Thinking about getting sick can be scary. Sometimes people think the conversation about advance health care directives is only for when you’re sick or older. Many times, our loved ones feel as uneasy talking to us about the subject as we do talking to them. Having a conversation about advance health care planning is very important.
Even though it may be hard, the best time to talk about it is now! It is easier than waiting until you become ill. No one makes the best decisions when not feeling well or during an emergency.
Making time for discussion can help families and loved ones understand each other’s views about health care during crucial times like medical emergencies and end of life care.
What is an advance directive?
An Advance Health Care Directive (also called medical power of attorney paperwork or power of attorney paperwork for health care) is a legal document that states your choices about medical treatment while naming the persons you want to make these decisions on your behalf when you are unable to do so. The people you appoint are known as your attorney-in-fact or your medical power of attorney/medical POA.
Who can make an advance directive?
In Nebraska, if you are 19 years of age or older and of “sound mind”, you can complete an AHCD.
Why should I have an advance directive?
Anyone can end up in a situation, emergency or not, where they are not able to communicate to their doctor. Reasons can be an unforeseen event like an accident or a sudden onset of an illness or a change in cognition. Under these circumstances, we want you to receive the treatment that you have chosen. We trust that the people you appoint as your medical POA will always know you better than any medical personnel you encounter in a hospital or care facility. Appointing someone as your medical POA and making sure you discuss your healthcare choices and preferences with them (while also having a chance to put them down on paper) will ensure that you are always in charge of your care.
What will the person I appoint be responsible for?
If you are unable to (or choose not to) take part in decision making about your health care, your medical POA plays a very important role, including the following: Meeting with healthcare providers to talk about your health Discussing your medications, tests and treatments Deciding when and where you will get care Reviewing your medical records and information, if necessary Authorizing the release of your medical records, if necessary Ensuring your wishes are followed (or making healthcare choices to the best of their knowledge of your wishes, if you have not expressed them)
When does an advance directive take effect?
An AHCD only takes effect in a situation where you are incapable of communicating to your doctor either due to physical or cognitive difficulties. Just because you completed an AHCD does not mean you are losing control. The medical team will always have you in charge as long as possible. During a regular hospitalization where you are cognizant and competent to communicate, the AHCD will not take effect. The reason we encourage you to complete an AHCD is that in case of an emergency or a sudden decline in communication or cognition you will most likely not have time to complete one and at that point the medical team will need to know who is authorized to speak on your behalf.
What happens if I don’t have an advance directive?
In the absence of an Advance Healthcare Directive, the medical team will follow the Nebraska Health Care Surrogacy Act (“Surrogacy Act”) to identify a person who is authorized to make medical decisions for you. This person is called a Surrogate. You may choose a Surrogate by informing your primary physician who will then record this in your medical record and may need you to complete a form. If you have not designated a Surrogate, the Surrogate Act provides a way to identify someone to speak on your behalf if you are unable to do so. The Surrogacy Act allows the following persons, in rank order, to agree to serve as your Surrogate: (1) spouse (unless legally separated or divorce proceedings have been initiated); (2) adult or emancipated children; (3) parents; (4) adult or emancipated siblings; and (5) a person who has exhibited “special care and concern” for you (e.g., a friend or a distant relative). You also need to know that under the Surrogacy Act, if there is no one available or willing to serve as a Surrogate, your treating physician may, within his professional judgment, make medical decisions that he or she believes is in your best interests. Yet, even with an appointed medical POA or Surrogate, we often see that in a crisis situation the person that is appointed to act on your behalf, along with your family may struggle to make these decisions if you have not discussed your healthcare choices with them. Keep in mind that without an appointed medical POA or Surrogate, and clearly communicated healthcare wishes, conflicts between different people in your life about what they think would be best for you can make it difficult for your doctors to honor your wishes. It will also most likely cause your loved ones to feel more helplessness, distress and pain. Also, under the Surrogacy Act, there may be a Surrogate appointed that you would not have otherwise selected if given a choice. Due to the uncertainties and complexities of appointing someone to speak for you, when you have not done so, it is much better to take the lead and complete an AHCD and discuss your feelings in advance about the types of medical care you would like to receive at end of life or in a medical emergency if you are unable to speak for yourself.
You may also find yourself in a situation where you may not want your direct next of kin to make medical decisions on your behalf. Your only way of making sure the medical team knows to turn to someone else other than a next of kin, is to complete an AHCD. If the medical center is unable to locate any family/next of kin to act on your behalf, they may ask the courts to appoint a person (a guardian) who will make decisions for you.
Whom should I appoint?
