HR 4449: Patient Self Determination Act of 1990

Your eyes have probably already glazed over at that title, and I don't blame you.  I'm studying for my test tomorrow on legal issues in nursing and I'm practically asleep in my notebook, however, as a patient, and as a nurse, and as a guardian I know that I am woefully unprepared in terms of understanding the difference between the terms "advanced directives," "living will," and "power of attorney," and that's a huge part of the federal act "Patient Self Determination Act of 1990."

I did try to find the full text online and failed because apparently congress.gov doesn't have full text of bills prior to 1993.  (Thanks, Congress.gov, for being totally unhelpful in this particular time.)  Don't believe me?  Look for yourself.  But luckily my textbook and the Americanbar.org, which is this online trove of law for every subject possibly needed (not really) has my back in terms of paraphrasing the law.

Basically, this is what Americanbar.org says, and you can navigate around the to subsections here.:

But that still doesn't clear up what the difference between an advanced directive is versus a power of attorney, versus a DNR.  So, here's the breakdown:

Advanced directives is an umbrella document that lists

1) a proxy in case the patient can't make his own decisions (aka "decisionally incompetent")

2) specific instructions about what care the patient wants, and more specifically, what procedures and treatments ARE NOT to be implemented (like, "do not insert a g-tube," "do not intubate me," etc).

3) authorization of the physician to withhold or discontinue life-sustaining procedures under specific conditions (like, "If after 30 days, my physicians believe that my status will not change, and life-sustaining procedures will only prolong the moment of my imminent death I want to withdraw treatment.")

In addition to this generic living will, there is another type of Advanced Directive called the "Medical or Physicians Directive," which includes the DNR orders.  Do Not Resuscitate lists whether or not the patient wants to be resuscitated if cardiopulmonary arrest occurs.  This piece of paper is what defends medical staff against claims of negligence or intentional wrongdoing in the event of the patient's death from cardiac arrest.  DNRs are REVERSIBLE by the patient at any time.  

A Durable Power of Attorney for Health Care is a person designated by the patient while the patient is still mentally competent to make the decisions regarding day-to-day care and end-of-life decisions once the patient becomes mentally incompetent.  

So what happens when, after a patient has become mentally incompetent, the POA makes a decision against what is stated in the Advanced Directives?  I have no idea.  I'll have to ask a lawyer and get back to you.

Meanwhile, IDPH has a nice page full of state standardized advanced directive pdfs for you to print and fill out for you, your loved ones, and your patients.  

Living will: http://www.idph.state.il.us/public/books/Livin.PDF

Power of Attorney: http://www.idph.state.il.us/public/books/PowerOfAttorney.pdf

Illinois Department of Public Health 

535 West Jefferson Street 

Springfield, Illinois 62761 

Phone 217-782-4977 

Fax 217-782-3987 

TTY 800-547-0466