Ethics, Communication & Professionalism

Advance directives: living wills and durable POA for healthcare

Clinical Overview and When to Suspect Need for Advance Directives

— Living will: written statement of wishes regarding specific interventions (intubation, CPR, artificial nutrition/hydration, dialysis) in defined clinical scenarios (terminal illness, permanent unconsciousness)

— Durable power of attorney for healthcare (DPOA-HC) / healthcare proxy: designates a surrogate decision-maker who speaks for the patient when capacity is lost; "durable" = remains valid through incapacity

— Any new diagnosis of serious/life-limiting illness (metastatic cancer, NYHA III–IV heart failure, GOLD D COPD, ESRD, dementia, ALS, advanced cirrhosis)

— Annual Medicare Wellness Visit — AD discussion is a required element and billable (CPT 99497/99498 for advance care planning, 30 min)

— Pre-operative evaluation for major/high-risk surgery

— Admission to nursing home, hospice, or after ICU stay

— Age ≥65 even when healthy — primary care opportunity

Advance directives (ADs) are legal documents that express a patient's healthcare preferences if they lose decision-making capacity

Both are products of the Patient Self-Determination Act (1990), which requires Medicare/Medicaid-participating hospitals to ask about ADs on admission and provide information

When to actively raise ADs in outpatient Step 3 vignettes:

Capacity must exist at the time the AD is created; once incapacity develops, the document governs

ADs apply only when the patient lacks decision-making capacity — a capacitated patient always overrides their own prior document

Board pearl: Advance directives ≠ DNR/POLST. ADs are patient-authored documents stating future wishes; POLST/MOLST is a portable physician order set translating those wishes into actionable orders (CPR, intubation, antibiotics, feeding) for EMS and facilities — appropriate when life expectancy is <1 year

Step 3 management: At every Medicare wellness visit, document AD status; if absent, offer counseling and provide state-specific forms — do not wait until acute illness

Presentation Patterns and Key History

— Pattern 1 — Incapacitated patient, no AD, family conflict: ICU patient with anoxic brain injury; spouse and adult child disagree on withdrawal. Action: identify legal surrogate hierarchy, convene family meeting, consider ethics consult

— Pattern 2 — Existing living will, ambiguous applicability: Patient with living will declining "heroic measures" now presents with reversible sepsis. Action: living wills typically apply only to terminal or irreversible conditions; reversible illness does NOT automatically trigger limitations

— Pattern 3 — DPOA-HC vs family disagreement: Designated proxy (e.g., friend) decides differently from biological family. Action: the legally designated DPOA-HC trumps family, regardless of biological relationship

— Prior conversations about end-of-life with family

— Religious/cultural framework affecting decisions (e.g., Jehovah's Witness and blood products, Orthodox Jewish considerations about withdrawal vs withholding)

— Specific scenarios patient fears (mechanical ventilation, tube feeding, nursing home, dementia)

— Identity of trusted decision-maker and whether that person knows the patient's values

— Prior experiences with death of family members shape preferences

Step 3 stems present advance directive issues in three recurring patterns:

Key history elements to elicit before/during AD discussion:

Goals-of-care framing outperforms checklist approach: ask "What gives your life meaning?" and "What would be worse than death?" before discussing specific interventions

Key distinction: A patient stating "I don't want to be a vegetable" in conversation is not a legally binding AD — Step 3 answers will require a written, signed, witnessed document or a designated surrogate to act on prior oral statements as substituted judgment

Document conversations contemporaneously in the chart; verbal preferences in the EHR can be honored as evidence of patient wishes even without formal paperwork

Assessing Decision-Making Capacity (Functional "Exam")

— Communicate a choice — stable, consistent expression of preference

— Understand relevant information about diagnosis, treatment options, risks/benefits

— Appreciate how the information applies to oneself (not just abstractly)

— Reason — weigh options in a manner consistent with personal values

— Psychiatric diagnosis alone (schizophrenia, depression do not automatically negate capacity)

— Cognitive screening score alone (MMSE/MoCA inform but don't decide)

— Whether the patient agrees with the physician — disagreement ≠ incapacity

— Age, disability, or involuntary commitment status

Capacity is the clinical assessment any physician can perform; competence is a legal determination by a court — Step 3 distinguishes these sharply

Four-component capacity assessment (Appelbaum criteria):

Capacity is decision-specific and time-specific: a patient may have capacity to choose a meal but not to refuse hemodialysis; capacity may fluctuate with delirium, sedation, or pain

