Doctors on COVID-19 front lines eye their own advance directives

Marc Zarefsky , Contributing News Writer

With the rise of the COVID-19 pandemic, more physicians are being forced to have difficult conversations with their loved ones. Much discussion has been focused on the essential need for adequate personal protective equipment and questions about how to keep families of emergency physicians and other front-line doctors safe from potential coronavirus infection.

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But for some younger doctors whose top priority has been excelling in residency or in early-career practice, the focus also is turning to their own need for advance-care planning. Already, hundreds of doctors and other health professionals around the world have died of COVID-19, according to news reports, though a definitive figure is not yet available.

Only about one in three Americans has some type of advance directive on file with their health care providers, according to AMA STEPS Forward™ module, “End-of-Life Care: Facilitate Early Discussions With Patients.”

Too many people believe that advance directives are only for seniors or terminally ill patients, but the reality is the legal document is valuable for everyone, no matter their age or current health status.

The benefit of advance care planning is that it allows an individual to express their attitudes about how to be cared for in case of a life-threatening condition. An advance directive provides the opportunity for a person to share their values and how they want those to affect the type of care they receive should they be incapacitated or unable to communicate for themselves.

Physicians routinely talk with patients about end-of-life planning, and Elliott Crigger, PhD, director of ethics policy at the AMA, said doctors should approach their own advance directives in the same way.

“At the time the directive goes into effect, they will be patients, and it’s what they want as patients—as wives or husbands, parents, daughters or sons—that should guide decision-making,” Crigger said. “The difference is that they may be a bit better positioned to understand what treatment means, but treatment can look very different when you're the one receiving it instead of providing it.”

The AMA Code of Medical Ethics offers advice on advance directives. Learn more with the AMA about how the pandemic is putting ethics to the test, and consult this curated guide to pandemic-relevant AMA Code of Medical Ethics entries as well as the AMA Journal of Ethics® COVID-19 Ethics Resource Center.

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Audiey Kao, MD, PhD, is not surprised with the surge of interest in advance directives. As vice president of ethics standards at the AMA, he recognizes the value and importance of end-of-life planning. That having been said, he cautioned against viewing an advance directive simply as a piece of paper.

“The motivation behind getting advance directives now is the COVID-19 pandemic, but for advance directives to be as valuable as they can be, they shouldn't be perceived as a document where [people] check off boxes,” Dr. Kao said. “That piece of paper is a manifestation of a larger conversation that individuals should have.”

That conversation should feature topics including, but not limited to:

  • What is most important to the individual.
  • Individual’s feelings about being put on or taken off a ventilator.
  • How to handle a life-threatening but curable condition.
  • Who speaks for the individual if there are “family” disagreements about treatment

A key point that should be discussed and resolved is who to appoint as durable power of attorney  for health care. That person (the agent) is given the responsibility to make decisions for the individual (the principal) should they be unable to do so themselves.

“These are conversations that are difficult to have,” Dr. Kao said. “Most people don't like to think about what they want to have happen when they face a life-or-death situation. You may be in a position where you can't speak for yourself, so you want someone who is going to speak for you and know what your values are.

Having a POA for health care does not take any rights away from the principal, said Leon Edelman, a lawyer in Chicago who specializes in family law and estate matters.

The power of attorney for health care “only means that if you're unable to speak for yourself, the health care agent can speak for you in terms of ordering procedures or indicating certain procedures that should not be given,” Edelman said.

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The AMA STEPS Forward module on end-of-life planning helps offers advice on how to approach different patient populations with the topic. The module is part of the AMA STEPS Forward collection that includes more than 50 practice-improvement education modules. It also is a good resource for physicians to review as they prepare to complete their own advance directive.

Edelman also suggested that advance directives should include the appointment of a POA for property. That agent will be responsible for making financial decisions for the principal as well as handling the principal’s money.

In addition, Crigger recommended that physicians worried about having an advance directive should also consider nonmedical issues that could become important in case of serious illness or death, such as documenting passcodes to a cellphone or computer.

“Thinking ahead to how you want your affairs handled in the worst-case scenario isn't macabre,” Crigger said. “It respects the people who are close to you, whom you care about, in giving them guidance when you no longer can.”

Stay up to speed on the fast-moving pandemic with the AMA's COVID-19 resource center, which offers a library of the most up-to-date resources from JAMA Network™, the Centers for Disease Control and Prevention, and the World Health Organization. Also check out the JAMA Network COVID-19 resource center