Health Care Planning Terms and Tips
Health care planning is a lifelong journey to get the kind of care you want at every phase of health. Here's a guide to help understand commonly used terms and definitions based on Massachusetts law and standardized medical information. Our Tips offer some practical information and links to resources.
For downloadable FAQs and Fact Sheets on many of the topics below, see our Resources page here.
Advance Care Planning
Advance care planning is commonly thought of as a process to think about your future medical care and write down your care preferences in Massachusetts care planning documents, such as a Health Care Proxy and Living Will, and sometimes a MOLST form, Medical Orders for Life-Sustaining Treatment.
TIP: Also read about Health Care Planning, which includes planning about future care and working in partnership with your care providers to get the best possible care today and every day over your lifetime.
The term Advance Directive can have several meanings. It is used as a general term referring to one or more care planning documents to direct future medical care. It also can refer solely to a Health Care Proxy, a legal document recognized as an advance directive in Massachusetts.
TIP: If you are asked – “Do you have an advanced directive?”, ask the person if they want to know if you completed a Health Care Proxy, or if you completed other planning documents that might include a MOLST form.
Artificial Hydration and Artificial Nutrition or Medically Assisted Nutrition
Artificial Hydration and Artificial Nutrition, also known as Medically Assisted Nutrition, is a medical treatment that supplements or replaces ordinary eating and drinking by giving a chemically balanced mix of nutrients and/or fluids through a tube placed directly into the digestive tract (enteral) or through a tube directly into a vein (parenteral).
Artificial respiration/ventilation is the forcing of air (either by mouth-to-mouth or mouth-to-nose means) into the lungs of a person who has stopped breathing.
TIP: If you have a serious illness or advancing frailty, you can complete a MOLST form with your clinician to communication your treatment choices regarding artificial respiration/ventilation in a medical emergency.
Capacity in health care decision-making typically refers to an individual’s ability to make and communicate decisions about his or her health care, safety and well-being. Generally speaking, adults have capacity if they can understand the medical diagnosis and prognosis, appreciate the nature of the recommended care and the risks and benefits of each alternative, and use logical reasoning to make a decision. Capacity can vary over time, and can be lost and regained.
TIP: Determining if a person has the capacity or ability to make and communicate health care decisions is a medical determination made by the individual’s attending physician. Since a person's capacity can be regained, it is important to ask for a medical reassessment to protect a person's right to make their own care decisions.
Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is the administration of heart compression and artificial respiration to restore circulation and breathing. CPR is a set of procedures that may include:
- Pressing on the chest to mimic the heart’s functions and cause blood to circulate
- Inserting an airway into the mouth and throat, or inserting a tube into the windpipe
- Ventilating artificially, through mouth-to-mouth or other mechanically assisted breathing
- Using drugs and/or electric shock (defibrillation) to stimulate the heart
TIP: If you have a serious illness or advancing frailty you can complete a MOLST form with your clinician to communication your treatment choices to attempt or not attempt CPR in a medical emergency.
Code status refers to a medical order directing treatment if a patient is unresponsive, without a pulse, and/or is not breathing. Typically, code status orders specify whether or not to initiate cardiopulmonary resuscitation (CPR) and endotracheal intubation and mechanical ventilation. In the absence of a specified code status, the default in health care facilities and emergency medical situations is to attempt resuscitation. A Do-Not-Resuscitate (DNR) order states that health professionals (in health facilities) and emergency first responders (outside health facilities) should not initiate CPR or perform intubation.
Comfort Care/Do Not Resuscitate Verification protocol (CC/DNR) or DNR
Comfort Care/Do Not Resuscitate Verification protocol (CC/DNR) is a followed by emergency medical service (EMS) personnel when encountering an authorized CC/DNR Verification Form outside of a hospital setting. It directs that a patient in respiratory or cardiac arrest be made as comfortable as possible, but that no resuscitative measures be attempted.
Comfort Measures Only Orders; or Comfort Care Measures; or Comfort-focused Treatment
Comfort Measures Only (CMO), also known as Comfort Care Measures or Comfort-focused Treatment, refer to medical orders for a seriously ill patient signed by a physician, nurse practitioner, or physician assistant, that indicate a patient’s care and treatment plan is to maximize comfort through symptom management and allow for a natural death.
A conservator is a person, such as a family member or friend or entity appointed by the court, to manage the money, property, and business affairs of a disabled or incapacitated person.
