Estate planning is a process that’s heavy on documents, often lots and lots of documents, starting with the all-important will.
What is overlooked by many people - and this can include estate planners, too - are the many important documents that affect medical care and end-of-life issues.
The practice of medicine and the legal issues surrounding it are constantly changing. Estate-planning professionals need to keep up with these changes just as we do with evolving tax laws.
Just the other day, a client who lives in a retirement community came to see me. She told me one of her friends and neighbors had recently suffered a heart attack and an ambulance was called to take her to the hospital. The emergency medical technicians wanted to know if the patient had something called a MOST form.
Well, I have to admit, at that point I had never heard of that particular document, and neither had my client. The patient had a living will, a health care power of attorney form and various other papers but the EMTs didn’t want to see any of that. They only wanted the MOST form, something even the staff at the retirement community wasn’t familiar with, either.
It turns out that a state law passed in 2013 created this MOST form to go along with, and expand on, the already familiar DNR or Do Not Resuscitate form that doctors, nursing homes and the like typically handle.
So having learned more about this latest development, I’d like to offer a brief overview of these important documents, what they mean and how they should be used.
The first two, which have the most direct life-and-death consequences, are typically handled together, at least in North Carolina.
A DNR is a Do Not Resuscitate order. This states that, in the event the patient’s heart or breathing stops, “efforts at cardiopulmonary resuscitation should not be initiated.” The DNR order does not affect any other “medically indicated or comfort care.” Of course, if you want CPR to be attempted under any circumstances, you shouldn’t complete a DNR form.
This is that new form I had to educate myself about. The acronym stands for Medical Orders for Scope of Treatment, and it includes what the DNR order covers, as the first of several yes or no options.
The form’s first section says that if the “patient has no pulse and is not breathing,” medical personnel either should perform cardiopulmonary resuscitation or not, according to the patient’s preference. The MOST form goes on to give instructions for less severe situations, with a choice of “full scope of treatment” including: hospitalization; “limited medical intervention” that should not include intensive care; or mere “comfort measures” to relieve pain and suffering.
Other sections address whether and how to use antibiotics, intravenous fluids and feeding tubes. The form also explicitly notes with whom these treatment requests have been discussed and agreed. That can include the patient, of course, but may also include a legal guardian, attorney in fact with power to make health care decisions (health care power of attorney), spouse or the patient’s adult family members.
According to North Carolina law, the DNR and MOST forms are available only through licensed medical offices. So, if you have not already completed these forms, I urge you to ask your doctor for copies, discuss your feelings about the various choices and complete them both.
Other relevant documents that should be part of anyone’s estate and end-of-life planning process include:
As noted earlier, this means “health care power of attorney.” It grants a responsible person the authority to make medical decisions on behalf of someone who can’t do so personally. This isn’t just for a person who has become legally incompetent because of dementia or a similar disability. It can also be invaluable for basically healthy people who unexpectedly become unable to make their own medical decisions.
Think of what would happen if you were in a coma as a result of a stroke. What if you were unconscious following a car accident? An NCPOA typically includes language that distinguishes between permanent and temporary disabilities. That means a patient has someone to speak for them in emergency situations like these, but allows the patient to resume responsibility for his or her own care during and after recovery.
It’s worth noting that the law gives spouses and “next of kin” legal authority to make medical decisions for someone who can’t do so themselves. But people who aren’t married or who disagree with close relatives about such things should not take chances. Discussing such matters with someone you trust, and designating them to act on your behalf, is only common sense.
This is a document that spells out in detail your wishes concerning medical care. It should cover all the issues included in the MOST form, ideally with enough specifics that medical professionals, your designated HCPOA and your family members have a good sense of your preferences.
Typical issues a living will addresses include resuscitation, mechanical ventilation, tube feeding, dialysis, antibiotics, palliative care and organ donation. Think of the living will as your instructions to the person you grant a health care POA. It should also be the basis for how your MOST form is filled out.
Remember, though, as in the case my client described to me, that when minutes count it’s the MOST form that will be used by EMTs or emergency-room doctors. Think of the living will as the detailed background instructions, which the MOST form summarizes on a single page.
Part of my responsibility as estate planner for my clients is to be sure I have either originals or copies of all of these documents and family members or other appropriate parties have them, as well. As important as it is to have a will – to ensure that your property is managed correctly after you’re gone – it may be even more important to have these documents, to ensure that you’re treated as you prefer while you’re alive.
Your estate planner, not just your physician, should be up to date on all of these important papers.
Old North State Trust, LLC (ONST) periodically produces publications as a service to clients and friends. The information contained in these publications is intended to provide general information about issues related to trust, investment and estate related topics. Readers should be aware that the facts may vary depending upon individual circumstances. The information contained in these publications is intended solely for informational purposes, is proprietary to ONST and is not guaranteed to be accurate, complete or timely.
Susan Willett is the director of trust services and oversees all aspects of trust administration for Old North State Trust, LLC. Old North State Trust, a North Carolina chartered trust company, provides: asset management services; income, estate and trust tax consulting; retirement planning and administration; and trustee and estate services to both individuals and businesses. Old North State Trust professionals have many years of experience and for over a decade have assisted clients in identifying and reaching their financial goals. For more information, visit www.oldnorthstatetrust.com or call 910-399-5470.
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