Capacity is NOT determined by:

Higher stakes → higher capacity threshold (sliding scale): refusing life-sustaining treatment requires more robust demonstration than consenting to a low-risk procedure

When capacity is borderline, psychiatry consult can assist but is not legally required — the treating physician is empowered to make the determination

Reversible causes of incapacity must be addressed before invoking the AD: delirium from infection/meds, hypoxia, hypoglycemia, severe pain, untreated depression, electrolyte derangement

Step 3 management: A patient with mild dementia who can articulate why they refuse a feeding tube ("I've lived a full life, I don't want to be kept alive that way") retains capacity for that decision — do not override based on MMSE alone

Board pearl: If the patient has capacity, always defer to the patient — even if family insists the AD or DPOA-HC be followed, the capacitated patient's contemporaneous wishes prevail

Diagnostic Workup — Identifying the Correct Surrogate

— 1. Court-appointed guardian (if exists)

— 2. Spouse (unless legally separated)

— 3. Adult children (majority rule if multiple)

— 4. Parents

— 5. Adult siblings

— 6. Other relatives or close friend with knowledge of patient's values

— Known wishes (explicit statements in living will or prior conversations) — highest priority

— Substituted judgment — what would this patient have chosen based on their values?

— Best interests — used only when patient's prior wishes are unknown (e.g., never-competent patients, young children)

— Verify written AD on file (scan into EHR)

— Confirm DPOA-HC name, contact, and document validity

— Check for POLST/MOLST form (bright pink in many states, follows patient between facilities)

— Out-of-state directives are generally honored under reciprocity, though specifics vary

When a patient lacks capacity and no DPOA-HC is designated, most states follow a statutory surrogate hierarchy (varies slightly by state):

DPOA-HC always supersedes the default hierarchy — a designated proxy (even a friend) outranks the spouse and adult children

Standards of surrogate decision-making, applied in order:

Documentation needed at admission/encounter:

Key distinction: DPOA-HC ≠ financial/general POA. A general POA does NOT confer healthcare decision-making authority; the document must specifically address healthcare. Conversely, the DPOA-HC has no authority over finances.

CCS pearl: On the CCS case, when a patient is intubated and family is at bedside, order "locate advance directive" and "identify healthcare proxy" early — this changes downstream management (DNR status, escalation decisions, family meeting orders) and is rewarded as part of comprehensive care

Documentation, Witnessing, and Legal Validity

— Patient must be ≥18 years and have capacity at signing

— Two witnesses (not related, not heirs, not the attending physician, not employees of the facility — to avoid conflict of interest)

— Some states require notarization instead of or in addition to witnesses

— Must be in writing; oral directives carry weight as evidence but are not formal ADs

— Designation must be in writing, signed, witnessed and/or notarized

— Proxy must accept the role (some states require proxy signature)

— Proxy cannot be the attending physician or facility employee

— Authority activates only on incapacity as determined by the physician (some states require two physicians)

— ADs from one state are generally honored in another under comity, though POLST forms may not transfer

— Hospitals must ask about ADs on admission (Patient Self-Determination Act) but cannot require them as a condition of care

— Religious-affiliated institutions may limit which interventions they will withhold/withdraw and must disclose this

— Witness was a beneficiary in the patient's will → AD invalid

— Patient signed during delirium → AD invalid; capacity must exist at signing

— Only a verbal request to family in the hospital → not a formal AD, but treated as evidence under substituted judgment

Living will requirements (vary by state, but commonly):

DPOA-HC requirements:

Revocation: A capacitated patient can revoke an AD at any time — verbally, in writing, or by destroying the document. Revocation must be documented in the chart

Validity across settings:

Common documentation pitfalls Step 3 tests:

Board pearl: If the AD was properly executed when the patient had capacity, subsequent loss of capacity does not invalidate it — that is the entire purpose of the "durable" designation

Decision Logic — Applying the Directive at the Bedside

— Step 1: Confirm the patient currently lacks capacity (and address reversible causes)

— Step 2: Locate written AD and identify DPOA-HC

— Step 3: Determine if the current clinical situation matches the scenario described in the living will (terminal condition, persistent vegetative state, end-stage disease)

— Step 4: Apply specific instructions in the document

— Step 5: For situations not covered, the DPOA-HC uses substituted judgment

— Step 6: Document reasoning and discussion in the chart

— Antibiotics, IV fluids, transfusions, dialysis, surgery, ICU admission, BiPAP for comfort

