Directives may be completed on one’s own, or a person might choose to seek legal counsel or consult a physician. A physician’s input may be particularly useful when an individual is aware of personal medical problems that may eventually complicate, or knows of a family history of health concerns that the person may face in the future. A doctor can alert the person to the care decisions that may arise and the effects of certain choices. Medicare covers these discussions at an annual wellness visit, and private health insurance may as well. Consulting a physician is not necessary, however, to design one’s advance health care directive. A person may assess her own values, fears, and goals and imagine the care she would want in certain situations (and perhaps asking the same of those closest to her and most affected by her medical decisions), which will guide that person in drafting her advance care decisions. Additionally, the purpose of an advanced health care directive is to provide a person’s intentions and wishes when she cannot. Reassessing these goals periodically is vital to making sure that the advance health care directive still represents an individual’s most current viewpoint and desire.
Advance health care directives most commonly consist of a living will and/or durable medical power of attorney, but advance health care directive formats and substance vary by state and may further differ depending on if a person chooses to use premade forms or draft her directive in consultation with an attorney.
1. Living Will
The living will may be the most dynamic and customizable advance health care directive. It allows a person to memorialize her treatment preferences and make clear the conditions under which those decisions apply. It can include guidelines that are also expressible through other documents, such as resuscitation orders. The living will may additionally communicate the person’s “wishes, values, or goals about any other aspect of [her] care and treatment.”
2. Medical Power of Attorney
Thinking about, discussing, and memorializing decisions related to incapacity, disability, or the end of one’s life may be uncomfortable or entirely unsettling to a person. Designating an individual that the patient trusts to make those decisions for him may replace the need to design his own care plan in advance. However, medical power of attorney does not require an adult to fully relinquish his health care decisions into the hands of this health care agent. He may still execute a living will or include guidelines and instructions in the power of attorney document. The appointed individual acts as an agent or proxy on the patient’s behalf in the event of incapacity and receives that proxy power when the patient preemptively legally prescribes the agent with durable power of attorney for health care. Though the power of attorney is set up while the person still has capacity, unless designated otherwise, the agent may not exercise this power until the person “is medically determined as unable to make decisions,” which may be due to unconsciousness or otherwise losing the capacity to make his own decisions.
In choosing a health care proxy, it is advisable for the person to consider who best shares his views and values about life and medical decisions, or at the very least determine whether the chosen proxy is familiar with his views and can be trusted to put her best effort toward realizing them when making health care decisions on that person’s behalf. After all, “[o]ne of the strongest reasons for naming a proxy is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee.” Appointing a health care proxy, in addition to drafting an advance health care directive, can help a person plan more fully for the future and further ensure that the person’s wishes, as expressed in the documents and previously explained to the health care proxy, are carried out as completely as possible.
3. DNR Order
While preferences regarding resuscitation may be included in a living will, an adult may alternatively or additionally express the desire to avoid resuscitation using a Do Not Resuscitate (DNR) order. The written order, often signed by the patient’s physician, makes clear that the patient wishes “to refuse resuscitative efforts.” This order can exist without needing to accompany a living will or other advance health care directive form, but it is advised that even if such a preference is expressed in a living will, a separate DNR order should also be established. Notably, DNR orders “are the only advance directives that [e]mergency [m]edical service (EMS) providers are legally obligated to consider in most states.”
4. Organ and Tissue Donation
Donation of body parts likewise may be included in other aspects of an advance health care directive and may be explained in further detail in that way. For example, a person’s desire to donate organs could require clarification on a DNR order that machines to keep the heart beating may be used until medical staff are able to remove the donated organs. The person should consider noting in her living will her awareness that such intervention might be required so that medical staff and health care proxies are not confused. However, a person’s desire to donate her organs may also be indicated with a card she keeps in her wallet or via a selection made through the DMV and noted on her driver’s license. A person may also work with a university or other donation program to register to have her body donated for research.
