Advance directives are instructions that outline how individuals want healthcare decisions to be made in the event that they are unable to make decisions themselves. Advance directives take many forms, including:

Advance directives are often spoken of in terms of a patient’s right to refuse medical treatment or the “right to die.” However, advance directives can do more than help patients refuse treatment. They are a means through which patients can ensure their wishes are met even if they become unable to speak for themselves.

Though advance directives may be completed at any time, they are most effective when prepared well in advance of a healthcare crisis. In addition, the decisions outlined in these documents should be discussed with family members.

The laws surrounding advance directives vary from state to state. This is especially true in the cases of living wills and healthcare proxies, which need to be carefully written in accordance with state laws. Individuals wishing to complete the forms may benefit from the assistance of an attorney.

Advance directives are instructions that outline how individuals want healthcare decisions to be made in the event they are unable to make decisions themselves. To be effective, advance directives need to be completed long before a healthcare crisis occurs. In addition, individuals completing advance directives should discuss the matter, and their wishes, with their loved ones. Advance directives hold legal power in all 50 states and the District of Columbia. However, enforcing the decisions outlined in an advanced directive is more difficult for healthcare professionals if family members are either unaware of the choices outlined or oppose those wishes. Family members who are aware of the individual’s wishes in advance find it easier to accept those wishes during a healthcare crisis.

Advance directives have been available to patients for more than 30 years, yet they are an underused resource. Patients with a potentially life-threatening condition are often hesitant to complete advance directives because they feel it is “giving up.” However, dealing with these difficult issues in advance allows the patients and their families the one thing that is needed most during crisis situations – time. Advance directives offer patients peace of mind, because they know their wishes will be communicated and followed even if they become unable to communicate for themselves.

By law, advance directives cannot be required before admission to any hospital or healthcare setting, including nursing homes. However, the 1990 Patient Self–Determination Act made it a federal law that healthcare facilities that accept Medicare or Medicaid reimbursement provide patients with information regarding advance directives at the time of admission. This provision of information should not be presented or perceived as a requirement for admission.

States have different laws governing the completion and use of advance directives. This is especially true in the cases of living wills and healthcare proxies, which need to be carefully written in accordance with state laws. Individuals wishing to complete the forms may benefit from the assistance of an attorney. Those who relocated from one state to another are advised to prepare a new document in their new state of residence. When traveling, patients should carry a card with their name, their healthcare agent’s name and contact information, and the location of their living will.

Many states recognize combined advance directives, but others do not. To ensure the proper execution of advance directives it is best to complete separate state–approved forms.

Advance directives are active until revoked. Additionally, both the appointment of a healthcare agent and the individual instructions given through do-not-resuscitate orders (DNRs), donor designation cards and living wills can be changed at any time. The purpose of an advance directive is to provide patients their medical treatment. Individuals are advised to review their advance directives periodically or whenever there are major changes in their lives to ensure their instructions still represent their wishes. They should then notify their healthcare agents, family members, physicians, attorney and other involved parties of any changes made to their advance directives.

Living wills are specific written instructions that outline an individual’s wishes regarding medical treatment. This should not be confused with a last will and testament, which distributes an individual’s estate after death. Living wills are separate documents completed for the sole purpose of guiding medical decisions in the event that the individual becomes unable to communicate. Living wills are also called a variety of other names from state to state, including:

In order for a living will to be effective, it must be very specific, stating treatment methods that are either acceptable or unacceptable. Common categories of treatment addressed in living wills are:

• Pain relief. Is it permitted to administer medication(s) to relieve pain?
  
  
• Artificial feeding. Is it permitted to feed the patient through feeding tubes and hydrate the patient through intravenous (IV) tubes?
  
  
• Respiration. Is it permitted to place the patient on a respirator if breathing indepently becomes impossible? If the patient is already on a respirator, should use of the respirator be continued?
  
  
• Diagnostic testing. Is it permitted to withdraw body fluids for the purpose of diagnostic testing? Should other testing be performed? Individuals can specify which tests are acceptable and which are not (for example, prohibiting invasive tests, such as blood tests, while allowing noninvasive tests such as an x-ray).

It is important to note that living wills are designed for use primarily in cases of terminal illness or healthcare events that lead to extensive brain damage or brain death. Living wills can be written to address only certain situations in which the patient is unable to communicate. For instance, the individual may wish to specify that all treatment except pain relief be withheld in the event of coma with extensive brain damage but that all treatments are allowed in the event of coma where the extent of brain damage is unknown.