Conservatorship is a protective legal process in which the court may appoint a person called a Conservator. A Conservator’s role is to marshal and manage the property of an individual who is disabled and who requires a substitute financial decision maker either to prevent the property from being wasted or dissipated, or so that the financial support, care, and welfare of the person is effectuated and managed.
Dementia is not a specific disease but an overall term that describes a wide range of symptoms and conditions. Dementia is associated with a decline in memory, thinking skills, and communication skills to the point that it the decline effects an adult’s ability to perform daily tasks. There are many types of diagnosed dementia conditions such as Alzheimer’s disease, Vascular Dementia, Lewy Body disease, Frontotemporal Dementia and others. Dementia can be diagnosed at several stages, as early, middle or late stage dementia. The diagnosis alone may not tell you whether an individual has the decision making capacity to sign a Health Care Proxy and participate in health care planning. If you are unsure whether a person has the ability to make effective health care decisions, ask a doctor or clinician to make a medical determination.
TIP: The Alzheimer’s Association 24/7 Helpline (800.272.3900) provides free confidential support and information to people living with the dementia and their caregivers, families and the public.
Dialysis, the process of filtering the blood through a machine via two small tubes inserted into the body, removes waste products from the body in the way that the kidneys normally do. Dialysis can be done temporarily in order to allow the kidneys time to heal, or it can be done on a longer term basis in order to prolong life.
Do Not Hospitalize Orders (DNH)
Do Not Hospitalize Orders (DNH) are medical orders, signed by a physician, nurse practitioner or physician assistant, that instruct health care providers not to transfer a patient from a setting (such as a nursing facility or the patient’s home) to the hospital unless needed for comfort- focused treatment.
Do Not Intubate Orders (DNI)
Do Not Intubate Orders (DNI) are medical orders, signed by a physician, nurse practitioner, or physician’s assistant, that instruct health care providers not to attempt intubation in the event of respiratory distress.
Do Not Resuscitate Orders (DNR)
Do Not Resuscitate Orders (DNR) are medical orders, signed by a physician, nurse practitioner, or physician’s assistant, that instruct health care providers not to attempt cardiopulmonary resuscitation (CPR) or endotracheal intubation in the event of cardiac and respiratory arrest.
Durable Power of Attorney
A Durable Power of Attorney is a legal document in which you appoint a person you trust, called an Attorney-in fact, to manage your money, property and business matters if in the future you become disabled or incapacitated and are unable to manage your financial affairs yourself. A Durable Power of Attorney is usually created with the help of an attorney. A Durable Power of Attorney can avoid the need for Conservatorship.
A Guardian is a person (such as a family member or friend) or entity appointed by the court to make some or all personal and health care decisions for an incapacitated person, as ordered by the court in a Guardianship hearing.
Guardianship is a legal process where the court can appoint a person to be a guardian to safeguard the rights of an incapacitated person and ensure that health care services are provided as needed. A Limited Guardianship is preferred in Massachusetts whenever possible, in which a guardian’s decision making authority is limited only to areas where the incapacitated person is unable to make effective decisions about his or her safety, health, and well-being. The incapacitated person retains the authority to make his or her own decisions in all other areas.
Tip: Read more about Massachusetts Guardianship law here.
Health Care Agent
Adults 18 years old and older can appoint a trusted person as their Health Care Agent in a legal document called a Health Care Proxy. A Health Care Agent (Agent) has the legal power to make health care decisions on the adult's behalf if the adult is unable to make or communicate health care decisions, even for a short time while the adult recovers from an injury or illness. The adult can give their Agent the same decision-making authority the adult has, including the right to refuse medical treatment, agree to medical treatment, and the right to make life-sustaining treatment decisions and sign a MOLST form, Medical Orders for Life-Sustaining Treatment.
TIP: The Health Care Agent's role and responsibilities is outlined in the Massachusetts Health Care Proxy Law. Read more about the MA Health Care Proxy law here.
Health Care Planning
Health care planning, as defined in the Honoring Choices Massachusetts Who's Your Agent? Program, is a planning process that focuses on getting good care that aligns with your care preferences today and everyday over your lifetime. It involves both:
- Everyday Planning, where adults and their care providers engage in goals of care conversations to explore an adult's health condition and treatment options and understand an adult's care preferences, and provide care to improve wellness and quality of life; and,
- Advance Care Planning, where adults make a written plan and document their care choices and preferences in Massachusetts care planning documents, to let others know the kind of care they want if they are unable to make or communicate health care decisions.