— These must be addressed separately and explicitly

Stepwise approach when an incapacitated patient presents with a treatment decision:

Common pitfall: Reflexive application of a living will to any serious illness. A living will declining "life-sustaining treatment" typically does not apply to a 70-year-old with reversible septic shock — it applies to terminal/irreversible conditions

DNR ≠ "do not treat." A DNR order means no CPR/defibrillation/intubation for cardiac arrest. It does NOT preclude:

Time-limited trials are an ethically sound approach when prognosis is uncertain: agree with family on a defined trial (e.g., 72 hours of full ICU care) with pre-specified outcomes that would prompt transition to comfort care

Withholding vs withdrawing: Ethically and legally equivalent — there is no moral or legal distinction between not starting and stopping a treatment once started. Many families and clinicians feel them differently; counseling addresses this

Step 3 management: When asked "what is the next best step" for an incapacitated ICU patient without an AD, the answer is almost always convene a family meeting to determine goals of care using substituted judgment — not immediately call ethics or withdraw care

Initiating the Advance Care Planning Conversation

— Setting: private room, sit down, minimize interruptions, invite family if patient wishes

— Perception: "What is your understanding of your illness?"

— Invitation: "Would it be helpful to talk about what to expect and your preferences?"

— Knowledge: share prognosis honestly using "I hope/I worry" framing

— Emotion: name and acknowledge ("I can see this is hard")

— Summary/strategy: translate values into specific decisions and document

— "What is your understanding of where you are with your illness?"

— "How much information would you like?"

— "If your health worsens, what are your most important goals?"

— "What gives your life meaning?"

— "What abilities are so critical that you can't imagine living without them?"

— "What are you willing/not willing to go through for the possibility of more time?"

— Medical jargon ("intubation," "pressors") without explanation

— Closed yes/no menu of interventions before establishing values

— "Do you want us to do everything?" — false binary; everyone wants "everything" that helps

Outpatient ACP is reimbursable (CPT 99497 for first 30 min, 99498 each additional 30 min) and can be billed alongside the Medicare Annual Wellness Visit with no patient copay

SPIKES protocol adapts to ACP conversations:

Serious Illness Conversation Guide (Ariadne Labs) — high-yield questions:

Avoid:

Cultural humility: some patients and families prefer that information be shared with family first (collective decision-making). Ask the patient up front who should receive information and make decisions — this is itself an autonomous choice

Board pearl: ACP is a process, not an event — preferences evolve with illness trajectory. Revisit at major transitions: new diagnosis, hospitalization, decline in function, loss of spouse, transition to long-term care

Implementation Across Care Settings — POLST and Portable Orders

— Bright pink/colored portable medical order signed by a physician/NP/PA

— Translates AD wishes into actionable orders honored across ED, EMS, hospital, SNF, home

— Travels with the patient; original or copy is valid

— Appropriate when clinician would not be surprised if the patient died within 1 year ("surprise question")

— CPR vs DNR if pulseless/apneic

— Level of medical interventions: comfort-focused / selective (antibiotics, IV fluids, no intubation) / full treatment

— Artificial nutrition (long-term tube feeding, trial period, none)

— Antibiotics preferences

— AD: patient-authored, future-oriented, for any adult, requires interpretation

— POLST: clinician-signed medical order, for seriously ill patients, immediately actionable by EMS without interpretation

— A patient ideally has both: AD names a proxy and broad values; POLST operationalizes orders for current illness

— Patient discharged from hospital with DNR but order does not transfer to SNF → cardiac arrest results in unwanted CPR

— Fix: ensure POLST accompanies patient at every transition; SNF/home health receive copy; family knows where original is kept

POLST/MOLST/POST (state-dependent name): Physician Orders for Life-Sustaining Treatment

POLST sections typically include:

Key distinction: AD vs POLST

Transitions of care risks (Step 3 favorite):

EMS and out-of-hospital DNR: in most states, EMS will perform CPR unless a valid POLST/out-of-hospital DNR is physically present at the scene — verbal family report is insufficient

CCS pearl: When discharging a patient with metastatic cancer or end-stage CHF home with hospice, the CCS-style orders should include "complete POLST form" and "provide copy to family and SNF/hospice agency" — this prevents the classic Step 3 "unwanted resuscitation during transition" scenario

Special Populations — Elderly and Cognitive Impairment

— Often retain capacity for advance care planning if performed early in disease course

