What are Advance Directives?

‍

An advance directive is a legal document that outlines how you would like medical decisions to be made on your behalf if you become unable to make them yourself. It is a useful document to put together because it helps you consider the kinds of care you might want and don’t want, and it provides a sort of roadmap of your wishes for your loved ones and health care team to follow to make the most appropriate decisions for you about your health.

An advance directive only concerns health care matters and has no bearing on financial issues. The laws surrounding advance directives vary from state to state, so talk with your health care provider or lawyer about filing one. It’s never too early to develop this document.

The Patient Self-Determination Act (PSDA)

The 1990 PSDA means that all hospitals, skilled nursing facilities, hospice programs, health maintenance organizations (health plans) and home health agencies must inform you about your rights to make care decisions under state laws. In addition, these organizations must ask whether you have an advance directive and honor your wishes in the advance directive, as well as treat all patients equally regardless of whether the patient has an advance directive.

There is no obligation to have an advance directive, and health care facilities cannot insist that you have one. The choice is entirely up to you.

What are the different types of advance directives?

The two most frequently used types of advance directives are the living will and the durable power of attorney for health care, sometimes referred to as the medical power of attorney.

The format of an advance directive can vary and is an individual choice. Some follow state law guidelines, while others are drawn up by lawyers or simply by the patient themselves. All states and the District of Colombia have their own laws about advance directives, so make sure you are aware of the specific requirements in your state before drafting one. You should be able to get an advance directive form from your state bar association, or from the National Hospice and Palliative Care Organization (NHPCO). Alternatively, your health care team may be able to help you acquire and complete the appropriate paperwork.

Before writing your advance directive, consult with your health care providers, loved ones, and at least one individual you would like to appoint as your decision-maker if you become unable to make decision for yourself.

What is a living will?

A living will is a legal document outlining future health decisions to be made on your behalf if you can no longer make decisions for yourself. It is only used in the final stages of life or if you become permanently unconscious. It details your preferences about the type of medical treatment you would or would not like to receive and may also state the conditions under which attempts to prolong life should be made, as well as when treatment should cease.

Before your health care providers follow your living will, two physicians must first confirm you are no longer capable of making your own medical decisions and that you fall into the categories as defined by state law regarding terminal illness or permanent unconsciousness.

What should you include in a living will?

A living will can cover a wide range of factors, such as whether you would want equipment to be used to help keep you alive (e.g., dialysis machines or ventilators), if you have a Do Not Resuscitate order, whether you would want IV or tube feeding if you were incapable of eating or drinking, and whether you wish to donate your organs.

While you may decide against having aggressive medical treatment for your condition, this does not mean you have to refuse all medical care. You may decide you would want palliative care, such as pain relief, antibiotics, food, etc.

You can change your living will at any time. You may want to review it regularly, perhaps once per year, as your goals and wishes may change over time.

What is a durable power of attorney for health care?

Sometimes known as a medical power of attorney, a durable power of attorney for health care is a legal document appointing someone as your proxy, or agent, with the power to make health care decisions on your behalf if you are unable to do so for yourself. Before a medical power of attorney can be used to make medical decisions, the individual’s physician needs to certify that the patient is no longer capable of making their own medical choices.

Your proxy will make decisions according to the information you have previously provided them with, either in your advance directive or by other means. If a situation arises in which your wishes are unknown, they will make a decision based on what they think you would want. If you regain the ability to determine your own health care, your proxy will no longer be able to make decisions on your behalf. As such, you should name someone who knows you well and who you trust to respect your wishes. You may also like to appoint a backup person in case your first choice is unavailable.

Do Not Resuscitate orders

A Do Not Resuscitate (DNR) order stipulates that if your breathing stops or your heart ceases to beat, no treatments will be provided to try and prolong your life. If you are in a hospital, you can request that your doctor add a DNR order to your medical record if you don’t want the medical team to attempt to revive you. Some hospitals require a new DNR order every time you’re admitted, so you may need to make your request whenever you go to a hospital.

A DNR order is only valid while you’re in the hospital, so you might like to ask your health care provider for a wallet card, bracelet or other form of DNR document to keep with you when you are not under hospital care. Some states have standard DNR forms to be used while you are outside a hospital.

If you do not wish to be resuscitated, a non-hospital DNR is essential for any Emergency Medical Service (EMS) team that may attend to you. Unless you have a valid, visible DNR order, any EMS team that responds to a 911 call is legally obligated to attempt revival and prolong life in any way possible. Talk to your health care team if you would like a DNR order to keep with you. A non-hospital DNR must be signed by both you and your health care provider.

Choosing to become an organ donor

If you would like to donate your organs or tissues, you can include this in your advance directive. Many states supply organ donor cards or note this on your driver’s license. ■