B. Physician Orders for Life Sustaining Treatment
By contrast, a Physician Orders for Life Sustaining Treatment (POLST) is completed by and with a medical professional and is a medical order, not a legal document. Though a POLST may complement an advance health care directive, they are not the same thing, and it is important to distinguish the two to avoid the misinformation that may contribute to low completion rates of advance health care directives.
A living will allows a person to document “more nuanced goals” to inform medical personnel and decision makers in continued care. While “[a]dvance directives are legally recognized documents and doctors must respect your known wishes,” they are not medical orders and “doctors can always refuse to comply with your wishes [as expressed in an advance health care directive] if they have an objection of conscience or consider your wishes medically inappropriate.”
Comparatively, a POLST “provid[es] out-of-hospital medical personnel with legal authority not to provide unwanted life-saving therapies.” A POLST provides clear directions for emergency care providers in a crisis and consists of more “[s]pecific medical orders,” compared to the “[g]eneral . . . treatment wishes” of an advance health care directive that merely act as a “guide” for continued care after the initial emergency.
POLSTs and similar forms often “put the salient points of the advance health care directive in the form of a medical order.” The forms have some variation by state, but they generally include directions regarding cardiopulmonary resuscitation (CPR) and medical interventions beyond CPR, where a person’s health care provider can advise emergency personnel on the treatments required or preferred by the patient.
C. Who Should Create an Advance Care Plan?
Advance care planning is most obviously advisable for those in a later stage of life, those who are currently experiencing a debilitating or terminal disease, or those who are aware of the possibility of such disease occurring. However, any adult capable of expressing his wishes to a family member, attorney, medical professional, or conservator should take the time to do so. At a minimum, voicing such thoughts aloud gives those close to the person a general idea of decisions they should make on that person’s behalf should he become incapacitated. However, memories are fallible, family members in particular may have competing interpretations and motivations, and their recollection of the person’s wishes may not be sufficient to sway a court. Completing documents that hold legal and medical weight while a person is still capable ensures that his wishes are carried out should the need arise. Neglecting to do so “has been shown to prolong a patient’s suffering, decrease their quality and length of life, and incur higher health care costs.” It can also lead to confusion, discord, and difficulties for those tasked with directing care on an incapacitated person’s behalf.
III. Advance Care Planning in the United States
The information above provides an overview of advance care planning generally, but the processes and requirements vary among the states. That said, “most, but not all, states” will honor advance health care directives finalized in another state. An appraisal of the various methods and requirements used by each state highlights common advance health care directive options given across the country and reveals the flaws of the present system.
A. Approaches by States
Certain elements and requirements of advance health care directives are common among many states, and some states make notable additions. All consist of at least a living will and/or medical power of attorney or health care proxy sections, though most include at least one other section. Most states also require either witnesses or notarization. Connecticut includes a witness affidavit section in its directive to help the document survive a potential court challenge. North Dakota requires that the health care agent sign to accept the power of appointment, which is a wise addition to ensure the agent is aware of and prepared for that role. Nevada requires that a physician, nurse, or psychiatric professional fill out a certification of competency for the directive to be effective if a person is already under skilled care. All states require that the person be of the state’s legal age of majority.
Additional sections beyond the living will and health care agent designation vary by state. Arizona, for example, has autopsy laws that merit a section to document wishes about whether to perform an autopsy when one is not required by law. Arizona also allows an adult to express how a funeral and burial should be handled. Georgia has a guardianship section and Connecticut lets a person name whom they would prefer to act as a conservator, should a court deem one necessary. Many states allow patients to designate a physician who will have primary responsibility for health care. Most states have some form of organ donation or other anatomical gift sections.
Almost none of the advance health care directive forms include sections that expressly address what should happen in the case of mental illness, though it will be interesting to see if that changes in the future as mental health awareness becomes more prevalent. Montana adds a section that allows patients to describe any chronic illness or serious disability they have in order to ensure that medical caregivers do not mistake it for a terminal condition that merits different care, and the patient may also provide special directions to accommodate that disability or name a physician who may direct care in that regard. Vermont is among the most detailed. It breaks up its living will into multiple sections that guide a resident to state who may be involved in health care decisions beyond the proxy; express his values and goals; record distinct wishes for end-of-life care, unconsciousness with the chance of recovery, and other situations; discuss disposition of remains; and express any other considerations that the rest of the form did not cover. Texas’s form includes an entire part dedicated to explaining terms used in the document, which is an important addition to clarify for adults precisely what their selections will mean in practice and clarify for health care providers how to implement such directions.
