Aging & Health A to Z
Basic Facts & Information
What are Advance Directives?
If you lose the capacity to make decisions, someone will have to make decisions on your behalf. In this case, the person you choose as a stand-in (surrogate) decision maker should try to honor any wishes you expressed while you were still capable of making decisions. Your expressed wishes are legally and ethically more important than what others want for you, even if they feel that they are acting in your best interests.
Two common types of advance directives (advance care plans) that express your wishes are:
- living wills
- durable power of attorney for healthcare.
Different states may have different names for durable power of attorney for healthcare, such as healthcare proxy or healthcare declaration. It is also important to remember that advance directives have some limitations.
Whenever possible, healthcare professionals should respect the informed choices that you have expressed while you were still capable of making decisions. Following these advance directives demonstrates respect for your individuality and self-determination. It is a legal and ethical obligation.
Most commonly, advance directives come out of the conversations that you had with relatives, friends, and healthcare workers while you were still capable.
Your advance directives should be written down carefully so that your wishes are specific, clear, and available later if needed.
You should provide advance directives in writing whenever possible, because written directives clearly reflect your intention to direct future healthcare and cannot be easily challenged in court.
Laws or legal opinions that authorize living wills have been enacted throughout the United States. These are often called natural death, death with dignity, or right-to-die laws. Generally, these laws allow you to direct healthcare providers to withhold or withdraw treatment that is keeping you alive if you become terminally ill and are no longer capable of making decisions. In a few states, an individual may also appoint surrogate decision makers. Legal immunity is given to caregivers who comply with an appropriately drafted living will.
Durable Power of Attorney for Healthcare
The durable power of attorney for healthcare is more flexible and comprehensive than a living will. It allows you to designate a surrogate decision maker (such as a friend or relative) to make your medical decisions if you lose the ability to make them yourself. You give the surrogate your informed consent (or refusal) while you are still capable. You should discuss with your surrogate ahead of time the types of treatment(s) you would or would not want in specific situations so that your surrogate has some guidelines if the need arises.
Traditionally, family members act as surrogate decision makers (or stand-ins) for incapacitated individuals, because most probably best know the person’s preferences and will act in their best interests. Family members are also normally consulted by the healthcare provider. However, the healthcare provider may sometimes decide that decisions by family members are questionable because of conflicting personalities, values, or interests. In addition, some family members may be estranged or unwilling to make decisions, or they may disagree among themselves. In other cases, older adults have no surviving relatives.
When there are no relatives or friends to represent you, it may be that your physician (or other healthcare provider) is the next best choice as your surrogate decision maker. Your physician understands the medical procedures and your condition. Your lawyer is another possibility, but bear in mind that the courts can be cumbersome, expensive, and slow.
Physician Orders for Life-Sustaining Treatment (POLST)
Physician Orders for Life-Sustaining Treatment (POLST) is a recently developed program that is designed to improve the quality of care people receive at the end of life. It effectively communicates medical orders and patient wishes on a brightly colored form that can be transferred from one care setting to another and that healthcare professionals have promised to honor. Visit the National POLST Program website to find more information and to locate community or state-based POLST programs.
Problems with Advance Directives
Limitations. Advance directives have limitations. For example, an older adult may not fully understand treatment options or appreciate the consequences of certain choices in the future. Sometimes, people change their minds after expressing advance directives and forget to inform others. Many times, advance directives are too vague to guide clinical decisions. For example, general statements rejecting "heroic treatments" are vague and do not indicate whether you want a particular treatment for a specific situation (such as antibiotics for pneumonia after a severe stroke). On the other hand, very specific directives for future care may not be useful when situations change in unexpected ways. New medical therapies may also have become available since an advance directive was given. You and your healthcare provider can do a great deal to avoid these problems by discussing advance directives with each other.
Importance of communication. Good communication can resolve many problems posed by advance directives. You and your healthcare provider should routinely share information on advance directives. A straightforward question you can ask to open the topic is: "Can we talk about how decisions will be made for my medical care in case I become too sick to talk to you directly?"
Ask or tell your healthcare professional about:
- Situations that commonly develop with your particular illness or condition.
- The various treatments and treatment options.
- Your wishes, including your designation of a surrogate decision maker.
- The amount of discretion that you want the surrogate to have and how you will let your surrogate know if you change your mind about something. It is also important for you to have periodic discussions about these issues with family members and friends.
Updated: March 2012
Posted: March 2012