— Mild cognitive impairment or mild dementia is NOT a bar to executing an AD — the question is decision-specific capacity at the time of signing

— Document capacity assessment contemporaneously with AD execution

— Encourage early ACP at diagnosis of dementia, while patient can articulate values

— Patient typically lacks capacity for complex healthcare decisions

— Surrogate decision-making applies; rely on previously executed AD and prior conversations

— Specific dementia-related decisions the AD should address: feeding tubes (PEG), hospitalization for pneumonia/UTI, antibiotics, attempted resuscitation, transition to hospice

— Feeding tubes in advanced dementia: not recommended — no mortality benefit, do not prevent aspiration, increase agitation/restraints; hand-feeding for comfort is preferred (AGS Choosing Wisely)

— Federal regulations require AD inquiry on admission

— Common gap: AD on file but not updated as patient declines → defaults to "full code" when family had assumed otherwise. Re-address at care plan meetings

Older adults with early dementia:

Moderate to severe dementia:

Nursing home residents:

Frailty and prognostic uncertainty: use validated tools (Clinical Frailty Scale, ePrognosis) to inform but not dictate ACP conversations

Elder abuse intersection: if family member designated as DPOA-HC is suspected of financial or physical abuse, the document can be challenged; consult ethics, social work, and Adult Protective Services

Board pearl: A patient with moderate Alzheimer dementia who refuses a flu shot, consistently and calmly, citing prior preferences — likely retains capacity for that specific low-stakes decision. Capacity is decision-specific; do not globally override

Step 3 management: At every nursing home transfer or hospital discharge of a patient with dementia, explicitly reconcile code status and feeding preferences with the AD and family — do not assume continuity

Special Populations — Pediatrics, Pregnancy, and Psychiatric Patients

— Minors generally cannot execute legally binding ADs; parents/guardians decide using best interests standard

— Assent (developmentally appropriate agreement) should be sought from children ~7 and older even when parents consent

— Mature minor doctrine (state-dependent): adolescents demonstrating capacity may participate substantively

— Tools like "Voicing My Choices" and "My Wishes" support adolescent/young adult ACP for chronic illness

— Parental refusal of life-saving treatment (e.g., transfusion for child of Jehovah's Witness) → court order overrides parental wishes; parents retain right to refuse for themselves

— Many states have pregnancy exclusion clauses that invalidate or limit a living will during pregnancy — highly state-specific and ethically contested

— Step 3 stems may test awareness that pregnancy status can affect AD enforceability; if unclear, escalate to ethics/legal

— Mental illness does not preclude capacity to execute an AD

— Psychiatric advance directives (PADs) allow patients with bipolar/schizophrenia to specify preferences for psychiatric care (medications, hospitalization, ECT) during future episodes of incapacity — recognized in many states

— Involuntary commitment for danger to self/others does not override AD for non-psychiatric medical care

— Capacity is assessed individually, not assumed absent; many adults with mild-moderate ID can execute ADs with appropriate support

— Supported decision-making is the emerging standard; guardianship is a last resort

Pediatrics:

Pregnancy:

Psychiatric patients:

Intellectual disability:

Key distinction: A patient on an involuntary psychiatric hold for suicidality who refuses a medical workup for sepsis — the involuntary hold addresses psychiatric care only; capacity for the medical decision must be separately assessed, and if intact, refusal must be respected

Board pearl: Pediatric end-of-life decisions use the best interests standard because young children have not yet developed values to substitute — this is a categorical distinction from adult substituted judgment

Complications and Adverse Outcomes of Poor ACP

— Higher rates of ICU admission, mechanical ventilation, CPR, and in-hospital death

— Lower hospice utilization, shorter hospice stays

— Higher caregiver depression and complicated grief at one year

— Higher cost of care without survival benefit

— Up to one-third of surrogates experience PTSD, depression, or complicated grief, especially when making withdrawal decisions without prior patient guidance

— Mitigation: explicit prior conversation, named proxy who knows values, framing decisions as "honoring the patient's wishes" rather than "choosing to end their life"

— Adult children disagreeing with each other or with the spouse/proxy

— Geographically distant family arriving late and disputing prior decisions

— Mitigation: early family meeting with all stakeholders, named single point of contact, ethics consult if intractable

— Withdrawing care without proper surrogate/AD documentation

— Ignoring a valid AD ("we kept doing CPR even though..."), which has produced wrongful-life suits