B. Faults in the Current U.S. System
While Texas made the effort to define key terms in its directive, most states did not, leaving room for misinterpretation by people who are unable to afford a lawyer to explain the precise legal effect of their selections. Moreover, lack of conformity between states in key term definitions creates uncertainty about whether an emergency in another state will result in wildly disparate care from what would be applied in a person’s home state. Even if a state’s law expressly honors advance health care directives that are valid in their state of origin, problems may arise, including the inability of health care professionals to know with certainty whether an out-of-state directive was validly executed and the possibility of said professionals misinterpreting terms that have different meanings to doctors in different regions.
Charles Sabatino’s article provides an example of this potential conflict. An advance health care directive executed in Illinois may extend authority over “health care decisions” to the person’s spouse. The term “health care” in Illinois means “‘any care, treatment, service, or procedure to maintain, diagnose, treat or provide for the patient’s physical or mental health or personal care.’” However, just across the border in Wisconsin, the term “does not include authority to consent to the withholding or withdrawal of a feeding tube or long-term admission to a nursing home, unless the advance health care directive explicitly authorizes those decisions.” Such a discrepancy can fundamentally change the way medical professionals across the border interpret the person’s Illinois advance health care directive and thus prevent his spouse from fully honoring his wishes should he become incapacitated during a trip to Wisconsin.
Further, state laws that may, in most situations, be wholly separate from end-of-life care can alter the enforcement of advance care plan provisions in certain circumstances. For example, state law in Alabama restricts the enforcement of provisions “authorizing the providing, withdrawal or withholding of life-sustaining treatments and artificially provided nutrition and hydration” when the incapacitated patient is pregnant.
The current system is also flawed in terms of providing access to the documents once executed. Most states have not created a system that ensures health care providers are “aware that the documents exist or have access to them when needed.” Only about one-fourth of states have registries that provide medical personnel with access to POLSTs and advance health care directives, and not all registries provide access to both. People are advised to provide copies of the documents “to your health care agent, your lawyer, your doctor, family members, and any other person who may be called if you have a medical emergency,” but doing so still might not provide emergency caregivers with timely instructions because individuals with copies of the document may not be around when the emergency occurs. As a result, there is no guarantee that the care provided in an emergency will align with the patient’s wishes, thereby wasting the effort put into the documents’ careful execution.
IV. Autonomy for the Few
The fundamental purpose of an advance health care directive and other advance care planning tools is to fulfill the wishes of a person who no longer has the ability or capacity to make those decisions herself. That alone should prompt individuals in all stages of life and health to formalize their wishes well in advance of any need to do so arising, though stories about ugly legal battles that result from a failure to do so make the argument more convincing. By memorializing health care and end-of-life decisions long before a person faces a dire situation, he can be sure that his wishes are taken seriously and are not called into question as having been fueled by emotion after a diagnosis. Advance care planning also helps ease the burden for family members who would otherwise be tasked with making decisions. Moreover, the documents “are associated with . . . lower health care costs, use of fewer health care services, and a lower chance of dying in a hospital,” as well as “better quality of life, . . . enhanced goal-consistent care, [and] more positive family outcomes.” In short, advance care plans may be greatly beneficial for all adults, regardless of their age or current health status.
A. Efforts to Increase Accessibility and Usage
Given the importance and benefits of drafting advance care plans, states and organizations have made efforts to increase accessibility to advance care planning documents. State government websites now have online advance care planning document forms that may be downloaded and filled out by residents, and some private organizations such as AARP have compiled a version for each state onto a single site, with informational introductions provided in each document. To encourage doctors to start the conversation, Medicare now reimburses physicians for advising patients about advance care plans. Louisiana established an advance health care directive registry in 1991, and in the subsequent decades about a dozen states have followed suit in hopes of allowing medical personnel to access a patient’s advance care planning documents.
