What documents must be completed when one is on palliative care and death is advancing?

Essential Documents for Patients on Palliative Care as Death Approaches

When a patient is on palliative care and death is approaching, an advance care plan must be documented in the medical record, including MOLST/POLST forms if applicable, to ensure accessibility of the plan to all providers across care settings. 1

Key Required Documentation

Advance Care Planning Documents

1. Advance Directives

   • Living Will (specifying treatment preferences)
   • Healthcare Proxy/Medical Power of Attorney (designating a surrogate decision-maker)
   • Documentation of the patient's values and preferences for end-of-life care 1

2. MOLST/POLST Forms (Medical/Physician Orders for Life-Sustaining Treatment)

   • These are actionable medical orders that must be accessible to all healthcare providers
   • Particularly important for patients with advanced illness and life expectancy less than 1 year 1
   • Must be completed, signed, and dated by a physician and witness 1

3. DNR/AND Orders (Do Not Resuscitate/Allow Natural Death)

   • Must be formally documented with specific codes as applicable
   • Should be readily available to all healthcare professionals 1

4. Documentation of Goals of Care

   • Patient's preferences for location of death
   • Specific medical treatments to be provided or withheld
   • Confirmation of the patient's values and decisions in light of changing status 1

Additional Required Documentation

1. Death Certificate (when death occurs)

   • Must be filed with appropriate authorities
   • Required forms for the funeral director 1

2. Organ Donation Documentation (if applicable)

   • Documentation addressing survivor concerns about organ donation 1

3. Autopsy Consent/Refusal (if applicable)

   • Documentation addressing survivor concerns about autopsy 1

Documentation Process Requirements

1. Verification of Decision-Making Capacity

   • Patient must be capable of making informed decisions about providing, withholding, or withdrawing specific medical treatments 1
   • If patient lacks capacity, documentation must include how decisions are being made and by whom

2. Proper Authentication

   • Documents must be dated and signed by the patient
   • If patient is unable to write, documents can be drafted by another person in the presence of an independent witness and treating physician 1
   • Witness and physician signatures required in such cases

3. Accessibility

   • All documents must be readily available in the medical record
   • Must be accessible to all providers across care settings, including during off-hours 1

Types of Living Wills to Consider

1. Positive Living Will

   • Patient expresses wishes for specific interventions (e.g., comfort care)
   • Expresses patient wishes but may not be legally binding for providers 1

2. Negative Living Will

   • Patient refuses specific interventions (e.g., CPR, ventilator, artificial nutrition/hydration)
   • Legally binding for healthcare providers as patient refuses consent 1

Implementation Process

1. Regular Review and Updates

   • ACP is a dynamic process requiring regular review
   • Documentation should be updated as disease progresses 1
   • Changes must be properly documented in the patient file

2. Resolution of Conflicts

   • Documentation of any conflicts between patient and family goals
   • Documentation of consultation with palliative care specialists if needed for conflict resolution 1

Common Pitfalls to Avoid

1. Delayed Documentation

   • Many patients report end-of-life discussions occurring too close to death, allowing little time for psychological preparation 1
   • Begin documentation process early in the disease trajectory

2. Incomplete Documentation

   • Ensure all required elements are included and properly signed
   • Verify that documents are accessible across all care settings

3. Failure to Update Documents

   • As disease progresses, patient preferences may change
   • Regular reassessment and documentation updates are essential 1

4. Neglecting Family Involvement

   • Document discussions with family members about the patient's plan
   • Address and document resolution of any conflicts between patient and family wishes 1

By ensuring these essential documents are properly completed and accessible, healthcare providers can honor patients' wishes and provide appropriate care as death approaches, ultimately improving quality of life in the final stages and supporting a dignified death aligned with the patient's values.