You can name anyone who is 19 years or older, whom you trust and with whom you are willing to discuss your healthcare choice. This can be a family member, a friend, or an acquaintance. We recommend that the people you name are easily reachable via phone and are able to communicate clearly in potentially stressful situations on your behalf. You also want to make sure that they are able and willing to communicate what you want and not insert their own opinions, preferences, values or feelings into decision making on your behalf. Your medical POA does not have to live near you, but they need to be available by phone. Your medical POA cannot be a licensed medical professional who is giving medical care to you.
How many people can I appoint?
At least one person. However, we recommend that you have a backup person, in case the first person is not available. Most AHCD forms let you name a primary medical POA/attorney in fact and one or several successors. The successor will be called upon if the person you choose as your primary medical POA is unable or unwilling to serve in that role. You should list your successor medical POAs in order of priority. No matter how many people you appoint, make sure you communicate your medical choices and preferences to all of them. In fact, we recommend that you communicate your choices and preferences to anyone you are close to that would in some way be involved in your care (even just by visiting) in case of a medical emergency. That allows everybody to be on the same page and be supportive of your wishes and your treatment. If you change your mind later, you can always modify your choice(s) simply by completing a new AHCD.
How do I talk to my loved ones about this?
We are aware that this is not an easy conversation to have. However, maybe you want to look at it as a gift that you are giving to the people you are close to. How so? You trust them and love them, hence you want them to have knowledge about who you are not just in good times but also in times of crisis and struggle. This is a part of who you are. Showing them this trust is an act of caring. You are giving them the gift of knowing. Imagine what kind of distress your loved ones may face if you have a medical emergency and they have no idea what you would want. You can help protect them from this situation of helplessness and fear as well as from struggles and hurtful disagreements on what “you might or might not want,” by communicating clearly. It is important that you talk about your medical wishes to your whole family, so that in case of an emergency everyone is on the same page and no one is surprised by your choices. It may help reduce possible hurt feelings and everyone can be supportive of one another and of you.
Does my AHCD cover my wishes about finances?
No, the Advance Health Care Directive, as the name says, only addresses your medical wishes. If you wish to choose someone to take care of your finances or other properties and belonging in case you are not able to, you will have to complete a financial POA paperwork. We recommend you talk to your bank or a lawyer about a financial POA document.
Is an advance directive the same as a DNR/DNI?
A DNR (do not resuscitate) and DNI (do not intubate) status describes your wishes in case your heart and/or your breathing stops. These are a doctor’s orders and need to be signed by a physician. A DNR/DNI order are sometimes chosen by patients who are near the end of life or who have a serious condition that won’t improve, but not always. If you want to be DNR/DNI while in the hospital, please speak to your doctor. He/she will sign the order and enter it into your medical record. You may also give instructions to your POA in an Advance Directive to request your doctor to make you a DNR/DNI during hospitalization under circumstances you determine. If you wish to be in DNR/DNI status at home in case of an emergency where someone would call EMS, we recommend you obtain an EMSOA form (https://lincoln.ne.gov/city/fire/emsoa/pdf/dnr.pdf)
What is the difference between an AHCD and a Living Will?
A Living will is a document where you make your wishes known in the event you are ever so sick that you most likely will not recover (”worst case scenario”). In a complete living will, you grant your doctor permission to withhold or withdraw any life sustaining treatments in case you are actively dying, or in a persistent vegetative state from which to the best assessment of your medical team, you will not wake up. In a Living Will you do not need a medical POA to speak on your behalf, you identify your wishes and communicate them directly to the doctor by way of the living Will document. However, since there are many potential and complex end of life scenarios, we recommend that you complete an AHCD and a Living Will, so you have someone to help make medical decisions on your behalf. The Bryan Medical Center AHCD booklet includes has a separate form for a Living Will (page 11). You may also choose to include instructions to your medical POA in your AHCD as well, in the event you become too ill to recover. (The Bryan Medical Center booklet gives you that option with the form on page 7)
Is a Living Will the same as a Last Will or a Living Trust?
No, a Living Will is about your directives for your physicians at the end of your life and will therefore cease to be effective after your death. A Last Will and Testament is a document about the distribution of your belongings and arrangement of your affairs after your death. A Living Trust is a written legal document through which your assets are placed into a trust for your benefit during your lifetime and then transferred to designated beneficiaries at your death by your chosen representative.
What do I need to know about the Bryan Medical Center AHCD booklet? How do I complete it?