B. Persistent Disparities
Despite the benefits of advance care plans and steps that states and organizations have taken to make advance health care directive forms more accessible, as of 2022, only one in three adults had completed any sort of advance health care directive, and that statistic has been stable for years. Studies have been conducted to inquire into the reason that so few adults have utilized these vitally important documents. The Government Accountability Office (GAO) interviewed officials from national organizations and state agencies in several states and reviewed relevant publications on the matter in 2019 and identified several primary challenges “affecting both individuals and health care providers.” These challenges included “a lack of understanding about how to complete the documents,” uncertainty about “how to initiate conversations about advance care planning,” and issues with ensuring that advance care planning documents would be accessible when the time came, “such as in an emergency situation.”
Not only have woefully few adults completed an advance health care directive, but among those who have finalized their advance care plans, there are clear disparities by age, race, health status, income level, and education level. In particular, age and race are the highest predictors of advance health care directive completion. Older adults are more likely to complete an advance health care directive. Even when weighted for population, studies show that white Americans are far more likely to have an advance health care directive than are Black and Hispanic Americans. Other factors contribute to the disparity, as well. Advance health care directives are more common among those with a chronic disease or who receive regular caretaking. Those with greater financial resources may also be more likely to execute a directive, as a 2022 sampling resulted in 70% of patients with advance health care directives falling within the highest income bracket. Higher education is also associated with a greater likelihood of completing an advance health care directive, particularly among white Americans. Comparatively, people with “limited health literacy,” incarcerated persons, racial and ethnic minorities, those who identify as LGBTQ+, and people without homes are among those with the lowest likelihoods of having completed an advance care plan. It is evident that the current system for advance care planning does not result in autonomy for all Americans.
V. An Approach to Advance Care Planning for All
The reality is that end-of-life care is not accessible for everyone. Even just basic knowledge of the various documents and considerations is not universal, and while lawyers are not necessary for filling out an advance health care directive given the prevalence of online versions, a person must still have time and access to internet, a printer, and a notary or witnesses to finalize the document. Should a person complete all of the steps to execute a living will or POLST, those wishes will only be put into effect when the time comes if a knowledgeable person is made aware of the situation and can advocate on the incapacitated person’s behalf to apply his advance care plan, or if the person becomes incapacitated in a location where EMTs can easily find the POLST to know what to do. People with less income, less education, no home, and no family are particularly disadvantaged when it comes to both creating and implementing these documents. The system needs to change to increase all adults’ access to advance care planning and allow medical professionals to easily access a patient’s care plan the moment an emergency arises.
The following proposal would ensure that all adults in the U.S. with a state ID are notified of the importance of an advance health care directive and are given the opportunity to complete one. Additionally, it creates an accessible registry for medical and emergency personnel to access the directive to ensure that a person’s wishes are carried out.
A. Maximizing Accessibility, Both for Patients and Medical Professionals
States should allow the completion of a basic advance health care directive through the DMV, which is then accessible to medical and emergency personnel through a person’s driver’s license information. The proposal is as follows. When individuals turn the legal age of majority, they are notified by the state that they may make their advance care plan selections through the DMV. The notice would include an informational section that (1) ensures individuals have a foundational understanding of their rights and the implications of their selections, (2) alerts them that they may change these selections at any time, (3) informs them that these selections are only used in the case of incapacity, and (4) encourages them to (a) consult a health care professional prior to making their selections and (b) consult an attorney to draft a more extensive advance care plan. Notices are sent out again at age thirty, and then every ten years after that, to let people know that (1) they should make use of the DMV process if they have not already and (2) they should review their prior selections to ensure the advance care plan still aligns with their current wishes.