— Bypassing DPOA-HC in favor of biologically related family

— POLST not transferred to SNF → unwanted CPR during transport

— Living will applied to reversible condition → premature withdrawal

— Capacitated patient overridden by family invoking old AD → battery

Unwanted aggressive end-of-life care when no AD exists:

Surrogate decision-maker burden:

Family conflict is a major source of moral distress for healthcare teams:

Moral distress and burnout in clinicians forced to provide non-beneficial treatment

Litigation risk:

Specific adverse scenarios Step 3 tests:

Key distinction: Non-beneficial ("futile") treatment — clinicians may decline to provide treatment that offers no realistic chance of achieving the patient's goals, but this requires institutional process, ethics consult, and transfer offer to another physician/facility — not unilateral withdrawal

Step 3 management: When family insists on continued aggressive care that the team believes is non-beneficial, the next step is ethics committee consultation, not unilateral action

When to Escalate — Ethics Consult, Legal, Guardianship

— Intractable family disagreement about goals of care

— Conflict between AD and family wishes

— Disagreement between treating team and family/surrogate

— Suspected surrogate not acting in patient's interest

— Requests for non-beneficial treatment

— Ambiguity in applying the living will to current situation

— Conscientious objection by clinician

— When withholding/withdrawing care without documented surrogate or AD

— Court order needed for emergent treatment over parental refusal (e.g., transfusion in minor)

— Disputed DPOA-HC validity

— Required when no surrogate is available (no family, no friends, no DPOA-HC) and significant decisions must be made

— Court appoints guardian, often a public guardian for "unbefriended" patients

— Time-consuming (weeks); for emergent decisions, two-physician concurrence or ethics consultation often suffices under state statute

— Many states permit two physicians (one being the attending, one independent) to make decisions about life-sustaining treatment for unrepresented incapacitated patients

— Documents must reflect that surrogate efforts were exhausted

— Clinicians may decline to participate in care that violates personal/religious values (e.g., withdrawal of nutrition)

— Must transfer care to another willing clinician; cannot abandon the patient

Ethics committee consultation indications:

Ethics consultation is advisory, not binding but is highly influential and well-documented; available 24/7 at most US hospitals (Joint Commission requirement)

Risk management/legal escalation:

Guardianship petition:

Two-physician rule:

Conscientious objection:

Step 3 management: For an unrepresented incapacitated patient needing urgent decisions, the sequence is: (1) exhaust search for surrogate, (2) ethics committee consultation, (3) two-physician concurrence per institutional policy, (4) guardianship only for non-emergent ongoing decisions

Board pearl: Ethics consults are available and free — there is no Step 3 scenario where calling ethics is "wrong"; it is the safe escalation answer

Differentials — Related Documents and Concepts (Same Category)

— Physician order in the chart, specific to current admission (unless converted to POLST)

— Does not address other interventions

— Can be written at patient request (with capacity) or by surrogate using AD/substituted judgment

— Widely used AD document covering medical, personal, emotional, spiritual wishes

— Legally valid as a living will in most states

— Springing: activates only on incapacity (most healthcare POAs)

— Immediate: active upon signing

— A patient names their adult daughter as DPOA-HC. The patient's spouse insists on aggressive care; daughter wants comfort care consistent with patient's prior statements.

— The daughter's decision controls — the designated proxy outranks the default statutory hierarchy (spouse). The team should honor the DPOA-HC unless evidence suggests she is not acting per patient's wishes

Living will vs DPOA-HC — covered above; complementary, not redundant

DNR/DNI order:

POLST/MOLST: portable, multi-intervention physician order; for seriously ill

Out-of-hospital DNR / EMS-DNR: state-specific document or bracelet recognized by EMS in the field

Five Wishes:

Healthcare proxy / healthcare agent / surrogate: synonyms for the person named in the DPOA-HC document

Allow Natural Death (AND): alternative framing to DNR, emphasizing what will happen rather than what won't

General/financial POA: does NOT confer healthcare authority; common Step 3 distractor

Springing vs immediate POA:

Mental health advance directive / PAD: for future psychiatric crises

Organ donation directive: separate document or driver's license designation; first-person consent generally overrides family objection legally, though many OPOs honor family wishes in practice

Key distinction (high-yield Step 3 trap):

Board pearl: When the question stem names a "healthcare proxy" or "healthcare agent," that person has legal authority equal to the patient for healthcare decisions during incapacity — supersedes all family relationships

