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Advance Directives in Massachusetts

Here’s a list of frequently asked questions and answers to help seniors and their families better understand advance directives. With proper documents in place, you can communicate your your end-of-life wishes.

(Please note that the information concerning Advance Directives pertains to the state of Massachusetts; forms and laws differ from state to state.)

What are Advance Directives? 

“Advance Directives” are legal documents which let doctors and other health care providers know your wishes concerning medical treatment in the event that you were too ill or hurt to express your wishes. They allow you to spell out your decisions about end-of-life care ahead of time to avoid confusion later on. It’s important to keep in mind that when patients choose not to receive or to stop treatment, medical care to manage pain and other physical symptoms (palliative care) continues.

Should I assign a Health Care Proxy? 

The short answer is Yes. The Health Care Proxy (also called a Medical Power of Attorney, “appointment of health care agent,” or Durable Power of Attorney for Health Care) allows you to appoint someone to make health care decisions for you if you are incapable of doing so yourself. Most people select someone (family member or friend) knowledgeable about their wishes and religious beliefs and in whom they have trust and confidence. The scope of a Health Care Proxy does not limit to choices at the end of life but also includes decisions in other medical situations.

A Health Care Proxy goes into effect when your attending physician decides that you cannot make or communicate health care decisions and your “Agent” consents to start making those decisions. If your doctor determines that you have regained the capacity to make or share your own choices, then your Agent’s authority will end, and treatment requires your consent. A Health Care Proxy only affects medical care. It is not a “Power of Attorney” which deals only with personal and financial matters. Learn more about the difference between a Health Care Proxy and Living Wills

Do I need a Living Will? 

A Living Will indicates which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You can include instructions on the use of life-sustaining equipment (such as dialysis and breathing machines). Instructions are based on if you want to be resuscitated in a scenario where your breathing or heartbeat stops. This is referred to as DNRs “Do not resuscitate” orders. You can also provide directives for artificial hydration and nutrition (tube feeding). Unless you write in other instructions, it tells your doctor that you do NOT want life-sustaining treatments.

A Living Will deals only with medical issues. It is completely different and separate from your will or living trust – these are financial documents. Some people who do not appoint a Health Care Proxy create a Living Will. Other people choose to have both a Health Care Proxy and a Living Will. In the majority of states, a Living Will is a legally enforceable document. It can insure that a doctor who abides by a patient’s wishes will not incur any liability. Even in states without Living Will laws this document is useful to a judge trying to decide what an unconscious patient would want.

According to the Massachusetts Medical Society (MMS), Massachusetts is one of only three states that recognizes Health Care Proxies but does not legally recognize Living Wills. However, the MMS encourages the use of Living Wills. Living Wills are “still potentially useful because they guide Agents and physicians about the types of choices a person would make”. The “Personal Wishes Statement” is available for Massachusetts residents as a substitute.

Why would I want a DNR? 

A Do Not Resuscitate order (DNR) covers only two types of situations. It states that if you suffer cardiac arrest (your heart stops beating) or respiratory arrest (you stop breathing), your health care providers are not to try to revive you by any means, such as with cardiopulmonary resuscitation (CPR). A DNR order is a document prepared by your doctor at your direction and placed in your medical records. You can have a DNR in addition to a Living Will and/or a Health Care Proxy. A Good Way to Kickstart End of Life Discussions

What is the “MOLST” form? 

MOLST “Massachusetts Medical Orders for Life-Sustaining Equipment” is a medical order form (similar to a prescription) that relays instructions between health professionals about a patient’s care. The order is based on individuals’ right to accept or refuse medical treatment, including treatment that might extend life. MOLST is not for everyone. In Massachusetts, patients of any age with a severe advanced illness may discuss filling out a MOLST form with their doctor. The process requires discussions between the signing clinician (physician, nurse practitioner, or physician assistant), the patient, and family members/trusted advisors. This discussion is based on the patient’s current medical condition, care goals, and possible treatment risks or benefits.

After these discussions, the MOLST form may be filled out and signed by the clinician and patient. The signed form will provide instructions about the use of life-sustaining treatments for the patient. The signed form is based on the patient’s own decisions and stays with the patient. In addition, it is to be honored by health professionals in any clinical care situation.  Frequently Asked Questions Regarding MOLST

Is the MOLST form an Advance Directive? 

The MOLST form is not an Advance Directive because it is a medical document that contains actionable medical orders. The orders are effective immediately based on a patient’s current medical condition. Advance Directives, including Health Care Proxies and Living Wills, are legal documents that are effective only after the patient has lost capacity. In other words, a health care agent can determine to make decisions for a person if the latter lacks the capacity to do so; a Living Will is relevant only after the patient can no longer be consulted. A MOLST form, on the other hand, is a medical document both the clinician and the patient signs. It is effective as soon as it is signed, regardless of a patient’s capacity to make decisions.

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