Selections will include (1) end-of-life decisions, (2) instructions for health care, (3) anatomical gifts, and (4) additional advance care plans. The first category includes choice between resuscitation or DNR order, and the choice to prolong or not prolong life in the event of (a) permanent state of unconsciousness or (b) terminal condition. Individuals may select different choices for each condition. The second category includes the choice to receive artificial nutrition and hydration (a) indefinitely (with option to select “unless” it increases suffering and is no longer in the patient’s best interest), (b) until shown unable to improve, or (c) not at all. It will also include selections for relief from pain (a) always, within medical standards, (b) only if improvement is possible, or (c) not at all. The third category will allow individuals to choose whether, upon their death, they wish to give (a) any needed tissues, organs, or body parts, (b) only the following (with selections), or (c) none. They can then choose whether the anatomical gifts may be used for the purpose of transplant, research, education, or any combination of the three. Finally, the fourth category will allow individuals to make clear the existence of an outside advance health care directive, durable medical power of attorney or health care proxy, or POLST.
States will upload these selections to a registry that allows authorized medical and emergency personnel to check whether an incapacitated patient has completed an advance care plan through the patient’s state ID. The National Driver Register (NDR), which receives information from state DMVs about updates to a person’s driver’s license status and then keeps those records in a computerized database for access by certain state officials, might also or alternatively be utilized to make certain that access extends across state lines. If a national database is used, it would be helpful for states to either establish consistent definitions of key advance health care directive terms across the U.S. or include a glossary of terms and definitions by state in that national database. At the very least, particularly if interstate access is established, it would be wise for an informational site to be created that is easily accessible by both medical personnel and laymen and regularly updated with the salient terms in advance health care directives and their various legal definitions by state.
B. Addressing Concerns
The current system needs massive improvements, and the above proposal will, at the very least, create an avenue to significantly increase awareness of and accessibility to advance health care planning and begin momentum for further changes. With greater accessibility, however, comes concerns that easier access will lead to a litany of security issues, misunderstandings, persistent disparities, and other problems. The following clarifications and suggestions may assuage such concerns.
1. Security
It is easy to imagine the mayhem that might ensue without safeguards to ensure that the individual affected by the advance health care directive is actually the person making selections. For example, for driver’s license renewals, many states allow people to log onto their states’ DMV website to update their changes rather than completing the process in person. A disgruntled son could log on in his mother’s name and select “do not resuscitate,” and no one would be the wiser. The proposed system must, therefore, be designed such that people are confident that no one else may change their selections.
All fifty states require either notarization or witnesses to finalize an advance health care directive, and most states have strict guidelines about who may serve as a witness to prevent undue influence. Requiring people to complete their selections or changes in-person at a DMV will ensure that security continues, perhaps at an even higher level. DMVs take great care in confirming identity before issuing a driver’s license, which is a commonly used means of identification for the notarization process. As such, DMVs are equipped to confirm identity with ease for the proposed advance health care directive process. To further instill confidence in the security of this system, as well as to give people a physical reminder of their prior choices, states may want to mail out a print confirmation of choices every time changes are made.
2. Ability to Access a DMV
While an in-person visit to the DMV is ideal for maximizing the security of the process, it is not a preferred or even possible option for many adults. People who are disabled, suffering from a debilitating illness, or of advanced age may lack the capability to complete an in-person visit to the DMV. Furthermore, the hours of operation of a person’s DMV may be wholly incompatible with a hectic work schedule, and many adults may be unable to access transportation to get there. Thus, requiring all adults to complete their initial or subsequent DMV advance health care directive choices in person may not fix the disparities present in the current system.
Additionally, DMVs are notoriously busy already, which dissuades people from visiting them until absolutely necessary. Even for those who have the time and health to make an in-person visit, the hassle alone could make this proposal ineffective. Opening other government entities like post offices to the public for the purpose of completing a DMV advance health care directive would make the process more accessible. California, for example, has expanded some DMV services to U.S. Post Office locations, which lessens the burden on DMV locations and expands the number of locations adults may access to complete DMV tasks. Still, another option is needed to combat barriers posed by health, work schedules, and transportation issues.
