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Patient’s Plan of Care: Goals and Treatment Options

As an attorney who advocates the use of advance directives for implementing health care decisions made by clients before a life-threatening situation arises, I am often asked how anyone can be sure whether that person’s decisions will actually be implemented. It is a question that is never easy to answer.

Over the 30 years since Karen Ann Quinlan’s parents fought to have their daughter’s artificial life-sustaining equipment removed, we, as a society, have struggled with the whole process of “end-of-life” healthcare decision making. In part, this struggle has required us to come to understand our own mortality. But, there has also been a struggle with doctors or other healthcare providers to have them follow the wishes of their patients.

Fortunately, times are changing. In 1993, Maryland passed the Health Care Decisions Act which gave us the opportunity to use advance directives, such as health care powers of attorney, with confidence. It also firmly established the use of living wills as tools for implementing our wishes at end of life.

Even with these tools, however, questions remained about whether anyone would follow a patient’s wishes. The Maryland’s Office of the Attorney General, under Joseph Curran and Jack Schwartz, has been working diligently on this question for the past few years. One piece of the answer was incorporated into legislation last year that established the requirement that a Patient’s Plan of Care (“PPOC”) be offered for everyone entering into a nursing home as of October 1, 2005.

A PPOC is meant to give health care providers specific guidance on what steps should be taken to a patient who is seriously ill or medically unstable. It can be prepared by the patient, the patient’s health care agent, or the patient’s health care proxy, depending upon the circumstances. Use of a PPOC is voluntary, but it should be offered to anyone entering a nursing home. Persons in assisted living facilities or other similar facilities may also complete PPOC’s.

In a PPOC, the primary health care goals should be described. For example, a patient could set forth his wishes that life should be prolonged, even in uncomfortable situations, or, alternatively, the patient could request palliative care only.

Other questions to be addressed include the use of cardiopulmonary resuscitation (CPR), extensive or intrusive medical testing, intravenous use of antibiotics, artificial ventilation, and artificially administered fluids and nutrition (tube feeding).

More about PPOC’s and end-of-life health care decision-making can be found at the website for Maryland’s Office of the Attorney General. Go to www.oag.state.md.us/Healthpol/PPOC.htm. This website is also an excellent resource for other related issues such as the State Advisory Council on Quality Care at End of Life and the Policy Study on Alzheimer’s Disease.

The process of a patient completing a PPOC with that patient’s physician or health care agent will uncover a variety of other questions that should be addressed. Hopefully, a dialogue between the patient and the health care agent will clarify exactly what the patient’s wishes might be. With that clarity, the prospect of fulfilling a patient’s wishes regarding end-of-life health care decisions will increase dramatically.