Acronym Soup: AHCD, HIPAA, POLST and DNR

Lawyers throw around a LOT of jargon. And if anyone uses more jargon than lawyers, it’s doctors. So when you need to make legal decisions about your medical care, you’re likely to be smacked in the face with unpronounceable acronyms and copious fine print.

But if ever there was a time to read the fine print, this is it.

Before you don your reading glasses, before you even consider signing (or letting your doctor sign) one of these instruments—lawyer-speak for “documents that do things”—you need to understand what they are.

DNR (Do Not Resuscitate) order, a.k.a. Do Not Attempt Resuscitation (DNAR), Allow Natural Death (AND), or no-code order. This one’s pretty straightforward. A DNR is a short, usually one-page document, signed by you and your doctor, that tells health care providers that you do not want heroic measures (like CPR, defribillation or intubation) in the event that your heart stops or you stop breathing. Preparing a DNR is only appropriate after careful consideration and consultation with your doctor, if you have a condition that renders you unlikely to survive resuscitation.

POLST (Physician’s Orders on Life-Sustaining Treatment). A POLST is a standing medical order (or set of orders) that is broader than a DNR but performs some of the same functions. It directs health care providers—including EMTs and other people who might need to make critical decisions about your treatment quickly—to do things like follow a specified care plan, take you to the hospital or leave you at home, or attempt CPR or not. It can be prepared by your doctor if you have a serious, life-limiting medical condition, like end-stage cancer or advanced frailty. Your doctor consults with you (or your representative, if you are incapacitated) before preparing the POLST. If you have an advance directive, your doctor can use it as a guideline when preparing the POLST. A POLST is not valid unless both doctor and patient (or incapacitated patient’s representative) sign the POLST form.

Some other names for POLST:

• MOLST (Medical Orders on Life-Sustaining Treatment),

• COLST (Clinician Orders for Life Sustaining Treatment),

• POST (Physician Orders for Scope of Treatment),

• MOST (Medical Orders for Scope of Treatment),

• TOPP (Transportable Orders for Patient Preferences),

• TPOPP (Transportable Physician Orders for Patient Preference); and

• SAPO (State Authorized Portable Orders).

To read more about POLSTs, check out https://polst.org/.

HIPAA (Health Insurance Portability and Accountability Act) authorization. A HIPAA authorization is a form you can sign to grant your health care provider permission to share your medical information with someone else. This includes not just medical records but “information” more broadly—so, for example, you need a HIPAA authorization if you want your doctor to discuss your care with a family member or caregiver. (There is an exception that allows your doctor to talk to your representative without a HIPAA authorization if your are incapacitated or unable to form consent.)

AHCD (Advance Health Care Directive), a.k.a. advance directive, medical directive, living will, directive to physicians, or healthcare declaration. Here are the basic features of an advance directive and the key ways in which it differs from the other documents described above:

• In addition to covering end-of-life care preferences (as you’d find in a POLST), an advance directive includes your instructions to both health care professionals and your named health care agent on a broad range of care topics. For example, you can use your advance directive to specify your desires around pain relief, diagnostic tests and surgical procedures, to nominate someone to serve as your conservator in the event one is needed, and to direct the disposition of your remains (including organ or whole-body donation, autopsy, cremation or burial).

• An advance directive usually includes a medical power of attorney, which is a formal grant of access and medical decision-making power to a representative of your choosing. This person is referred to as a health care agent or health care “attorney-in-fact.” If you appoint more than one health care agent, you can direct whether they must act jointly, may act separately, or are alternates.

• An advance directive usually includes a HIPAA authorization.

• An advance directive is usually prepared before it’s needed—i.e., in advance.

• Your doctor is not involved in preparing an advance directive.

• An advance directive is typically prepared by an attorney, but if you’re comfortable with “fine print” and the basic options offered in a fill-in-the-blanks form meet your needs, you may be able to prepare one yourself using a form modeled on California Probate Code Section 4701 (or the comparable statute in your state).

Thinking about preparing an advance directive, but not sure if you need a lawyer? Some factors that might affect your decision:

• A do-it-yourself advance directive is prepared using a fill-in-the-blanks form that may be provided at low or no cost by a government or non-profit agency, a legal publisher, or a health care facility. If you find a form that you think is suitable, make sure that (a) it was created by a trustworthy entity such as a reputable non-profit organization, and (b) it was specifically prepared for use in your state. The rules about what constitutes a valid advance directive vary from state to state.

• There are state-specific legal requirements for not only the content and form of an advance directive but also the manner in which it is signed and witnessed (or notarized). Executing an advance directive without following those rules can render it invalid.

• Unlike a DIY form, an advance directive prepared by a lawyer is customizable. For example, your lawyer can draft a directive that names two people (say, two adult children) to have equal roles as your health care co-agents, while the typical DIY form does not allow you to name more than one health care agent at a time. Another example: your lawyer-drafted advance directive can be as specific as you want about the medical circumstances in which you would want artificial nutrition and hydration to be withdrawn. In contrast, the typical DIY form gives you a binary choice (“choice to prolong life” or “choice not to prolong life”) regarding a vague, catch-all scenario in which “the likely risks and burdens of treatment would outweigh the expected benefits.”

Contact Caplan Wilkinson if you’d like help drafting your advance directive or other estate planning documents.