Health Care Planning Terms and Tips
The terms, definition and tips are based on Massachusetts law, standard medical and legal information, and best practices. The tips offer some practical information and links to further resources.
Advance Care Planning
Advance care planning is an ongoing process of discussing and clarifying the current state of a person’s goals, values and preferences for future medical care.
Advance directive is a general term referring to a written document to direct future medical care in the event that a person loses capacity to make health care decisions (i.e., becomes incapacitated). It sometimes results from the process known as advance care planning. A health care proxy or a living will is considered to be an advance directive.
Artificial Hydration and Artificial Nutrition
Artificial hydration and Artificial 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).
Capacity in health care planning usually refers to an adult’s ability to make effective 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 illness or medication can affect the person’s capacity. If you are unsure whether a person has capacity to make health care decisions, you can ask a doctor or clinician to make a medical determination.
Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a set of medical procedures that attempt to restart the heartbeat and breathing of a person who has no heartbeat and has stopped breathing. Such procedures may include the following:
- 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
- CPR can be life-saving in certain cases for otherwise healthy people but is much less effective when a person has a serious chronic illness.
Comfort Care/Do Not Resuscitate Verification protocol (CC/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. The CC/DNR protocol directs that a patient in respiratory or cardiac arrest be made as comfortable as possible, but that no resuscitative measures be attempted.
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.
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’s assistant,to 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.
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 or artificial ventilation 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) 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..
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.
Health Care Agent
A Health Care Agent is a trusted person, officially appointed, who speaks on behalf of a person 18 years of age or older who is unable to make or communicate health care decisions. In Massachusetts, this person is appointed in advance via a health care proxy. The agent is called upon only if the doctor determines in writing that a patient lacks capacity to make health care decisions. Unless otherwise limited by the person, the agent has all the rights that the patient has with regard to medical decision-making, including the rights to refuse treatment, agree to treatment, or have treatment withdrawn. Decisions should first be made based on the patient’s stated wishes, if known; or if unknown, an interpretation of what the patient would have wanted; or finally, an assessment of the patient’s best interest.
Health Care Planning
Health care planning, as referred to in the Honoring Choices Massachusetts process, involves both:
- Everyday Planning: making health care decisions with your doctors based on your current health status, and
- Advance Care Planning: creating a written plan about your choices and preferences for future medical care in advance to let others know how to care for you if you are unable to make medical decisions yourself.
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.
Hospice is a philosophy of holistic end-of-life care and a program model for delivering comprehensive palliative care to people who are in the final stages of terminal illness, and to their loved ones, in the home or a home-like setting. Hospice provides palliative care in the last months of life. It involves a team-oriented approach that is tailored to the specific physical, psychosocial and spiritual needs of the person and includes support to the family during the dying process. Hospice also provides bereavement support after death occurs.
An incapacitated person is an adult who has a clinically diagnosed medical condition that results in the inability to receive and evaluate information or make or communicate decisions.The incapacitated person is unable to make some or all effective decisions about his or her safety, health, and well-being. If the Massachusetts court determines a person to be incapacitated, and that guardianship is appropriate, the court can appoint a guardian to advocate for the person’s autonomy and make personal and health care decisions on the person’s behalf, as ordered by the court.
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 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 document or statement in which a person specifies future medical treatments in the event of incapacity, usually at end of life or if one becomes permanently unconscious, in a persistent vegetative state or “beyond reasonable hope of recovery.” Since there is no statute in Massachusetts that expressly authorizes living wills, they are not considered to have legal authority. They may, however, be used as evidence of a person’s wishes. (Also see Personal Directive)
Medical Orders for Life-Sustaining Treatment (MOLST)
Medical Orders for Life-Sustaining Treatment (MOLST) is a document intended for seriously ill patients that documents decisions for life-sustaining treatment based on the patient’s current condition. A MOLST form becomes effective immediately upon signing and is not dependent upon a person’s loss of capacity. It does not take the place of a health care proxy. Consideration of MOLST may be an outcome of the advance care planning process.
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.
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.