Nursing Home Social Services Reference/Flow of Care/Advanced Directives

Advanced Directives COLST, POLST, MOLST, MOST and Other Portable DNR Forms These include several documents that indicate the resident's wishes for life-sustaining care in the case of a medical emergency such as a heart-attack a stroke or a life-threatening accident. Requests for extreme measures to preserve the resident's life can be indicated and indications that the resident would prefer to not have any or all of the following: CPR, intubation, ventilators, dialysis and aggressive antibiotic treatments. (The forms a state prefers by state law can be found here: https://polst.org/state-programs/.) A copy of the POLST form can be found at here: https://polst.org/wp-content/uploads/2026/02/National_POLST-Form-12.25.pdf. Durable Medical Power of Attorney Advanced directives also includes the Durable Medical Power of Attorney (DMPOA/MDPOA). This is a person who knows the resident's preferences for medical care and someone the resident would recommend to make decisions for the resident if needed. This need would arise in the case that the resident is unable or not competent to make a decision. That a resident requires a substitute decision-maker is usually declared by the physician for the resident. Some states have various conditions or requirements for this decision. It would be important to understand this. Your Medical Director might like to make a presentation about declarations of (in)competence to the staff at your nursing home or you can ask a local eldercare lawyer to do this. The Durable Medical Power of Attorney is called a power of attorney because it enables the named person (or persons) to make decisions for the resident that signs it. It is a medical power of attorney because this decision-making power is limited to medical decisions for the resident. It is called "durable" when it is declared once and can be used for any number of events where the resident is unable to make decisions for themselves, they recover and the again need a surrogate decision-maker. This is the kind of advanced directive that could and should be in the resident's chart. These documents to be valid must have a "wet-signature" on them. To make this clear, the signature could be in blue ink. Because these go to the hospital or other places with the resident, you will want to have a few "wet-signed" copies of the MDPOA. State Required Formats In some states, like CO, the MDPOA must be a standalone document. It cannot be part of a global Power of Attorney document granting decision-making for other areas beyond medical decisions. In some states the MDPOA needs to be witnessed or notarized or both. Look up the specific laws in your state for the endorsement requirements. POA is NOT Guardianship In no state, is the Medical Power of Attorney making decisions for the resident when a resident can competently (again as decided my an MD) make their own decisions about their medical care or anything else. For residents who need on-going medical and other decisions made for them, see the section on Guardianship. Medical Proxy When there is not a MDPOA document and a resident needs a surrogate decision-maker, some states allow the medical team to help to appoint such a person. The team must assemble a group of as many "interested parties" for the resident as possible. The next step is to gather them on a conference call, Zoom or do shuttle diplomacy (talk to each member separately, carrying the messages of all the other members to each other) and have this group appoint a proxy decision-maker for medical decisions. This proxy generally is valid while the doctor who signs the proxy is engaged with the resident, so that this is usually limited to a single hospital stay. Since the person who is the proxy has agreed once to represent the resident, they may be a likely candidate for an MDPOA if the resident is competent to agree to it. Living Wills This is a document that may contain any or all of the above documents (except the Medical Proxy). It is designed to help the healthcare team understand their wishes for medical emergencies as well as funeral service and interment wishes. It may describe those whom the resident would like to make decisions for them when they are not able. If properly endorsed, it may be used as the DMPOA. The Living Will may have detailed requests for the format, songs, presiding cleric, and other specifics of the funeral service. It may also describe the kinds of foods, essential oils/candles, music, readings and other desires for the environment around their deathbed before and after death. It may also include requests for burial and site, cremation and ash spreading, or other details of the interment. Five Wishes is a popular living will form. There is a cost to using this form. This can be found here: https://www.fivewishes.org/for-myself/