The primary limitation of a living will is that it is impossible to know in advance the exact health situation that will occur in the future. For this reason, it is often beneficial to use a living will in combination with a healthcare proxy (see next section). Also, laws regarding living wills vary from state to state. More information about each state’s laws can be found through state bar associations, medical associations, healthcare organizations and other support organizations.

A healthcare proxy is a document that enables an individual to appoint an agent to make healthcare decisions in the event that the individual becomes unable to communicate. The name of this document varies greatly from state to state. These variations include:

Individuals can give their healthcare agent as little or as much authority as they choose and can even leave their agent detailed instructions that the agent must follow. A living will can be helpful for this purpose. Healthcare providers are required to accept the healthcare decisions of an agent as if those decisions were being made by the patient.

Healthcare proxies are often referred to as a “healthcare power of attorney,” which can be confusing. A traditional power of attorney (POA) is not an advanced directive at all, but a written document that designates a person (agent) to act for another person (principal) in a legal capacity. Most frequently, a person will give an agent a power of attorney when the principal is ill or for some other reason unable to conduct financial and legal affairs. Most states will not allow an agent holding a traditional power of attorney to make healthcare decisions.

Individuals may choose anyone to be their healthcare agent, including family, close friends, clergy, lawyers or physicians. People are advised to choose someone they not only trust but who will be able to cope with the responsibility being entrusted to them. In addition, it important that the person discuss the healthcare proxy and any other advanced directives with the appointed agent.

The healthcare proxy does not limit the patient’s control or flexibility in choosing his or her treatment options. The proxy can be in effect only if the patient is unable to communicate in any manner, including speaking, writing or other methods.

A DNR (do not resuscitate) order instructs healthcare professionals not to provide emergency treatments to restart the heart and lungs when breathing or circulation has stopped (cardiac arrest). A DNR is only a decision about cardiopulmonary resuscitation (CPR) or defibrillation and does not relate to any other treatment. DNRs are most often used by terminally ill patients in acute care setting or in home hospice programs.

The DNR order must be written by a physician and can be done at the request of either the patient or the patient’s surrogate (e.g., holder of the healthcare proxy). Though CPR can save lives, it can also cause pain and injuries, such as cracked or broken ribs. Patients who are terminally ill or have a serious medical condition may choose not to have CPR performed even if that choice means they may die. Physicians will discuss the benefits and risks of CPR with a seriously ill patient, or the surrogate, before signing a DNR order.

Patients have the right to refuse treatment at any time; however, a DNR ensures that patient wishes will be met even if they cannot communicate those wishes. As with all advance directives, patients can change their mind at any time. In addition, issuing a DNR order does not prevent medical professionals from providing comfort care, such as pain-relieving medications, even though it prevents the use of CPR.

Laws regarding DNR orders vary from state to state, and some states have multiple forms of DNR orders. For instance, one type of DNR order may state that only comfort care can be provided before, during and after the patient’s breathing and/or heartbeat stops. Another type of DNR allows medical professionals to administer powerful medications before a person’s heartbeat or breathing stops to prevent cardiac arrest. Another type of DNR order allows the patient to specify the extent of medical intervention allowable at each stage of the medical crisis. In some states DNRs are portable, meaning they can be used in other states. However, as a precaution, patients who move to another state are advised to complete new DNR orders and advance directives in that state.

Though DNRs are primarily used in residential healthcare settings such as hospitals and nursing homes, they are not always limited to those locations. When receiving care in a hospital or nursing facility patients with DNR orders may be asked to wear a special bracelet to identify that a DNR order is in place. When outside of a healthcare setting, patients can complete state–approved DNR forms with their physicians and may choose to wear a DNR bracelet or necklace or carry a DNR wallet card.

At any time patients who wish to revoke the DNR order should:

• Inform physician(s) that a DNR order is no longer desired.
  
  
• Inform family members, caregivers and any other people who were aware that a DNR order was in place.
  
  
• Destroy any forms, documents, wallet cards or identification jewelry that may have been created when the DNR was first issued.

Organs, such as the heart, lungs, kidneys and liver, can be donated only by individuals who have suffered brain death (the stopping of all brain activity) but whose bodies are still alive and circulating blood to these organs. Because of this requirement, there is a severe shortage of donor organs available for heart transplants and other life-saving procedures. One person who donates organs can save the lives of five to seven other people.