Differentials — Other-Category Decision-Making Frameworks

— Treatment can be provided without consent when life/limb is threatened and consent cannot be obtained

— Presumes a reasonable person would consent

— Cannot override a known valid refusal (e.g., AD declining transfusion in Jehovah's Witness with bracelet)

— Used for never-competent patients (young children, severe lifelong intellectual disability) and when prior wishes are unknown

— Considers benefits/burdens, quality of life from the patient's perspective when knowable

— Capacitated patient refusing recommended treatment → autonomy prevails

— Even if refusal will result in death, the capacitated adult's right to refuse is paramount (e.g., Jehovah's Witness refusing transfusion, patient with cancer refusing chemo)

— Legal in select states (OR, WA, VT, CA, CO, HI, NJ, ME, NM, DC, others); requires terminal diagnosis (<6 months), two requests, capacity, self-administration

— Distinct from euthanasia (physician-administered, illegal in US)

— Legally and ethically equivalent to withdrawing other treatments (Cruzan v. Director, MO Dept of Health, 1990)

— Living wills frequently address this specifically

Emergency exception to informed consent ("emergency doctrine"):

Therapeutic privilege: withholding information believed to cause serious harm — extremely narrow, rarely justified in modern practice; not a route around informed consent

Best interests standard:

Substituted judgment: used when prior preferences are inferable from values/statements

Patient autonomy vs beneficence conflict:

Capacity vs competence: clinical vs legal determination

Voluntarily Stopping Eating and Drinking (VSED): capacitated patient's choice; ethically and legally permissible; distinct from physician-assisted death

Medical aid in dying (MAID):

Withdrawal of artificial nutrition/hydration:

Step 3 management: When a Jehovah's Witness with a valid signed refusal card arrives unconscious after MVC with hemorrhagic shock, honor the refusal — the card serves as an AD; emergency doctrine does not override known wishes. Use alternatives: cell saver, hemostatic agents, factor concentrates

Long-Term Plan — Integrating ACP into Longitudinal Care

— Initiate AD discussion by age 65 or at diagnosis of chronic serious illness — whichever comes first

— Revisit at annual wellness visits (CPT 99497 reimbursed)

— Update with major life events: new diagnosis, hospitalization, loss of spouse, functional decline, transition to assisted living

— Scan AD and DPOA-HC into the EHR with a flag visible on the front page

— Patient keeps original; copies to proxy, primary care, specialists, hospital, family

— State registries exist in some states for centralized access

— Wallet card identifying DPOA-HC and AD location

— Oncology, cardiology, nephrology, pulmonology should reinforce and operationalize ACP with disease-specific information (prognosis, expected complications)

— Avoid contradictory messaging — primary care quarterbacks

— Palliative care: appropriate at any stage of serious illness, concurrent with disease-directed treatment — improves quality of life, mood, and sometimes survival (e.g., early palliative care in metastatic NSCLC)

— Hospice: Medicare benefit for prognosis ≤6 months, focus shifts to comfort; covers nursing, meds for primary diagnosis, equipment, bereavement

Primary care responsibility:

Document storage and access:

Coordination across specialists:

Hospice and palliative care referral:

Re-confirmation triggers (the "5 D's"): Decade of life, Death of loved one, Diagnosis (new), Divorce, Decline (functional)

Quality metrics: AD documentation is a Medicare ACO and MIPS quality measure

Board pearl: Early palliative care referral in metastatic cancer (Temel et al., NSCLC) improved quality of life AND survival vs standard care — palliative ≠ hospice, and early integration is a Step 3 quality-of-care answer

Step 3 management: At diagnosis of metastatic cancer or NYHA IV heart failure, simultaneously order: (1) disease-directed treatment plan, (2) advance care planning visit, (3) palliative care consultation, (4) symptom management

Follow-Up, Monitoring, and Counseling

— Annual Medicare Wellness Visit

— Within 30 days of hospital discharge for serious illness

— At each major care transition (home → SNF, SNF → hospital, hospice enrollment)

— Whenever patient's clinical status or values shift

— Is the named proxy still appropriate and available?

— Do current preferences still match the document?

— Does the family/proxy understand the current prognosis?

— Are POLST orders consistent with current AD?

— Has the patient experienced a clinical event that should prompt update (new dx of dementia, dialysis initiation, ventilator dependence)?

— Distinguish AD from POLST in lay terms

— Reassure patient that AD does not "give up" — it ensures wishes are honored

— Discuss specific scenarios: "If you had a severe stroke and couldn't recognize family, what would you want?"

