Governance









White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care

Table of Contents
  1. Introduction
  2. Competence
  3. Decision-Making Capacity
  4. A framework for assessing decision-making capacity
  5. Surrogate Decision-Making
  6. Advance Directives
  7. Guardianship
  8. An Ethical Framework for Surrogate Decision-Making
  9. Decision-making by mentally incapacitated long-term care facility residents
  10. The hierarchy of medical decision-making for incapacitated nursing home residents
  11. Guidance for guardians and other surrogates about medical decision-making
  12. What surrogates and health care provider should expect from each other
  13. Some Important Clinical Issues
  14. Summary and Conclusions
  15. References

Advance Directives

Advance directives are instructions given by persons to direct their health care in the event that they lose the ability to make and communicate medical decisions for themselves. The purpose of an advance directive is to define the medical care desired and to specify whom to ask for decisions in the future, in order to make medical decisions that are consonant with the wishes and values of the person who has become incapacitated.

Formal written advance directives may take the form of a living will, a durable power of attorney for healthcare (DPOAHC), or some combination of the two. The terminology, statutes, and documents relating to advance directives vary from state to state. Nevertheless, an advance directive created in one state is valid in all other states and advance directives are thus portable from state to state. By law, health care facilities may not base admission on whether a person has or does not have an advance directive. (482 CRF section 489.102(a)(3)) In any health care facility, a copy of written advance directives should be placed in the patient's chart so that all caregivers are aware of its existence and contents.

A living will is a document in which a person specifies preferences for care or treatment in the event of future incapacity. A separate document designating a surrogate is called a durable power of attorney for health care (DPOAHC). Some states may require that a DPOAHC be separate from the living will; others may combine the provisions of a living will and a DPOAHC. A person completing a living will or DPOAHC may rescind or change it at any time, provided he or she still possesses the capacity to make decisions. Neither a living will nor a DPOAHC becomes active unless the person becomes incapacitated. In some states, an individual may choose to activate a surrogate while he or she still has decision-making capacity.

Living wills may vary considerably in their degree of detail. They may simply specify general goals, comfort over aggressive treatment, for example, or discontinuation of treatment that appears to be futile. They may also specify types of care or treatment, such as attempted cardiopulmonary resuscitation, intubation, intravenous hydration or medication, hospitalization in the event of a serious illness, antibiotic therapy, or the use of feeding tubes.

A person completing an advance directive cannot foresee or address all the situations in which choices about treatment may be required. Choosing someone to make decisions on one's behalf provides additional flexibility in dealing with unforeseen circumstances.
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