Although only those who are declared brain dead can become organ donors, the majority of people can become tissue donors. Tissue donations can be made after a death by nearly any cause. Body tissue, such as corneas, heart valves, skin, bones and connective tissue from one person can help improve the lives of more than 50 others. In addition, tissue donations can be made by individuals of any age, from newborns to those over 80.

Without an advance directive, the decision regarding whether an individual will become an organ or tissue donor is left to the next of kin (healthcare proxies are not valid after the patient’s death). For loved ones, it is a very difficult decision to face, especially because the decision needs to be made immediately upon learning of the patient’s death (or brain death). When individuals determine their wishes in advance and communicate them clearly to their loved ones, the decision of whether or not to donate organs or tissue can be made without that emotional strain.

There are three steps that people should take if they wish to be an organ and tissue donor:

• Complete a donor card.
  
  
• Designate donor preference on their state driver's license (if available).
  
  
• Talk to family members and loved ones about their decision to be an organ and tissue donor. Families who are unaware of their loved one’s decision to donate often oppose the donation and can be successful in their attempts to prevent organs or body tissue from being donated.

A power of attorney (POA) is a written document that designates a person or party (agent) to act for another person (principal) in a legal capacity. Most frequently, people will give another person power of attorney when they are ill or for other reasons are unable to conduct their own financial and legal affairs. In most states, agents holding traditional powers of attorney cannot make healthcare decision for the principal. They are generally used for:

Powers of attorney come in three forms:

• Nondurable (short-term). This takes effect immediately and is often used for a specific transaction, such as closing on the sale of a home or managing the financial affairs of someone traveling out of the country. It remains in effect until the principal revokes it, becomes mentally incompetent or dies.
  
  
• Durable (long-term). This enables the agent to act for the principal even if the principal becomes mentally incompetent or physically unable to make decisions. It takes effect immediately and remains in effect until the principal revokes it or dies.
  
  
• Springing (triggered by a predetermined event). A springing POA becomes effective at a predetermined point in the future (chosen by the principal). It “springs into action” when that specific event, often an illness or disability, occurs. There is usually a provision in the springing POA that the principal’s physician will determine whether the principal is competent to handle financial affairs. A springing POA remains in effect until it is revoked by a court of law or the principal dies.

The authority given to an agent by the principal can be as broad or as limited as the principal wants. Choosing an agent is a crucial decision. There is no official or government agency responsible for monitoring. The principals can monitor the agents themselves or appoint a third party to do so. A POA can be like a blank check, so principals need to be extremely selective in choosing an agent. It is possible to appoint more than one agent. The POA can require that both agents work together in making decisions or allow each to act separately. The principals may continue to act for themselves in a legal capacity as long as they remain legally capable.

Attorney services are a good idea, but are not necessary to complete a legal power of attorney.

Advance directives are often thought of as a device for the terminally ill or elderly. However, accidents can affect anyone at any age, and these documents are the best way of ensuring that the individual’s wishes are met. By law, anyone over 18 can complete advance directives, with the exception of DNR (do not resuscitate) orders, which must be completed by a physician. Though advance directive forms may be completed by children under 18, parents and healthcare providers are usually not required by law to honor those documents.

Though living wills tend the get the most attention in media reports and television dramas, it is really the healthcare proxy that the majority of people will find most beneficial. Without a living will, agents holding a healthcare proxy can still make treatment decisions. However, without a healthcare proxy, living wills are usually difficult to enforce.

Healthcare proxies are also a good starting point for discussions regarding advanced directives. People often find it easier to decide who they want in charge of their medical decisions than to outline in detail the instructions needed for a living will (e.g., denying artificial respiration).

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to advance directives:

1. Do you recommend that I complete an advanced directive?
   
   
2. What type of advanced directive should I complete (e.g., living will, healthcare proxy)?
   
   
3. What kind of decisions would an advanced directive allow me to make?
   
   
4. Are there any drawbacks to having an advanced directive?
   
   
5. Should I create an advanced directive now, or wait until my condition worsens?
   
   
6. Do I need to tell my family members about the choices I've made in my advanced directive?
   
   
7. If I create an advanced directive now, can I change it in the future?
   
   
8. Are there any circumstances when a physician can override the decisions made in an advanced directive?
   
   
9. Can I complete a DNR (do not resuscitate) order if I am pregnant? How does pregnancy affect any advanced directives I have already completed?