— Encourage patient to discuss with proxy directly — proxy must know the values to apply them

— Provide written materials at appropriate literacy level; many state forms have plain-language guides

— Identify caregiver burden; refer to respite care, support groups

— Hospice/palliative social work

— Anticipatory grief counseling

— Contact family after death (call, condolence card)

— Medicare hospice benefit includes 13 months of bereavement services for family

— Identify complicated grief and refer to mental health

— Code status banner visible

— AD/DPOA-HC scanned and tagged

— ACP discussions in structured notes for billing and continuity

Cadence for AD review:

What to "monitor" in ACP follow-up:

Counseling content:

Caregiver support:

Bereavement follow-up:

Documentation in EHR:

Board pearl: A common Step 3 quality-improvement vignette: hospital readmission of a hospice-eligible patient with metastatic cancer for unwanted aggressive care — root cause is usually failure to revisit goals of care at discharge and absence of POLST. Fix: standardized ACP at every transition

Ethical, Legal, and Patient Safety Considerations

— Autonomy: patient's right to direct their own care, including future care via AD — the ethical foundation of ADs

— Beneficence/non-maleficence: clinician obligation to act in patient's interest and avoid harm; may include declining non-beneficial treatment

— Justice: equitable access to ACP across socioeconomic and racial groups — significant disparities exist

— Quinlan (1976, NJ): family can request withdrawal of ventilator from PVS patient — established right to refuse treatment via surrogate

— Cruzan (1990, US Supreme Court): states may require clear and convincing evidence of patient's wishes to withdraw artificial nutrition; affirmed competent adults' right to refuse treatment

— Schiavo (2005): highlighted importance of written ADs; PVS patient without AD, prolonged family/legal dispute

— Bouvia (1986, CA): capacitated patients can refuse life-sustaining treatment including artificial nutrition

— Code status not communicated at handoff → unwanted CPR. Mitigation: structured handoff (SBAR/I-PASS) must include code status

— DNR not transferred from hospital to SNF → resuscitation during ambulance transport. Mitigation: POLST accompanies patient

— EHR error showing "full code" despite patient's DNR → wrong-patient or copy-forward error. Mitigation: verify code status at every shift change, with patient/family when possible

— Language barrier in ACP conversations → unreliable consent and surrogate selection. Mitigation: certified medical interpreter, never family member, for high-stakes ACP

Foundational ethical principles:

Landmark legal cases (high-yield):

Patient Self-Determination Act (1990): federal requirement for Medicare/Medicaid facilities to inform patients of AD rights

Patient safety / transition-of-care risks (Step 3 essentials):

Disparities: Black, Hispanic, and low-income patients have lower AD completion rates and higher rates of unwanted aggressive end-of-life care — driven by mistrust, access, and culturally non-adapted materials. Equity-focused ACP is a Step 3 patient safety/health systems theme

Mandatory reporting overlap: suspected elder abuse by named proxy → report to Adult Protective Services regardless of AD status

Step 3 management: At every shift handoff for an ICU patient with an AD, explicitly verbalize code status and goals of care — listed in I-PASS as part of "patient summary." Failure to communicate is a top root cause of unwanted resuscitation

High-Yield Associations and Rapid-Fire Facts

Capacity is clinical; competence is legal — any physician can assess capacity

Capacity is decision-specific and time-specific

A capacitated patient always overrides their own prior AD

DPOA-HC > statutory surrogate hierarchy (proxy beats spouse/children)

General/financial POA ≠ healthcare POA — separate documents

Withholding = withdrawing — ethically and legally equivalent

DNR ≠ "do not treat" — does not preclude antibiotics, fluids, surgery, ICU

AD vs POLST: AD is patient-authored future-oriented; POLST is clinician order immediately actionable by EMS

POLST trigger: "Would you be surprised if this patient died within 1 year?"

