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Eldercare Specialists’ Advance Care Planning Toolkit

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Eldercare Specialists’ Advance Care Planning Toolkit

Purpose of Advance Care Planning 

To enable you to choose a spokesperson who can legally make healthcare decisions for you, if you are unable to do so, and who understands your choices for medical treatments in order to ensure these wishes are respected and followed.

Advance Care Planning Goals

  1. Establish Goals of Medical Care, present and future
  2. Establish the Level of Treatment you prefer
  3. Communicate these Goals and Choices to Family, Medical Providers and Caregivers
  4. Complete necessary Legal Documents and Distribute to Family Members and Medical Providers

Legal Forms in California

Advance Directives:  A legally binding document which appoints a person and alternate person of your choosing (“agent”) to make health care decisions for you, in the event you are unable to do so, and which enables one to choose general treatment options.

Durable Power of Attorney for Healthcare: This is a legal term in an Advance Directive for the person you select to be your healthcare “agent” or decision-maker.  You should select someone who knows you well, can support what you want or don’t want, and whom you trust.

Pre-Hospital Do Not Resuscitate (DNR):  This form allows one to withhold resuscitative measures outside the hospital setting when one’s heart and lungs stop functioning.  It is valid when signed by both the person and their doctor and provides direction to paramedics and health care providers.

Preferred Intensity of Care/Treatment:  This is a document used to promote preferences for care and treatments, and is generally used in a skilled nursing facility. A discussion with your physician and/or legal representative occurs prior to creating this document. (Note: This document must be signed by the physician).

Physician Orders for Life-Sustaining Treatment (POLST): POLST is a physician order form which enables one to make specific choices about medical interventions and to document these wishes on a legal bright pink form which travels with the person from home to all health settings.  Law mandates that medical providers honor valid POLST forms signed by both the patient and physician, to ensure one receives treatment both wanted and unwanted.

Determining Levels of Medical Intervention[1]

  Full Treatment

  • Primary Goals
    • This is full medical support and treatment of all medical issues; may include hospitalization, intensive care unit, intubation, and breathing machine, as well as comfort measures.
  • Legal Documents:
    • In the absence of any other documents stating otherwise, medical care defaults to full treatment, unless the physician determines this to be medically ineffective.  To ensure one’s wishes are followed, an Advance Directive and POLST (when appropriate) should be completed.
    • Example:  you have a full cardiac arrest which results in no breathing and no pulse.  You choose “attempt resuscitation”/CPR which, if successful, would involve intubation, breathing machine, and intensive care in a hospital.

Limited Additional Interventions  

  • The Primary Goals
    •  Improve or maintain one’s current level of health by treating in a less aggressive and less intrusive manner; may include hospitalization, IV hydration, IV antibiotics, and non-invasive oxygen.
    • Evaluate whether additional tests or treatments for major life- threatening diseases are necessary; focus of care is on treatments which restore comfort and alleviate symptoms and avoids intensive care and intubation.
    • Medication and treatment goals of care attempt to maintain basic health and medically manages simply treatable issues:
      • Example:  you take a fall and break a leg – the leg gets treated so that it will repair correctly and you are given pain management medications and follow up therapy.
      • Example:  you have a stroke, lose some swallowing ability, and choose to try a feeding tube with artificial nutrition until your swallowing ability is restored.
      • Example:  you have dementia, become dehydrated, and choose to have some IV hydration at the hospital.
  • Legal Documents -Advance Directive, POLST, DNR

Comfort Measures Only

  • Primary Goals
    • Relieve pain and suffering through the use of medication by any route, positioning, wound care, oxygen, suction, and other less invasive measures usually in a home setting. Treatment goals are generally not to prolong life in situations where treatments will not change the outcome. If comfort cannot be achieved at home, one might go to the hospital for symptom management.
    • Example:  your treated breast cancer returns and has spread to your liver.  You choose to not have more chemotherapy and to focus on alleviating pain and discomfort.
    • Example:  you have dementia or other end-stage disease and are losing weight, have no appetite, and choose to not have IV fluids or artificial nutrition because you prefer to not prolong life.
    • Example:  you have a urinary tract infection and choose to take oral antibiotics for comfort, but want to avoid IV medications.
  • Legal Documents – Advance Directive, POLST, DNR, (if person is in nursing home a Preferred Intensity of Care/Treatment Form may be applicable)

Levels of Care[2]

Determines the level of care and outlines how much treatment is preferred if a person is no longer able to make healthcare decisions.  The following table outlines, in general terms (treatment varies by person, physician and facility), what restorative, supportive and palliative treatment may or may not include. Comfort is a right and is included in implied in all treatment options

level of care

Advance Care Planning Worksheets

The following worksheets can be used to facilitate communication regarding end of life wishes with your healthcare decision makers and/or attorney.  These worksheets are not inclusive of all decisions; however, discussing these with your agent and physician will provide them with information to make better decisions which reflect your wishes.

