Advance Directives and Living Wills

Even though it can be difficult to discuss serious illness and death with your loved ones, communicating your values and wishes now can avoid stress and confusion later.

What are advance directives?
Advance directives are legal documents that allow people to convey their decisions about end-of-life care ahead of time. Advance directives include a living will and durable power of attorney for health care.

What is a living will?
A living will is a set of instructions that communicates your wishes about specific medical interventions that are intended to sustain life. You have the right to accept or refuse medical care at any time, but if you are unconscious or unable to make decisions the living will helps your family and physicians know how to best care for you.

There are many types of life-sustaining medical interventions to consider when writing a living will. Treatments to discuss include:

• Cardiopulmonary resuscitation (CPR)
  If you stop breathing or your heart stops beating, health care professionals will try to revive you with CPR. Many times this is unsuccessful if the person already has a serious illness. If you do not want to be resuscitated, your medical records will be marked with a do-not-resuscitate (DNR) order.
• Mechanical ventilation
  If your lungs stop working, a machine called a ventilator can breathe for you. You will need to decide if you would want to be put on this machine on a short-term or long-term basis, or not at all.
• Nutritional and hydration assistance
  There are many ways to feed a person who can no longer eat. A tube can be inserted into the stomach through the nose or stomach wall, and liquid nutrition can be given through the tube. You will need to decide if you would want to be fed through a tube on a short-term or long-term basis, or not at all.
• Dialysis
  Dialysis removes waste products from your blood and manages fluid levels if your kidneys are no longer working. You will need to decide if you would want to receive dialysis on a short-term or long-term basis, or not at all.

It is also important to designate whether you'd like to donate your organs in the event of your death.

What is a durable power of attorney for health care?
A durable power of attorney for health care is the legal document that names the person you wish to make medical decisions for you if you are unable to do so yourself. This person is then referred to as a health care proxy. It is important to assign someone you trust, and with whom you've discussed your living will and values. This person will not need to make decisions that are clearly laid out in your living will; rather he or she may need to exercise judgment in the event that your wishes are not known.

You may also want to designate a durable power of attorney for finances in a separate document. The person you designate will manage your financial affairs if you are unable to.

The durable power of attorney for health care and finances document should be signed, dated, witnessed, notarized, copied and distributed to your family and physician (to be placed in your medical record).

When should advance directives be put in writing?
You don't have to be elderly or seriously ill to discuss end-of-life care. The decisions are complex, so it is best to make them when you are well and thinking clearly. In addition, you can always make changes to your advance directives as your perspective and values change. Ideally, advance directives should be revisited periodically. If any changes are made, they should be signed and dated, and copies should be given to your family and physician.

How is an advance directive written?
There are different resources available to help you write an advance directive.

• Request forms from your doctor.
• Write your wishes down by yourself.
• Access state-specific advance directive forms on the Internet.
• Call your health department or state department on aging to get a form.
• Call a lawyer.
• Use a computer software program that lets you download legal documents.

Each state has its own laws about advance directives. If you are not using a state-specific form, you may your doctor or a lawyer to review your advance directive. The National Hospice and Palliative Care Foundation sponsors a website called, Caring Connections. You can access state-specific advance directive forms at: http://www.caringinfo.org/i4a/pages/Index.cfm?pageid=3425

Once you have completed your advance directive, it should be signed, dated, witnessed, notarized and copied. Copies should be distributed to your doctor, health care proxy and family members. You can place the original document in a safe deposit box, but if you don't distribute copies your loved ones will not have access to that document when they need it.

Illness and death are not easy to talk about, but by planning ahead you can ensure that your wishes concerning your medical care are implemented.

Last Updated: February 2008

References

Pace B. Decisions about end-of-life care. JAMA. 2000;284(19):2550.

American Bar Association. Consumer?s Tool Kit for Health Care Advance Planning. Available from: http://www.abanet.org/aging/toolkit/home.html. Accessed February 2008.

American Academy of Family Physicians. Advance directives and do not resuscitate orders. Familydoctor.org. March 2005. Available at: http://familydoctor.org/003.xml. Accessed June 1, 2006 and February 2008.

National Cancer Institute. Advance directives. National Cancer Institute FactSheet. March 2000. Available at: http://www.cancer.gov/cancertopics/factsheet/support/advance-directives. Accessed June 1, 2006 and February 2008.

Mayo Clinic. Living wills and other tools to convey medical wishes. MayoClinic.com. July 2005. Available at: http://www.mayoclinic.com/health/living-wills/HA00014. Accessed June 1, 2006and February 2008.

American Hospital Association. Put it in writing. April 2005. Available at: http://www.putitinwriting.org/putitinwriting/content/piiwbrochure.pdf. Accessed June 1, 2006 and February 2008.