Living wills apply to terminal/irreversible conditions — not all serious illness

Cruzan: states may require clear and convincing evidence; affirmed right to refuse

PSDA (1990): hospitals must inform patients of AD rights on admission

Annual Wellness Visit ACP: CPT 99497/99498, billable, no copay

Two-witness rule for living will signing; witnesses cannot be heirs or treating physicians

Mental illness does not preclude capacity — assess decision-specifically

Best interests for never-competent (pediatric); substituted judgment for previously competent adults

Feeding tubes in advanced dementia: not recommended (no survival, no aspiration reduction)

Early palliative care in metastatic NSCLC improved QoL and survival (Temel)

Jehovah's Witness with valid refusal card — honor refusal even unconscious; emergency doctrine does not override known wishes

Pregnancy exclusion clauses in some state AD statutes — state-specific

Ethics consults are advisory, not binding, available 24/7, never wrong to call

Conscientious objection requires transfer of care, not abandonment

MAID legal in select states for terminal patients with <6 months prognosis, self-administered

VSED is permissible exercise of autonomy

Board pearl: When a Step 3 stem highlights a specific signed document on file — your reflex must be to ask "is this an AD, a DPOA-HC, a POLST, or just a financial POA?" — the document type drives the legal authority

Board Question Stem Patterns

— 70-year-old with metastatic cancer refuses further chemo; daughter (DPOA-HC) insists on continuing. Answer: Patient is capacitated; DPOA-HC does not activate. Honor patient's refusal

— 75-year-old with living will declining "life support" presents with septic shock, intubation likely brief. Answer: Living will applies to terminal/irreversible conditions; treat sepsis; clarify goals when stabilized

— Patient incapacitated, named friend as DPOA-HC; spouse disagrees. Answer: DPOA-HC supersedes spouse

— Homeless patient in ICU, no family, no AD, needs decision about withdrawing care. Answer: Exhaust surrogate search → ethics committee → two-physician concurrence or guardianship per state

— DNR patient discharged to SNF, transferred back to ED in arrest, CPR performed. Question: what could have prevented this? Answer: POLST form accompanying transfer

— Unconscious after trauma, card refusing blood. Answer: Honor refusal; use alternatives (cell saver, factor concentrates)

— Depressed patient refuses life-saving surgery. Answer: Treat depression if it impairs reasoning; reassess capacity. If capacity intact despite depression, honor refusal

— Mild-moderate dementia patient consistently refuses PEG. Answer: Assess capacity for this specific decision; if intact, honor; advanced dementia → not recommended regardless

— Family demands continued ICU care for brain-dead patient. Answer: Brain death = legal death; treatment withdrawal not "decision." Provide bereavement support, consider organ donation discussion

— Family says patient verbally stated "no machines." Answer: Use as substituted judgment evidence; encourage written documents in future

Stem 1 — Family override of capacitated patient:

Stem 2 — Living will misapplied to reversible illness:

Stem 3 — Proxy vs spouse conflict:

Stem 4 — Unrepresented patient:

Stem 5 — POLST not transferred:

Stem 6 — Jehovah's Witness with refusal card:

Stem 7 — Capacity assessment in depression:

Stem 8 — Dementia patient refusing feeding tube:

Stem 9 — Family insists on non-beneficial care:

Stem 10 — Verbal AD only:

Step 3 management: First-line answer in nearly every ACP stem is to convene a family meeting / clarify goals of care before invoking ethics, courts, or unilateral action

One-Line Recap

Advance directives — the living will (what care is wanted) and the durable power of attorney for healthcare (who decides) — translate a capacitated patient's autonomous wishes into a legally durable plan that activates only when capacity is lost; honor the capacitated patient's current voice above all, defer to the designated proxy over default family hierarchy, and operationalize wishes across care settings with a POLST.

High-yield recap bullets:

Capacity is decision-specific and clinical, assessed by any physician using the four-component Appelbaum framework; reversible causes (delirium, pain, depression) must be addressed before invoking the AD

DPOA-HC > statutory surrogate hierarchy: the named proxy outranks spouse, children, and siblings — and a financial POA confers no healthcare authority

Living wills apply to terminal/irreversible conditions, not to all serious illness; withholding = withdrawing ethically and legally; DNR ≠ do not treat

POLST translates AD wishes into portable physician orders for seriously ill patients (1-year mortality), preventing the classic Step 3 transition-of-care failure where DNR doesn't follow the patient to the SNF or in the ambulance

Initiate ACP early — at Medicare Annual Wellness Visit (CPT 99497, no copay), at diagnosis of serious illness, and revisit at every major transition; document in EHR, share with proxy and across specialists

When in doubt — family meeting first, ethics consult second, court last; ethics consults are advisory, free, and never a wrong answer on Step 3

Board pearl: The capacitated patient's contemporaneous wish always wins; the AD is a voice-extension into incapacity, not a substitute for the present voice — this single principle resolves the majority of Step 3 advance-directive vignettes