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What are Important Documents?

It’s never too early – even though it may be a difficult conversation, many people have said they felt empowered after expressing their final wishes.

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Planning for your future healthcare needs can be a challenging and confusing process. The many legal and medical forms can leave you uncertain of which one to complete. However stressful it is, deciding and completing these documents now can prevent a lot of pain, confusion, and stress in the future. Outlining your medical wishes and end-of-life care helps ensure your wishes are fulfilled and alleviates the challenges your family may suffer from making decisions for you.

Although the terminology may vary by state, there are:


  • Medical forms completed by physicians (e.g., Physician Order for Life-Sustaining Treatment, Do Not Resuscitate)
  • Legal documents completed with the assistance of an attorney or judge (e.g., Power of Attorney, Living Will)
  • Independently completed documents with or without attorney assistance (e.g., Advance Directive)

Many of these documents cover the same information but are focused on communicating different aspects of your medical and financial care. If you would like to discuss these options further, a great place to start is your primary care physician and an AT Home Care and Hospice hospice case manager or medical social worker.

Physician Order for Life-Sustaining Treatment (POLST)

A physician order for life-sustaining treatment (POLST) has different titles for each state. For example, in your state, it may be called a Medical Orders for Scope of Treatment or Portable Medical Orders. Regardless of its title, a POLST is a medical order that remains valid even outside the doctor’s office. This order is similar to a prescription for medications.

The POLST can include several things, such as:


  • Part of your advance care planning to help you live your best life
  • A discussion with your provider that includes information regarding your medical condition, treatment options, and your medical decisions
  • A form that can travel with you to communicate this information

The POLST form outlines to all healthcare providers what you would like to happen if you were in a medical emergency. These choices can include:


  • “I want to be taken to the hospital” or “ I would like to stay in my own home”
  • “Perform CPR” or “Do not attempt CPR”
  • The types of treatments you are willing to accept and those you are not
  • The plan you would like to have followed if you are unable to communicate your wishes

Although this may sound like other plans of care, like a Do Not Resuscitate, the POLST gives you specific direction over the types of healthcare treatments and for how long. The POLST is especially useful for those who are seriously ill.

Do Not Resuscitate (DNR)

A Do Not Resuscitate (DNR) is a medical order written by a physician. This order informs healthcare providers not to perform cardiopulmonary resuscitation (CPR). CPR is typically performed when your heart stops or you stop breathing. DNRs can also include a Do Not Intubate (DNI) order. A DNI informs healthcare providers you do not wish to be placed on ventilation for breathing.

A DNR is specific to CPR and does not include information regarding continued life-sustaining methods. CPR can involve:


  • Mouth-to-mouth breathing
  • Pressing down onto your chest
  • An electric shock to your body in an attempt to restart your heart
  • Breathing tubes
  • Life-saving medications

Although it is recommended to have an advance directive or living will, you do not need either to have a DNR.

Choosing a DNR can be a very difficult decision, so it is important to talk about it with your doctor, who can help you understand any pros and cons of choosing a DNR. Once you have made the decision, you inform your doctor, who then writes the medical order in your medical record.

A DNR can be part of a hospice care plan. Palliative care and hospice focus on treating your symptoms in order to achieve and maintain an acceptable level of comfort. Hospice care is neither designed to treat your disease nor hasten its progression; rather, hospice is meant to make the remainder of your life comfortable. If admitted to hospice care, your hospice care team can assist you with these types of decisions. Additionally, your hospice care medical social worker can assist you in discussing your wishes with your loved ones.

Power of Attorney (POA)

A power of attorney (POA) is a legalized document that gives permission to someone of your choosing to act on your behalf, should you be deemed unable to do so for yourself. In some states, this can be also be referred to as a durable power of attorney.

In the POA, you will identify at least one person whom you trust to make decisions for you. POA forms are available online, but you might want an attorney to assist you in creating your POA. In some cases, if someone is not identified in a POA, a court will assign someone to be your guardian.

In your POA, you can give permission to different people for different roles, such as:


  • Financial POA
  • Medical POA
  • Combined POA

The financial POA is allowed access to your finances to pay your bills or sell your property. The medical POA, whether you select them or they are assigned, will be able to make medical decisions for you if you are incapacitated for any reason. A combined POA can allow you to control multiple aspects, such as both financial and medical decisions.

A POA does have some risk involved, as you are giving power to someone else. Unfortunately, some may abuse this power. Abuse of a POA can be seen as:


  • A forgery of the document
  • Pressuring you to grant them authority even if you do not want to
  • Pressuring you to spend money on them or for their benefit
  • Doing things that you did not authorize them to do

Be sure to select a POA that can be trusted and considers your best interests as top priority.

Our services include:

  • On-Call Hospice Support – 24 hours a day, 7 days a week
  • Pain Management – Treatments to help with pain and discomfort
  • Symptom Management – Treatments to aid with anxiety, breathing, nausea and other symptoms
  • Medication Coordination – Allows proper medication to be available when needed
  • Registered Hospice Nurses Visits – Scheduled to meet your individualized hospice nursing care plan
  • Nurse Aide Visits – Scheduled to aid with  personal care: bathing, feeding, dressing and other duties
  • Hospice Team Visits – Hospice counseling, program implementation, insurance  coverage, support and follow-up visits
  • Volunteer Visits – Scheduled for companionship, errands and light duties
  • Bereavement Services – 13-month bereavement services post-death to all family members and loved ones

Living Will

A living will is also a written legal document. A living will outlines your preferences for medical care. A living will provides instructions on how you would like to be cared for if you are unable to make those decisions for yourself. Your living will should address several of your end-of-life decisions such as your interest in:


  • Receiving cardiopulmonary resuscitation (CPR)
  • Enduring mechanical ventilation (i.e., machines that take over your breathing)
  • Enduring tube feeding
  • Receiving dialysis
  • Taking antibiotics or antiviral medications
  • Participating in comfort care, palliative care, and hospice
  • Donating your organs and tissue
  • Donating your body to schools and science

Advance Directives

An advance directive informs doctors and caregivers of your healthcare choices and can help guide them when you are:


  • Terminally ill
  • Seriously injured
  • In a coma
  • In a late stage of dementia
  • Near the end of your life

Each state has different requirements and forms to make your advance directive legal. You may consider consulting with an attorney to assist you in creating this document; however, it is not necessary. For many states, it is sufficient to have yourself and a witness sign, whereas in others, you may need to have the document notarized.

When completing your advance directive, it is a good idea to discuss it with your doctor so they can ensure the form is filled out correctly. An advance directive can be changed. Sometimes you may want to change your medical preferences due to:


  • New medical diagnoses
  • Change in marital status
  • Age of the document

AT Home Care & Hospice is Your Partner in Care

Couple in process of care planning with doctor

If you are under the care of our hospice team, your hospice social worker can be helpful throughout the process of making these types of decisions. Your hospice social worker can also help you and your family create these documents or get you connected with local attorneys.

If you are not already connected to a hospice care team, start with your primary care physician (PCP). Your PCP can help get you connected to resources in your area who can help with these types of documents.

Regardless of which documents you choose, always:


  • Keep the originals safe
  • Provide copies to your doctor
  • Provide copies to any involved party (e.g., who you selected as your POA)
  • Talk to your providers, family members, and other important people about what is outlined in these documents
  • Keep a copy on you when traveling

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