Health Care Proxies and Advance Directives help Doctors in critical care of patients

The New Jersey Department of Health issued a comprehensive statement concerning triage and the care of COVID-19 patients in different kinds of licensed health care facilities. This is one among many directives issued in the past six weeks. Read the directive here: FinalAllocationPolicy4.11.20v2

As the patient is being treated, many decisions need to be made along the way, often in rapid-fire fashion. The patient may not be able to communicate or make decisions. It is very important that patients or potential patients have a signed Advance Directive, or Health Care Power of Attorney (proxy) so that if the patient loses his or her capacity to make medical decisions, they have an authorized person who can communicate with the medical professionals as critical decisions need to be made. Certain treatment will be rendered automatically as a response to the patient’s emergency, but in areas where choices and decisions need to be made, it’s vital that there be a designated person. A well-written advance directive will be explicit and reasonably easy to interpret. Whenever possible, naming several back-ups to the primary Health Care Representative (decision-maker) is preferable because if the primary person cannot be reached or has become ill, having a backup to make a crucial decision is vital. If the patient is incapacitated, it would be their representative who has the discussions with the doctor or nurse pertaining to filling out the POLST formPhysician’s Orders Concerning Life Sustaining treatment — which is now a regular part of hospital practice..

We will continue to monitor developments that affect the delivery of crucial health care to our clients If you have concerns or a problem, call for a telephone consultation with one of our attorneys…. 732-382-6070

The Tender Talk about End-of-Life Planning

A regular part of the estate planning process involves a discussion with the client about selecting a line up of trusted individuals to serve as the client’s medical decision-makers. If the doctor determines that the patient has become incapacitated, there needs to be a designated proxy who can act on the patient’s behalf. Ideally, this person was selected by the patient beforehand in writing, because, otherwise, dreadful and lengthy court battles can ensue. I explain to the client that they need to choose the right person for this immensely difficult and emotional job. The person who might be just fine as Executor of the estate might be a poor choice as health care proxy.  The health care proxy will be responsible for the day-to-day health care decisions — should you continue to take this medication? should you have this elective surgery? Should you get a bridge or an implant when your tooth  is extracted? — as well as the major ones when life itself is threatened — should you be placed on a ventilator? should a feeding tube be installed? should the pacemaker battery be replaced?.

Many people have strong feelings about whether they would want certain mechanical means used to sustain their life if they become incapacitated and their quality of life has become terribly diminished due to various severe and chronic disabilities. The means to express these wishes is called a “Living Will” or “Advance Directive for Health Care.”  Essentially, the document speaks for a patient who can no longer express their wishes.

Advance Care Planning is the process of talking with your health care team and your trusted individuals about what you would want if certain things occur. In the hospital setting, the patient is asked to provide instructions which get written on a special form called a POLST that is then signed by the doctor and is placed in the chart as a physician’s order.   If a “living will” was previously signed, the instructions on the POLST form likely will match up with that document. But a patient can of course change their mind. The discussion needs to address the specifics of the condition being treated, the prognosis and potential outcomes, and the patient’s worries. The patient may feel that they never want to be maintained on a ventilator or kidney dialysis, but that they would still want artificial feeding and hydration if they could no longer chew or swallow. Alternatively, the patient may feel that they would want to be maintained on a ventilator no matter what, even if they could no longer interact with those around them due to severe incapacity, and even if this could go on for years.

If the patient is already incapacitated, it could be the designated health care proxy or the legal guardian who is engaging in these delicate discussions with the physician. Sometimes, shorthand is used such as “do you want a DNR put on his chart?” This decision-maker has the authority to complete the POLST on behalf of the patient. Either way, it is important that these serious issues be discussed in advance, since it can be so very difficult to make the necessary choices in the midst of a medical crisis if there was no prior guidance.

Call us for advice regarding estate planning, health care decision-making issues and elder care planning …….. 732-382-6070

Thoughtful Catholic approach to conversations about end of life care

I had the opportunity today to read a very thoughtful article about a meeting of Catholic physicians who are helping their very ill patients to wrestle with hard decisions about whether to utilize palliative care in place of active treatment with mechanical life support. The organization is the Catholic Health Association of the United States (CHA) and the online newsletter article in the section on Physicians Articles is called  “Pathways to Convergence: EXAMINING DIVERSE PERSPECTIVES OF CATHOLICS ON ADVANCE CARE PLANNING, PALLIATIVE CARE, AND END-OF-LIFE CARE IN THE UNITED STATES,” subtitled ” Untangling the Gordian Knot of Language and Attitude about Palliative Care and Advance Care Planning: Pathways to Convergence,”

The article reports on the findings that stemmed from a 2015 initiative in which the Pew Charitable Trusts “gathered a group of six Catholic ethicists who worked in and with the Catholic health ministry from a variety of perspectives. All of them served as resources to help organizations in the ministry remain faithful to and compliant with Catholic teaching. Serving as a kind of steering committee, this initial group sketched out a framework for a project that would look at three main topics in Catholic health care” [including] …”:3. the specific issues and decisions made by patients and families and providers in the setting of living with serious illness and, ultimately, dying from it.”