Due to the Covid-19 pandemic, in-person notary laws were relaxed and forty-one states now allow for remote online notarization. Additionally, as mentioned above, over one-third of states allow for online renewal of drivers’ licenses, though many states limit that option to only those above a certain age. Allowing online alterations to advance health care directives under the proposed system is not out of the realm of possibilities, and may be utilized by states already comfortable with the potential security risks posed by online license renewals. However, given the literal life-and-death nature of security concerns that come with online alterations to advance health care directives, states may feel more comfortable with allowing notarized selections to be mailed in to the DMV. Such an option could be open to all of the state’s residents, or it may be limited only to those who have petitioned with a legitimate reason.
3. Capacity
As with any legal document, the issue of ensuring capacity arises. Encouraging younger and healthier adults to complete advance health care directives before any physical or mental ailments are at issue would ideally lower the likelihood that an advance health care directive is challenged on the grounds that the person lacked capacity at the time the person executed the directive. However, the DMV would likely not be prepared to assess a person’s capacity, which may just as easily be at issue with a young person on his very first time filling out his DMV advance health care directive as it could be for a person who received notice to review her selections ahead of her seventieth birthday.
Legal documents require a certain level of capacity for completion, and “the threshold level of capacity required for legal competence has to rise as the consequences become more serious.” Ultimately, it is a matter of balancing autonomy with wellbeing and determining risks and benefits of prioritizing autonomy in certain decisions. In general, “[a]dults are presumed to have legal capacity unless demonstrated otherwise.” It has been suggested that, for completing an advance health care directive, “the standard should be set so that a person who can retain information long enough to reach a thoughtful decision should be considered competent. This time might be as short as 10 minutes.” California’s standard is likewise a rather low burden, allowing “[a]ny person 18 years or older who has the ‘capacity’ to make health care decisions” to complete an advance health care directive. Capacity to make health care decisions means, in California, that “the person understands the nature and consequences of the proposed healthcare, including the possible risks and benefits and is able to make and communicate decisions about that healthcare.” Importantly, an adult in California is “[l]egally . . . assumed to be competent unless proven otherwise.”
At its most fundamental level, an advance health care directive is meant to champion autonomy and give adults the ability to make decisions for themselves no matter their health situation. Thus, barriers to completing a directive should be as few and unrestrictive as possible. This paper proposes to adopt the California method: an adult is considered competent to complete an advance health care directive unless proven otherwise. Thus, anyone of the age of majority may be assumed competent by the DMV unless their capacity to do so has been formally called into question with supportive evidence.
However, minors are generally considered to inherently lack the same level of capacity as adults and are thus not given the same legal autonomy until they reach the age of majority. Minors are presumed to be under the care of a parent or guardian, and that caretaker makes health decisions on the minor’s behalf. It is no wonder, then, that states limit completion of an advance health care directive to those who have reached the age of majority. In recognition of that limitation, the proposed system recommends that states not allow people to make advance health care directive selections through the DMV until they reach the age of majority, except in the case of emancipated minors.
4. Adequately Informing Adults and Encouraging Further Medical and Legal Consultation
Wishes expressed in an advance health care directive will guide emergency and medical personnel if a person lacks the capacity to direct her medical and end-of-life care when the time comes. The choices do not simply advise on what is to be done after a patient passes. Advance health care directives can also direct the level of comfort and types of care provided in various situations, or whether a person is revived at all. An adult’s selections thus are highly consequential in the event of a medical emergency, and as such, she must be adequately informed of her rights and options as well as what her choices will ultimately mean when carried out.
As laid out in more detail above, this proposal includes sending out notice that explains the process and advises people to seek out further consultation from medical and legal professionals. This notice should be sent out well in advance to give a person adequate time to seek out such consultation, if possible, or at the very least begin thinking about preferences. However, given the persistent disparities under the current system, it is unlikely that such advice alone will close the barriers faced by those with less income and education when trying to understand the highly precise terms and their full implications. Furthermore, people without homes may miss the state’s attempts to send notice. States should therefore take steps to provide as much free and easily accessible information as possible. These steps may include directing people to a website that contains educational resources such as written clarifications of terms and selections, or videos that make the process and requisite information more digestible. Legal aid organizations may also step in to assist those who cannot afford legal advice by hosting clinics and offering services specifically dedicated to advance care planning, and homeless shelters might post information about the subject and flyers for upcoming local legal aid clinics.
5. Providing Sufficient Level of Detail
A natural limitation to this system is that, unlike a living will completed on one’s own or with the help of an attorney, the DMV system will allow only for check boxes to be clicked and will not let a person type in written clarifications. This method minimizes the chance that a person’s DMV directive confuses medical personnel, but it also means that selections may not fully reflect a person’s wishes or the conditions under which a different action should be taken. To balance those competing interests, the proposed system should include as many conditional choices as is reasonable to most fully express the adult’s wishes without adding unnecessary confusion for the adult or medical professionals.
Further, the notice and DMV advance health care directive form will remind adults that they are not required to select anything. If a person does not feel prepared to create an advance care plan through the DMV at this time, he may leave the form entirely blank until he is ready. If he wants no part in directing his end-of-life care, he can take the proper steps to appoint a health care proxy and then check the box on the DMV form that notifies health care providers they should seek out that agent for further instructions in an emergency. If he feels the DMV form does not fully encompass his plan, he may select the choice that alerts emergency personnel to the existence of more detailed documents that supplement or wholly replace the DMV directive so that care providers know to ask the health care proxy or family members to furnish that document.
6. Disparate Levels of Care
Some people harbor fear that certain advance health care directive selections will trigger harmful bias by medical personnel who may intuit that the patient requires less attention and care and will thus treat the patient differently than if the patient had made no advance health care directive at all. In particular, data regarding DNR orders suggests that patients who have such an order on their chart may receive different treatment options from physicians than patients without. Further, the DNR order “only applies to the decision to withhold CPR in the event of a cardiopulmonary arrest,” but it “may be interpreted by some health care providers as meaning, do not provide additional lifesaving care.” Studies have found that “many providers inappropriately alter treatment plans for patients with a DNR order without discussion with the patient or surrogate.” It is thought that a DNR order may “result in a negative effect on the overall quality of care, which may contribute to the variation noted in mortality rates between patient[s] with and without a DNR order.”
Ultimately, this bias must be addressed within the medical field. It is possible, however, that a normalization effect will occur as more people utilize advance health care directives and make clear whether they wish to be resuscitated. Additionally, wider usage of the documents could also help to identify patterns from certain providers in the level of care they take with patients dependent on their DNR selection so that legal and professional repercussions may follow.
C. Benefits of the Proposed System
The benefits of offering DMV advance health care directives are plentiful. Because adults generally need some form of ID and interact with the DMV throughout their lives for other purposes, the proposed system would encourage more than just elderly, ill, and wealthy people to formalize a basic advance care plan. The notice requirement involved in this system would also increase awareness of the existence of advance care planning tools, provide a basic understanding of an adult’s rights and options in that regard, and encourage further consultation about and preparation for end-of-life and emergency care. This increased awareness and usage should begin normalizing preparation for end-of-life and emergency care at any age and health level.
The proposed system will also benefit health care and emergency care providers. Providers will be able to access patients’ selections simply by scanning their driver’s license, which will give emergency professionals immediate orders regarding resuscitation and will ensure that medical personnel know if there are specific care wishes or a health care proxy that should be consulted before providing further care. If an interstate registry is utilized, health care providers across state lines will be able to honor the selections as well. Standardization of key terms by states—or at least including states’ definitions in a nationwide database or collecting the various definitions in some other online source—would also provide certainty for medical professionals and patients about the implications of each selection. This information would lessen the chance of confusion, discrepancy, or error in how an advance care plan is implemented across state lines, even if the precise components of each state’s DMV advance health care directive vary to some degree.
VI. Conclusion
Advance care plans produce widely felt benefits—they give incapacitated patients a voice, provide peace of mind for patients and families, lessen the chance of discord and expensive legal battles, lower health care costs, and guide caregivers. The current system, however, has not remedied the shockingly low rates of completion and unfortunate disparities. The proposed method would increase awareness, usage, and accessibility to promote autonomy for all.
