care except artificial hydration and feeding. Therefore, the proxy should indicate if the agent is permitted to refuse hydration or feeding.  While only one person can act as agent at a time, the Health Care Proxy can have a list of successor agents in case the initial agent is unable, unavailable or unwilling to act.

Many clients choose to sign a Living Will at the same time as signing a Health Care Proxy.  This is a document which evidences an individual’s wishes regarding medical care or life support to be administered in the event their condition is terminal. This document can be used to show your mom’s wishes if she is unable to communicate them for herself.  Some of the treatments that could be accepted or refused on the individual’s behalf include cardiac resuscitation, mechanical respiration, artificial nutrition and hydration, antibiotics, blood or blood products, kidney dialysis and surgery or invasive diagnostic tests.

Unlike the Living Will, the Do Not Resuscitate (DNR) form and procedures are governed by New York State law and these orders are signed in a hospital, nursing home or mental health facility.  (New York law also permits “out of hospital” DNR’s in specific situations but this is outside the scope of this article). DNR orders are only applicable to incidents of cardiac respiratory arrest and direct that no chest compression, ventilation, defibrillation, endotracheal intubation or medications be administered.  A patient may express his wishes or if he is unable to do so then a family member, agent or friend can consent to the DNR.  The DNR is issued by a physician and must be on a Department of Health form.

The Medical Orders for Life-Sustaining Treatment (MOLST) form is a document executed with a physician regarding the patient’s wishes with respect to life-sustaining treatment plans. The purpose of this New York State Department of Health form is to create a dialogue between a patient with a chronic or terminal illness and their physician that will transcend the DNR and Living Will. Unlike a DNR, the MOLST form follows the patient from one health care setting to another. For example, your mother were transferred from a hospital to a nursing home the form would follow her; thus ensuring that her medical wishes would be conveyed and respected consistently across care settings.

Regardless of who your mom decides to name as agent to make decisions or what her wishes are regarding future administration or withholding of treatments, it is important that these topics are discussed.  The documents are the first step but they should be followed up with conversations that will allow your mom’s agents to make decisions as close to those she would make for herself.  Having these conversations will only serve to make the agent’s decisions easier.