Worksheet 1:  Determining Desired Level of Care [1]

The following table can be used to help communicate specific wishes in regards to various treatments, if you are unable to verbalize them yourself.

worksheet 1

Overview of Treatment Options

Kidney Dialysis

Dialysis is an option when the kidneys stop functioning and waste products build up in the blood stream.  Dialysis is a process in which your blood is circulated outside your body into a machine that cleans it. A needle is inserted

into one of your veins (usually in your arm) and an attached tube carries a steady flow of your blood into the machine and another tube returns the filtered blood back to the body. This treatment takes a few hours at a time and is done three to four days a week.

What happens when dialysis is not received?

If the waste products in your bloodstream continue to accumulate over time (weeks to months), you will eventually go into a coma and ultimately your heart will stop.

CPR or cardiopulmonary resuscitation:  when your heart stops

 Cardio = heart          Pulmonary = lungs          Resuscitation = try to restart

CPR involves pressing hard on your chest to keep blood circulating, sometimes so forcefully that it breaks ribs. Electrical shock is applied to your chest in an attempt to “jump start” your heart. A mask or a breathing tube attached to a bag is placed into your windpipe to pump air into your lungs. This continues until a pulse is restored or the intervention is determined to be ineffective.

Most people who need CPR need mechanical ventilator to support their breathing afterwards. If you are under age 65, the success rate ranges between 25-40%. If you are over age 65, this rate drops to between 1-4%. (Note: this will vary depending on your overall health status).

What happens without CPR?

With the heart and lungs not working, loss of consciousness is followed by death in about five to 10 minutes.  This is called “Allow Natural Death”.

Mechanical Ventilation:  Breathing machine

Mechanical ventilators take over the task of breathing when the lungs aren’t working well enough on their own. A tube is placed into your windpipe, either through your mouth or through a small surgical incision at the base of your neck and attaches to the machine. Most patients on a mechanical ventilator are in a hospital, usually in an intensive care unit. They are usually not able to get out of bed, nor talk. In some situations, a portable ventilator allows a patient who is completely paralyzed to get around in a specially-equipped wheelchair.

Though mechanical ventilation can be uncomfortable, it provides a way to prolong your life. It may be needed for only a short time, for example, just long enough to let your body recover from a serious illness such as pneumonia. In some cases, it can relieve the discomfort of feeling breathless. If you need a ventilator for a long time, it can sustain your life indefinitely when you might otherwise die.

What happens without a mechanical ventilator?

Without some external breathing assistance when your lungs are not working, you will die quickly.

Feeding Tubes – Artificial delivery of nutrition and fluids when you can’t swallow

A feeding tube is used to carry liquid nutrition and fluids into your body. One kind of tube goes in your nose, down your throat, and into the stomach. Another kind of tube is surgically placed into the wall of your stomach. Once the tube is in place it is relatively painless. With either tube, you will not be able to taste anything. If you are already in the terminal stage of an illness, a feeding tube will likely postpone your death. Tube feeding also makes it possible (in some cases) to prolong life to those in a coma, have severe strokes, or end stage dementia. There is still the risk of aspiration with feeding tube use.

What happens without a feeding tube?

If you are unable to swallow all food and fluids, you will eventually fall into a coma. This will take about one to several weeks, during which time, comfort and hygiene measures will be applied. One does not usually feel hungry or thirsty as your body shuts down and dehydrates.  Dehydration is the natural process which allows easier breathing and ultimately leads to heart and lungs stopping.

Worksheet 2:  Determining What Makes Life Meaningful 

This worksheet will help you think about what you feel gives your life meaning.


Worksheet 3:  Planning Ahead for Last Days of Life

This worksheet is to help determine what you feel would make your end of life most peaceful during the last weeks, days and hours of your life.


If you would like assistance with advance care planning, please contact Eldercare Specialists at (415) 259-4864.

© Copyright Reserved, Eldercare Specialists, LLC, May 2012 Version 2.0


[1] The terms used in the following section to describe level of care are based on the POLST form terminology.

[2]The terms used to describe level of care are based on the POLST form terminology.

[3]The pages following this worksheet overview some of the treatment options.