The article goes on to report thatPathways to Convergence, a project supported by The Pew Charitable Trusts, enabled a broad array of clergy, clinicians, practitioners and ethicists to explore Catholic perspectives on these issues for more than a year. Participants engaged in a series of in-depth conversations on how Catholics accompany the sick and dying, how end-of-life medical decisions are made and what role the church has in promoting its message and vision in the public square. It was acknowledged at the outset that although Catholics share many strongly held views that converge, they also hold divergent views and practices that cause confusion and misunderstanding. The project was established with the hope that, through a respectful exploration of the convergence and divergence of views, participants could recognize a path forward that would enable Catholics to speak more clearly and distinctly about these issues to one another and to others as well. …”

Discussions between physician and patient, or patient and nurse practitioner, about care at end of life are challenging, sensitive, and fraught with the difficulty of accepting certain medical inevitabilities without giving up hope. One’s concept of what constitutes good life at end of life must be explored. Individuals can sign advance directives, and patients or their authorized proxies can confer with physicians about POLST – Physicians Orders for Life Sustaining Treatment — that become part of the medical record both in and out of the hospital. Above all, the issues need to be explored with the team that is important to the patient, which will often include clergy as well as health care personnel and trusted family members.


Call us for advice on personalized advance care senior planning … 732-382-6070

What is Hospice care all about, really?

Palliative care is a specialized team approach to helping a patient to cope with the debilitating symptoms of certain serious complicated illnesses such as parkinsons Disease, heart failure, kidney failure, or COPD. The patient is receiving curative treatment and emergency room care during acute episodes of illness, and can receive dietary support, pain management, grief counselling, massage and other forms of care from the palliative care team of health professionals. This can greatly improve the patient’s ability to cope with the symptoms of their illness.

Palliative care services are generally provided at the bedside in a hospital or skilled care facility (nursing home or rehabilitation center) and can still be covered by certain health insurance programs such as Medicare. That would include room and board under Medicare part A . Of course each insurance plan has to be scrutinized to verify the coverage.

Hospice care is sometimes referred to as “palliative care,” but is really something different. It is an alternative to curative treatment,  for a patient who no longer wants medical treatment, and is often provided in the home . When a person with terminal illness feels that they have exhausted the benefits of ongoing aggressive treatment, they may decide that it is time to forego further “treatment” and focus instead on remaining as comfortable as possible for as much time as they have left.. The patient or their health care proxy decision-maker opts out of further curative treatment. The patient then will receive palliative care and pain control. The patient may be at home, in a health care facility or in a hospice facility. Medicare does not pay the room and board charges for hospice care. Although the point of decision may be more apparent for certain patients whose cancer treatment is no longer productive, there can also come a time when further treatment will be declined by a patient with stage four heart failure, or who has advanced alzheimers dementia  and other progressively degenerative clinical conditions such as congestive heart failure or kidney failure.

It is very important that all patients sign a health care proxy (to designate their medical decision-maker should they become incapable of making decisions), and if they have particular wishes regarding the use or non-use of lifesaving treatment,  an advance directive. When in the hospital, they or the health care proxy needs to make their wishes known so that the treatment doesn’t run away with the patient at a time that the patient or their proxy prefers to forego treatment.. In New Jersey, physicians must discuss these issues with the patient and complete a form called POLST setting down the patient’s wishes.

Elder Care requires a team approach. The palliative care team can greatly enhance the family’s experience at the end of life.

 For legal advice on preparation and implementation of health care directives, powers of attorney and elder care planning, call … 732-382-6070

Governor has signed the CARE Act A2955

Yesterday afternoon, Governor Christie signed A2955, called the CARE Act.

The bill requires hospitals to ask patients to identify their intended post-discharge caregiver, and obligates the hospitals to provide information and instruction to the caregiver no later than 24 hours prior to discharge concerning the components of the discharge care plan and the tasks that must be performed for the patient after discharge to take care of the patient’s medical and nursing needs at home.

Here’s the final bill:

When a patient goes into the hospital, coordination of care is a complex task involving the medical/nursing team, the patient and the authorized family or other individuals. Patients can sign health care proxies to designate decision – makers (in the event the patient becomes incapacitated), advance directives (concerning wishes for use or non-use of life-saving treatment when the patient is at late or advanced stages of debilitating illness), POLST instructions (concerning the patient’s goals for the treatment), and now, designation of the person who will coordinate the care upon discharge. It’s vital that the patient have someone there for them to advocate for the patient throughout the hospitalization process and to help the patient understand both their rights and their medical issues. The CARE Act should go along way to protecting the interests of patients in the frenzied environment of the hospital discharge process.

If an elderly patient is discharged from the hospital and their caregiver has been given full information about the patient’s medical and nursing needs, there is a greater likelihood that the home care plan will be effective. Communication among all members of the team is so crucial.

For legal advice on coordinating discharge and assembling your team for aging in palace, call 732-382-6070