Advance directives (ADs) are legal documents a person completes - while still in possession of decisional capacity - about how treatment decisions should be made on her or his behalf in the future – in the event she or he loses the capacity to make and/or communicate such decisions. They are legal tools directing treatment decision-making and/or appointing surrogate decision makers for the future. Advance directives are only acted upon if the patient loses the ability to make decisions and/or speak for him or herself. Advance directives may be revoked orally or in writing by the patient at any time (so long as he or she has maintained decisional capacity).

Advance care planning research has demonstrated that advance directive documents, in and of themselves, without additional preparation and discussion, have minimal effect on end-of-life decision-making. The literature strongly identifies the importance of repeated, meaningful reflection and discussion among patient, family, and health care providers as being a critical factor in effective advance care planning. While the existence of an advance directive makes a difference, the real driver for having patients’ wishes known and honored is the conversation before and during any clinical episode.

Resources:

Myths and Facts about Healthcare Advance Directives – American Bar Association

Advance Care Planning conversations and completion of advance directives are reimbursable by Medicare.

Resources:

Centers for Medicaid and Medicare – Advance Care Planning
End of Life Care Conversations: Medicare Reimbursement FAQs – Conversation Ready

There are several types of advance directives and every state has laws governing them. Information for Indiana can be found on the Indiana State Department of Health website.

Resources:

Indiana State Department of Health – Advance Directives Resource Center
Indiana State Department of Health - Advance Directives Brochure – Your Right to Choose

Resources:

The Conversation Project - How to Choose and Be a Healthcare Proxy
Choosing a Healthcare Representative - PCHPCA
Choosing a Legal Healthcare Representative – The Optimistic Project
How to Select a Healthcare Proxy – American Bar Association
Guide for Healthcare Proxies – American Bar Association
Indiana Healthcare Representative Appointment Information
Indiana Healthcare Representative Appointment Form

Resources:

Comparison: Living Will/Out of Hospital Do Not Resuscitate Order/Physician Orders for Scope of Treatment.

The Optimistic Project – Treatment Decision Aids

CPR or No CPR: What you should know
Tube Feeding: What you should know
Help with Breathing: What you should know
Antibiotics: What you should know

Indiana Living Will Declaration Form

Resources:

The Optimistic Project

CPR or No CPR: What you should know
Tube Feeding: What you should know
Help with Breathing: What you should know
Antibiotics: What you should know
A Guide to Comfort Care

Indiana Life Prolonging Procedures Declaration Form

Physician orders are documents that a physician signs designating specific medical treatments that the patient or the patient’s legally designated health care representative indicates are in the patient’s best interest.

• Physician orders are effective immediately. They are based upon a patient’s current medical condition and current wishes.
• Physician orders must be signed and dated by the patient (or his/her legal representative) and by the physician (or physician’s assistant, or advanced practice registered nurse). The Out of Hospital Do Not Resuscitate Declaration and Order must also be signed by two witnesses.
• Physician orders are revocable. They can be revoked orally or in writing by the patient or the patient’s healthcare representative at any time.

1. Out of Hospital Do Not Resuscitate (DNR) Declaration and Order. Indiana law allows a qualified person to say they do not want CPR given if the heart or lungs stop working in a location that is not a hospital. A physician must certify that the patient has a terminal condition or that resuscitation would likely be unsuccessful. This order may override other advance directives. Prior to completing, the patient should understand about various life-sustaining procedures and what they can and cannot do.

Resources:

CPR or No CPR: What you should know - The Optimistic Project
Indiana Out of Hospital Do Not Resuscitate Declaration and Order Form

1. Indiana Physician Orders for Scope of Treatment (POST). The Indiana POST is a physician order for treatment determined by a patient’s goals and the treatment options available to the patient. Orders are based on the individual’s current health situation. In consultation with the patient and/or the patient’s legal healthcare representative, a physician will write orders that reflect patient wishes with regards to cardiopulmonary resuscitation (CPR), medical interventions (comfort measures, limited additional interventions, or full treatment), antibiotics, and artificially administered nutrition. Prior to completing, the patient should understand about various life-sustaining procedures and comfort care and what they can and cannot do.

It is recommended that completed POST forms be printed on Astrobright’s Pulsar Pink 65lb paper for inclusion in patient files and records.

Five features make the POST useful:

1. Recognizable, standardized form;
2. Addresses not only code status, but a variety of other treatment categories;
3. Allows patients to determine their healthcare plan;
4. Converts treatment preferences into immediately actionable medical orders;
5. Transfers across treatment settings with the patient, including pre-hospital.

To be eligible for a POST, a person must have at least one of the following:

1. An advanced chronic progressive illness.
2. An advanced chronic progressive frailty.
3. A condition caused by injury, disease, or illness from which, to a reasonable degree of medical certainty there can be no recovery, and death will occur within a short period without the provision of life-prolonging procedures.
4. A medical condition that, if the person were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period the person would experience repeated cardiac or pulmonary failure resulting in death.

Indiana POST Resources:
The Indiana POST Program
The Indiana POST for Healthcare Providers
Using the Indiana POST Form: Guidance for Healthcare Professionals
Indiana POST information for healthcare professionals
Indiana POST information for patients
The Indiana POST Program – FAQ’s
Indiana POST and Advance Directives EMS Study Guide
Indiana Physician Orders for Scope of Treatment (POST) Form

Other Resources:

National Physician Orders for Life Sustaining Treatment (POLST) Program
Comparison: Living Will/Out of Hospital Do Not Resuscitate Order/Physician Orders for Scope of Treatment.

The Optimistic Project – Treatment Decision Aids

CPR or No CPR: What you should know
Tube Feeding: What you should know
Help with Breathing: What you should know
Antibiotics: What you should know
A Guide to Comfort Care for Patients and Families

Good advance planning for healthcare is a continuing conversation and a work in progress because circumstances change, and lives change. One’s values and priorities may even change.

Resource:

What to do after signing your advance directive? American Bar Association

The American Bar Association recommends that individuals revisit and discuss their advance care plans and documents whenever any of the “six Ds” occur: