Medical Advance Directives

What are Medical Advance Directives?

Advance Care Planning is about making decisions for the treatment you want if you become unable to speak for yourself. Advance Directives are the documents used to document medical treatment preferences.

Advance Directives are legal documents that inform medical professionals, family, friends, and others about your medical treatment choices in the event you become incapacitated and cannot speak for yourself. Advance Directives refer to a Living Will, Medical Durable Power of Attorney (MDPOA), Cardiopulmonary Resuscitation (CPR) Directive, Medical Orders for Scope of Treatment (MOST), and other directives concerning your medical care in the event you become incapacitated and cannot speak for yourself or you are at end-of-life.

Most people ages 18 and over should use the MDPOA and Living Will. These two documents tell health care providers whom you want to speak for you if cannot speak for yourself and what types of treatments you may or may not want in case of a future, unknown medical emergency. For people that do not want Cardiopulmonary Resuscitation (CPR) they should talk to their doctor to complete a CPR Directive that tells doctors and other medical professional to not give CPR in case of a medical emergency. People that want CPR in case of an emergency do not have to take additional steps.

People with a serious life-limiting condition or who are really sick or very frail should consider having a Medical Orders for Scope of Treatment (MOST) Form. A MOST Form is a doctor’s order and gives specific directions about medical treatment, including treatment of infections, CPR, and comfort care such as food and water.

You should review your advance directives at least annually to ensure they still meet your needs and preferences. Other major life events in which you should review your advance directives are in case of marriage, divorce, change in health condition or new diagnosis, or if you change your mind about your agent, representative, or choices. If you make changes to any advance directives, provide new copies to all the appropriate parties and ask them to destroy the previous copy.

Storage of Advance Directives

On May 16, 2019 the Colorado legislature passed into law bill SB19-173 to create a statewide electronic system for advance directives. The Department of Public Health and Environment (department) was allocated $1 million to set up the system. The department is required to contract with one or more health information organization networks for the creation, administration, and maintenance of a statewide electronic system that allows qualified providers to upload and access advance directives.

While the electronic statewide system for advance directives is under construction, we encourage everyone to continue to use paper copies and give copies of your advance directives to your agent, alternate agent(s), and doctor.

A tool to manage an individual's medical affairs, including making medical decisions. An MDPOA is given with the individual's consent while still capable.

What is an MDPOA?

A medical durable power of attorney (MPOA or MDPOA) authorizes a named agent to make any and all health care decisions for an individual upon incapacitation. While legally recognized, there is no standardized form and individuals are free to make their own or use another one. There can be limitations on what authority is given to the agent, what specific treatment should be pursued in specific cases, how it relates to other directives and anatomical gifts. An individual must give informed consent to a MDPOA, meaning that the individual must be commonly judged to be of sound mind and capable of understanding the repercussions of such an action. Individuals who cannot give consent cannot have a MDPOA, and must instead use a medical health care proxy or court-appointed guardianship.
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A tool for an individual to lay out in advance their preferences for life-sustaining treatment, artificial nutrition and hydration when medically incapable of speaking for themselves.

What is a Living Will?

A living will provides for the termination of medical intervention after the attending physician and another physician have determined that the suffered condition is irreversible and the patient has been comatose for seven consecutive days. Forty-eight hours later, artificial nourishment or life-sustaining procedures can then be terminated. A living will is a legal document, but should be accompanied by a medical power of attorney to verify that an individual’s wishes will be faithfully executed.
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A tool to inform medical personnel to withhold cardiopulmonary resuscitation (CPR) in emergency and non-emergency situations.

What is a CPR Directive?

The CPR Directive instructs medical personnel to withhold Cardiopulmonary Resuscitation (CPR) in the event a patient’s heart or breathing stops. By law this is an opt-out medical service, with the legal assumption being that an individual has consented to CPR unless a Directive is executed. A CPR Directive may be issued independently or as part of the MOST form discussed below. A CPR Directive must be signed by the primary physician and the individual (or the individual’s Medical Power of Attorney or Medical Health Care Proxy) in order to be valid. It is recommended to keep a copy at all times, as EMT or other emergency personnel may not be adequately informed of an individual’s intentions.
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A tool whereby an individual can choose their broad wishes for care, particularly for those individuals who deal with multiple medical providers.

What is a MOST?

The Medical Orders for Scope of Treatment (MOST) is a form executed by both an individual and his/her physician, advanced practice nurse or physician assistant. It outlines the broad wishes for care, including the use of CPR, antibiotics, artificially administered nutrition and the level of medical intervention. It is intended for chronically or seriously ill patients who will interact with many health care professionals where a standardized form is helpful. The form follows an individual from one health care setting to another, and organizations are assumed to comply with MOST unless they specifically inform an individual and offer him/her transfer to a facility that does comply. The Colorado Advance Directives Consortium has also created an instruction booklet on how to use the form.
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A tool for selecting a responsible person to make medical decisions for a person who is incapacitated and had no other arrangements in advance.

What is a Medical Health Care Proxy?

This is a document drawn up by interested parties to assign an individual the right to make medical decisions for another individual who is unable to make his/her own decisions and does not have a medical power of attorney. The health care proxy can eliminate the need to go to court for a full guardianship to medical decisions for the incapacitated individual. There is no standardized document, but many physicians and hospitals may have their own form. Because this is not standardized, the authority does not follow an individual and must be confirmed by the interested parties after every transfer.
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A tool for terminally ill individuals who are otherwise capable to choose end-of-life options in a time and place of their own preference.

What is Medical Aid in Dying?

Colorado’s End-of-Life Options Act authorizes the practice of medical aid in dying, allowing a terminally ill, mentally capable adult with six months or less to live to request from their doctor a prescription for medication that the patient can decide to self-ingest to die peacefully if their suffering becomes unbearable. Two Colorado physicians must confirm the patient’s eligibility, as well as confirm that the patient is making an informed decision and voluntarily requesting the aid-in-dying medication. The patient may change their mind at any time and withdraw their request, or choose not to take the medication.
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A tool for individuals with mental or behavioral conditions to specify their preferences for treatment and medication, as well as for alternative therapies, and to record behavioral health history.

What is a Behavioral Health Order?

A Behavioral Health Order Form (or Psychiatric Advance Directive, PAD) is a document that outlines that individual’s instructions concerning behavioral health treatment medication, and alternative treatment decisions, preferences, and history in the event that the individual lacks decisional capacity to provide consent to, withdraw from, or refuse treatment or medication. The form optionally allows for an individual to appoint an agent to execute these preferences and make medical decisions within that scope. The form is effective for two years unless revoked earlier, and can be renewed. The form also follows an individual through multiple medical providers.
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