There are several important steps for good advance care planning. First, think about your wishes for care in a life-threatening medical situation. When would you want aggressive treatment and when would you want care focused on comfort and quality of life? Who would you want to make these decisions on your behalf if you were unable to communicate? Document your wishes and communicate them to your family and loved ones. In your advance directive, it is important to ensure that anyone you want to represent you in decision-making has been given the authority to do so. Be sure family and loved ones have copies of your advance directive documents and that the documents are available when needed. The resources listed below provide information to help you make these decisions and have conversations with those you love.
TYPES of ADVANCE DIRECTIVES in MASSACHUSETTS
The role of this agent is to make decisions based on what he or she believes you would want or, if this is unknown, to decide based on your medical best interest. This agent may make healthcare decisions in any situation where you are unable to make or communicate your wishes, not just in end of life situations. You may also place specific limitations on the agent's decision-making power.
Before signing a healthcare proxy, it is important to talk to your agent to make sure he or she is willing to take on this important role. Choosing an agent is an important decision. Select someone who knows you and is comfortable honoring your specific wishes. When you choose an agent there are some exclusions you need to be aware of. The agent cannot be an “operator, administrator, or employee of a hospital, nursing home, rest home, etc. … where the principal is presently a patient." Discuss your wishes candidly and in detail so that your agent can represent you well. Having this conversation is important so that your agent will know what you would want. In Massachusetts, in order for a healthcare proxy to be legal, two witnesses must sign the proxy document.
There is no Massachusetts law specifically governing or recognizing living wills. However, if you have appointed a healthcare proxy, living will instructions are recognized as evidence of your wishes.
Advance Directive Forms
2. Other Forms
b. Personal Wishes Statement, a form developed by the Central Massachusetts Partnership to Improve Care at the End of Life for documenting personal wishes, is available at www.betterending.org
Note: Although it is not necessary for an attorney or a notary to be present when you execute your healthcare proxy, you may want to check with an attorney if you are not certain whether a particular form is recognized under Massachusetts law. Each state has specific laws governing advance directives. If you regularly spend time in another state, you may wish to consider completing the documents that are legally recognized in that state.
Standard of Care:
Massachusetts is one of 42 states that has (as of September 1999) adopted protocols to address the possibility of unwanted medical encounters with EMS personnel. These protocols permit the creation and recognition of do-not-resuscitate (DNR) orders that are effective in non-hospital settings and are appropriate for seriously ill people living in the community when death is expected or when medical intervention is expected to be ineffective.
Requirements of the Massachusetts Comfort Care Protocols
Comfort Care forms and bracelets must be obtained by a physician but can be distributed by a physician to an authorized physician assistant or nurse practitioner. The forms are sequentially numbered and must be signed and dated by either the physician or the authorized physician assistant or nurse practitioner in order to be valid.
If EMS personnel arrive to find an individual in cardiac or respiratory arrest with a valid DNR but no original Comfort Care/DNR verification form (copies are not acceptable) or bracelet, they are obligated to begin CPR. Even if the duly appointed healthcare proxy states that resuscitation is not warranted, resuscitation and transport must occur unless a Comfort Care/DNR verification form or bracelet is visible.
If there is any good faith basis to doubt the continued validity of the Comfort Care/DNR order, EMS personnel are instructed to resuscitate.
Additional information about the Massachusetts Comfort Care protocols is available on the OEMS website at
School districts should prepare a policy on the care of a child with a DNR order. Special consideration must be given to meeting the child's and his or her family's needs, as well as the needs of the students and staff. The child should be placed only in a school that has a full-time school nurse. The local emergency medical services should be informed (with written permission from the parent or guardian) that there is a child in the specific building with a DNR/Comfort Care order.
If a child has a DNR order, a physician can submit a Comfort Care/DNR verification form to the Office of Emergency Medical Services in the Massachusetts Department of Public Health and obtain a Comfort Care form and an identifying bracelet. As stated above, Comfort Care identification (either the bracelet or the fully executed original form) is the only authorized way for EMS personnel to recognize a patient with a current, valid DNR order. EMS personnel called to a school will honor a DNR only if the child has a Comfort Care identification. Without a Comfort Care bracelet or original form, EMS personnel who are called to a school will provide emergency treatment, including resuscitation, in accordance with standard EMS protocols, and transport to a hospital. The following website provides further information: www.mass.gov/dph/oems/comfort/ccprot2a.htm.
Respecting the family's wishes involves much pre-planning in the school setting. An individualized care plan should be developed in collaboration with the family, the child's physician, and the school physician or nurse. It should include (a) how the child will be moved to the health room or other designated area if serious distress or death should occur at another location in the school; (b) what, if any, comfort measures should be given to the child; (c) protocols for notification of the family; and, if the child has died in school; (d) who will make the pronouncement of death (physician, nurse practitioner, or physician assistant)*; and (e) how the deceased will be removed from the school. This may involve planning with the family's designated funeral home and include such factors as type of vehicle, where it will park, who will clear the corridors, and what kind of stretcher or other method of transport will be used. According to the Department of Public Health’s regulations, EMS personnel cannot transport a deceased person in an ambulance. The Office of the Chief Medical Examiner (CME) also has regulations that cover issues such as declaring the death and moving the deceased.
The plan should also address what will happen if the child is in distress but does not appear to face an imminent risk of death. The response should include immediate consultation with the parents and, consistent with the plan, contact with the local EMS provider. If EMS is called, and the child has a Comfort Care bracelet or form, EMS personnel can provide comfort care and transport to a hospital. The type of care that EMS is able to provide in this situation is spelled out in the Comfort Care Protocol, available on the above-referenced website.
When a plan is in place, the school nurse should convey the plan to the appropriate school staff and administrators, answering any questions that they may have.
Whenever a death occurs in school, a crisis team must be activated immediately to assist the family, staff, and students in coping with the loss. Special consideration must be made for any students or staff who witness the death, especially if (per DNR orders) no treatment was performed by school staff or EMS. Questions such as "What if this happens to me?" and "Will they do anything for me?" may need to be addressed.
*Nurse practitioner (NP) and physician assistant (PA) pronouncements function as "removal permits" allowing the deceased to be removed from the school grounds by a funeral director. However, the NP or PA who pronounces the death must (a) before the pronouncement try to reach the attending doctor so that the doctor can declare the death and complete the death certificate and (b) after the pronouncement, notify the attending doctor of the location to which the body has been removed so that the doctor can complete the death certificate. State law (M.G.L. Chapter 46, section 9) requires that a physician or the medical examiner complete the death certificate.
In addition, you should give a copy of these documents to any healthcare facility where you are admitted. Hospitals, nursing homes, and other healthcare facilities that accept Medicaid or Medicare are required to inform patients of their rights to have advance directives. They must also keep the directives in the medical record and let patients know of any policies that would keep the facility from fully complying with the directive. Be aware that if you should complete a new healthcare proxy form, the proxy signed most recently will replace any proxy that you signed earlier.
You may revoke your healthcare proxy or living will at any time while you are competent, and it will be automatically revoked if you become divorced or legally separated and your spouse was named as your agent. However, it does not have to be replaced if used or in the event that you later regain the capacity to make your own decisions.
You should periodically review your healthcare proxy and living will and discuss them with your agent to make sure they still accurately reflect your wishes.