Health Care Proxy
Health Care Proxy is a legal document in which you appoint a trusted person, called a Health Care Agent, to make health care decisions on your behalf if you become unable to make effective health care decisions for yourself. This may be an outcome of the advance care planning process and is expressly authorized in Massachusetts by statute (MGL 201D). A Health Care Proxy can avoid the need for Guardianship.
TIP: You can download a free Health Care Proxy is 15 languages on our Resources page here.
Hospice is medical care for individuals with a terminal or serious illness resulting in a life expectancy of six months or less, when curative treatments are no longer an option. Hospice care focuses on symptom management and is tailored to the specific physical, psychosocial and spiritual needs of the person. Hospice care also includes support for family and caregivers during the dying process and often provides bereavement services.
TIP: Read more about Hospice care and helpful Hospice Locator at the Hospice a & Palliative Care Federation of MA here.
An Incapacitated person is an individual who for reasons other than advanced age or minority has a clinically diagnosed condition that results in an inability to receive and evaluate information or make or communicate decisions to such an extent that the individual lacks the ability to meet essential requirements for physical health, safety, or self-care, even with appropriate technological assistance.
An adult with an intellectual disability is defined as a person with sub-average intellectual functioning existing concurrently with limitations in adaptive skills. The abilities and limitations of a person with an intellectual disability diagnosis can vary widely. The diagnosis alone may not tell you whether an individual has the decision making capacity to sign a Health Care Proxy and other documents. If you are unsure whether a person has the ability to make effective health care decisions, ask a doctor or clinician to make a medical determination.
Life-Sustaining Medical Treatments
Life-sustaining treatment refers to medical procedures such as cardiopulmonary resuscitation, artificial hydration and artificial nutrition, and artificial ventilation/ breathing and other medical treatments intended to prolong life by supporting an essential function of the body when the body is not able to function on its own.
A Living Will is a personal care planning document where you write down what's important to you and give your Health Care Agent, family and care providers information about the care you want and do not want. Although a Living Will is not legally binding in Massachusetts, it is an essential part of your health care plan. It's "your voice" for the care you want when you are unable to make or communicate health care decisions for yourself.
TIP: The term Living Will is often confused with a Last Will and Testament, which documents how you want to distribute your estate after you die. Honoring Choices created a Personal Directive (Living Will) to help clarify that this care planning document is a personal statement or directive about the kind of care you want when you are alive if you get sick or injured.
MOLST, Medical Orders for Life-Sustaining Treatment
Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order, intended for seriously ill patients, that documents a patient’s decisions for life-sustaining treatment based on the patient’s current condition and care choices. A MOLST medical order or form becomes effective immediately upon signing and is not dependent upon a person’s loss of capacity.
Palliative care is a comprehensive approach to treating serious illness that focuses on the physical, psychosocial and spiritual needs of the patient. The goal of palliative care is to prevent and relieve suffering and to support the best quality of life for patients and their families through such interventions as managing pain and other uncomfortable symptoms, assisting with difficult decision-making, and providing support, regardless of whether or not a patient chooses to continue curative, aggressive medical treatment.
Personal Directive (Living Will)
A personal directive is a personal document or statement in which you give your Health Care Agent information and instructions about your values, preferences and choices for future medical care. A personal directive can be a personal letter or memo, and is also commonly known as an advance care directive, a living will, or medical directive. A personal directive is not legally binding but offers your health care agent essential information about the kind of care you want if you become incapacitated.
TIP: You can download a free Personal Directive (Living Will) in 5 languages on our Resources page here.
Serious illness is a health condition that carries a high risk of mortality and either negatively impacts a person's daily functioning or quality of life or excessively strains his or her caregivers.
Serious illness care is provided to individuals of any age, from infants to older adults, living with a serious life-limiting medical condition or advancing frailty.
Serious illness conversations between patients and clinicians can start at first diagnosis of a serious illness, continue through changing treatment options to end of life care. It's a time when:
- Clinicians and Patients or their Health Care Agents & Guardians (legal advocates) have conversations about the patient's medical condition, care goals and treatment options;
- Patients/legal advocates make treatment choices about the kind of care they want and do not want, and can document their choices in a MOLST form;
- Clinicians and Patients/legal advocates work together to honor patient choices and offer the best possible care throughout serious illness and at end of life;
- Patients and families may need specialized care throughout serious illness, such as adult and pediatric palliative care, behavioral health services, hospice care, and community/ home-based services.
Tip: A person with a serious illness or advancing frailty can complete a MOLST form with their clinician after a serious illness conversation. It's also helpful to complete Health Care Proxy to choose a Health Care Agent to make health care decisions on your behalf, if you are unable to make health care decisions yourself.