Advance Directives

What are Advance Directives?

If you lose the ability to make decisions, someone will have to make decisions for you. The person you choose to make those decisions for you is known as a surrogate.  Your surrogate 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.

In order to help a surrogate carry out your wishes, there are legal documents that allow you to spell out your healthcare decisions ahead of time.  These documents are called advance directives (also known as advance care plans).  Advance directives go into effect only when you lose the ability to make decisions. (Only healthcare professionals can determine if you do or don’t have the ability to make decisions.)

Types of advance directives

There are two common types of advance directives that express your wishes about the health care you desire:

  1. Living wills
  2. 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. 

A specific and common example of an advance directive is a “do not resuscitate” order (or DNR), which guides care only in the event of cardiac arrest. Someone who chooses a DNR order may or may not choose to go without other life-sustaining treatments. It is best to discuss preferences regarding resuscitation in the context of your overall goals of care.

Whenever possible, your healthcare providers 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. Advanced directives can be stopped orally or in writing by you at any time, as long as you maintain the capacity to make decisions.

Most commonly, advance directives come out of the conversations you had with relatives, friends, and healthcare providers while you were still capable. It is never too early to have these conversations.

Your advance directives should be written down carefully so that your wishes are specific, clear, and available later if needed. They should be reevaluated and revised whenever your medical condition changes.

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.  It has been found that advance care planning helps to allow people to have improved satisfaction with their quality of care, die in their preferred place, receive less intensive treatments at the end of life, and reduce hospitalizations at the end of life. It also results in lower stress, depression and anxiety in the surviving relatives of deceased persons.

Living Wills

Throughout the United States, there are laws or legal opinions that authorize living wills. 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 able to make decisions.  Some examples of life-sustaining treatment include CPR (cardiopulmonary resuscitation), mechanical ventilation for breathing, or artificial feeding. In a few states, an individual may also appoint surrogate decision makers through a living will. 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 choose 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 or religious community members act as surrogates for people who are not able to make their own healthcare decisions. This is because they probably know best what the person’s preferences are, 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. Your provider understands the medical procedures and your condition. Your lawyer is another possibility, but keep in mind that the courts can be cumbersome, expensive, and slow. If a surrogate decision maker cannot be found, a court may appoint a guardian to act as a surrogate.

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 based on your advance care planning wishes using a brightly colored form. It can be transferred from one care setting to another, and healthcare providers have promised to honor it.  For example, when your POLST form is shown, your advance care plans will be honored by the Emergency Medical Service team (ambulance or fire personnel), staff in the emergency room, the hospital team, and nursing home staff.

Since the POLST contains a set of valid legal orders, it requires a discussion with your physician and their signature to be fully activated. When you complete the POLST, it is best to keep it at home in a visible spot, like your refrigerator, so it can be easily found by an emergency responder. 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 recognize 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, your family, 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 solve many problems that can happen with advance directives. You and your healthcare provider should regularly share information about 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 provider about:
 
  • Situations that commonly develop with your specific illness or condition.
  • Various treatments and treatment options.
  • Your wishes, including who you choose as a surrogate decision maker.
  • The amount of responsibility 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.

 

Last Updated August 2017