If using the Bryan Medical Center Advance Health Care Directive (AHCD) you have the following choices: Page 7: pre-printed version that includes preprinted, frequently expressed instructions how to treat an end of life scenario (it does not limit the medical POA power to only end of life decisions, it only spells them out specifically for everyone, including your medical team, to see. By choosing this page your medical POA will still be able to make any other medical decision on your behalf that are not end of life related in case you need that help) Page 9: open version; you can individualize your wishes (including not spelling out your wishes by simply stating “medical decisions will be made with the help of the POA” – then nay and all medical decisions will be made by your POA to the best of their knowledge and from your previous discussions before you became unable to communicate) Choose either page 7 or page 9 for your AHCD needs (not both)! Note: Page 11 is the Standard Living Will document without the medical POA part (note this is only for an End of Life scenario, it does not replace an AHCD!) Notarization Note: please do not sign your AHCD until you have a notary present (or two eligible witnesses). There are notaries at Bryan Medical Center that are happy to assist you with notarization free of charge. Please call the Bryan operator (402-481-1111), they will direct you to a notary and you can set up an appointment. There are many other places in the community that have notaries, e.g. banks, municipalities, post offices. Public notaries may charge a small fee. For any notarization, please have a government issued photo ID (e.g. driver’s license, passport) with you for the notary to see before you sign your document.
What should I do once my AHCD is signed and notarized?
Make sure that everyone you appointed has a copy of the completed and notarized AHCD. The original stays with you. We encourage you to give copies to any medical facility where you think you may become a patient or where you have been a patient, so that in case of an emergency a copy is already in your medical file. At Bryan Medical Center, you can simply bring it to the Health Information Management office and they will incorporate it into your medical record file. It is also a good idea to have one copy on file at your primary care physician’s office. Once my AHCD is signed and notarized – is it set in stone? No, life changes and so do you. We encourage you to revisit your AHCD every so often to see whether it is still current for your situation. As long as you are alert and oriented, you can change it at any time. Changes may include both: your medical wishes and the people you designated. Note that for any of these changes you will have to fill in a new AHCD form that will have to be notarized again. You can always get another copy of the AHCD booklet at Bryan and use our notaries for your notarization needs (as well as any public notary). Just make sure you replace any old copy with the new version.
Where should I keep my AHCD?
When possible, a copy of your directive should be uploaded into an electronic medical record. Without a copy of your AHCD, it cannot be used as a guide for your treatment Also, you should keep the original in a safe but accessible place. (Do not keep it in a safe deposit box/lockbox.) Make sure to give copies to your medical POA(s), loved ones (if you feel comfortable), physician(s) and lawyer(s).
When does an AHCD take effect?
An AHCD does only take effect when you are physically not able to communicate or are not of sound mind to make your own decisions. Both of these states will be determined by the medical team. Hence, even though you may be filling in an AHCD now, in most cases your AHCD will not take effect until a future point in time. Look at it as a way for you to ensure that even once you are unable to communicate and make your own choices, you will stay remain in control by having communicated your wishes to a trustworthy individual who will be your voice.
Will my Nebraska AHCD be honored in another state?
Laws about AHCD are different in each state. If you plan to spend more than a little time in another state you may wish to complete an AHCD from that state. Completing an AHCD in another state does not invalidate your Nebraska AHCD.
Are there other versions of AHCD?
AHCDs that comply with another state’s law will be honored in Nebraska if they comply with Nebraska law..
Are Advance Health Care Directives from another state valid in Nebraska?
Yes, there are plenty of other options. You can have your lawyer create an AHCD for you. Note: costs will vary depending on what you want on the document and which lawyer you use. Other popular versions are: Standard plain NE medical POA https://supremecourt.nebraska.gov/sites/default/files/DC-6-13-fillin16.pdf 5 wishes https://www.agingwithdignity.org/ Nebraska Emergency Treatment Orders https://www.nebraskahealthnetwork.com/wp-content/uploads/2018/01/NETOformjan2018-1.pdf
What other resources are available to me if I have questions?
Your physician or other healthcare providers can help you understand your health needs and the options for treating these needs as well as helping communicate your wishes for care in the future to your family or those you might wish to speak for you.
I belong to a faith tradition that has specific opinions about medical care including emergency and end of life care. Can I still use the Bryan Medical Center AHCD booklet?
We recommend you check with your faith group about whether they have their own version of an AHCD. Many do. Examples are Jehovah’s Witness, Orthodox Jews, Conservative Jews, or traditional Catholics. You are always welcome to use the Bryan Medical Center AHCD booklet, but we want to make sure your AHCD reflects who you are as well as your values and beliefs. Bryan Medical Center will, of course, honor any faith based AHCD within the parameters of Nebraska law.