Guide to Advance Directives

What is an Advance Directive?
As a competent adult, you have the right to decide to accept or refuse any medical treatment. As long as you are competent, you are the only person who can decide what medical treatment you want and do not want to receive. A situation may arise in future when you are unable to make medical decisions for yourself due to some illness, how can one know as what treatment you want and do not want then. In such cases, an advance directive comes into play.

An Advance Directive is a document that directs your doctor what kind of care you would like to have if you become unable to make medical decisions for yourself. A good advance directive describes the kind of treatment you would want depending on how sick you are. For example, the directives would describe what kind of care you want if you have an illness that you are unlikely to recover from, or if you are permanently unconscious. Advance directives usually tell your doctor that you do not want certain kinds of treatment. However, they can also say that you want a certain treatment no matter how ill you are.
Advance directives can take many forms. Laws about advance directives are different in each state. You should be aware of the laws in your state.

What is a Living Will?
A living will is one type of advance directive. It only comes into effect when you are terminally ill. Being terminally ill generally means that you have less than six months to live. In a living will, you can describe the kind of treatment you want in certain situations. A living will does not let you select someone to make decisions for you.

What is a Durable Power of Attorney for Health Care?
A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states that you have chosen someone to make health care decisions for you. It becomes active any time you are unconscious or unable to make medical decisions for yourself. A DPA is generally more useful than a living will. However, a DPA may not be a good choice if you do not have another person you trust to make these decisions for you.
Living wills and DPAs are legal in most states. Even if the law in your state does not officially recognize them, they can still guide your loved ones and doctor if you are unable to make decisions about your medical care. Ask your doctor, lawyer or state representative about the law in your state.

Why is Advance Directive Important?
Complex choices about end-of-life care are difficult even when people are well. If a person is seriously ill, these decisions can seem overwhelming. Patients should keep in mind that avoiding these decisions when they are well would only place a heavier burden on them and their loved ones later on. Communicating wishes about end-of-life care will ensure that people with cancer face the end of their lives with dignity and with the same values by which they have lived.

What is a Do Not Resuscitate (DNR) Order?
A does not resuscitate (DNR) order one type of request under your Living Will. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your doctor that you do not want to be resuscitated. In this case, a DNR order is put in your medical chart by your doctor. DNR orders are accepted by doctors and hospitals in all states.
Most patients who die in a hospital have had a DNR order written for them. Patients who are not likely to benefit from CPR include people who have cancer that has spread, people whose kidneys do not work well, people who need a lot of help with daily activities, or people who have severe infections such as pneumonia that require hospitalization. If you already have one or more of these conditions, you should discuss your wishes about CPR with your doctor, in either the doctor’s office or when you go to the hospital. It is best to do this early, before you are very sick and are considered unable to make your own decisions.

What is a Do Not Intubate (DNI) Order?
A Do Not Intubate (DNI) order is another type of request under your Living Will. A DNI is a request not to have intubation done if you stop breathing. You can use advance directive form or tell your doctor that you do not want to be intubated. In this case, a DNI order is put it your medical chart by your doctor. DNI orders are accepted by doctors and hospitals in all states.

How can I write an Advance Directive?
Before writing an Advance Directive, one should discuss his / her beliefs and wishes with family members – partner, spouse, children, friends, clergy or your doctor.
Once decided about advance directives, one can approach the following ways to get started:

  • Use a form provided by your doctor.
  • Write your wishes down by yourself.
  • Call your state senator or state representative to get a form. (Go to Resources for State Specific Downloadable Forms).
  • Call a lawyer.
  • Use a computer software package for legal documents.

Review the forms carefully. You may need the advice of your doctor when specifying which types of treatment you do not want. You can differentiate between life-prolonging procedures and those that alleviate pain. Detail specific wishes you have about your care that the form does not cover.
Advance directives and living wills do not have to be complicated legal documents. They can be short, simple statements about what you want done or not done if you cannot speak for yourself. Remember, anything you write by yourself or with a computer software package should follow your state laws. You may also want to have what you have written reviewed by your doctor or a lawyer to make sure your directives are understood exactly as you intended. When you are satisfied with your directives, the orders should be notarized if possible, and copies should be given to your family, your doctor and your lawyer.

Can I make changes to my Advance Directive?
You may change or cancel your advance directive at any time, as long as you are considered of sound mind to do so. Being of sound mind means that you are still able to think rationally and communicate your wishes in a clear manner. Again, your changes must be made, signed and notarized according to the laws in your state. Make sure that your doctor and any family members who knew about your directives are also aware that you have changed them.
If you do not have time to put your changes in writing, you can make them known while you are in the hospital. Tell your doctor and any family or friends present exactly what you want to happen. Usually, wishes that are made in person will be followed in place of the ones made earlier in writing. Be sure your instructions are clearly understood by everyone you have told.

Frequently Asked Questions about Advance Directives

  1. Do I need both a Healthcare Directive and a Durable Power of Attorney for Health Care Decisions?
    It is not necessary but it is useful to have both. Since making medical decisions especially about end-of-life care could be very complex and your living will may not cover every situation. To provide directions in such situation, you should name a person (agent) who you can trust to make decisions for you.
  2. Do I need an attorney to make a Healthcare Directive or a Durable Power of Attorney for Healthcare Decisions?
    No, you do not require a attorney to make an advance directive. However, you may want to discuss your advance directive with your attorney, if you have one.
  3. Will my advance directive be valid in another state?
    Yes, especially if it is both notarized and witnessed. The right to make an advance directive has been constitutionally affirmed.

Online resources for Advance Health Care Directives
General Information

  • The Living Will: A Guide To Health Care Decision Making – Article by a physician and attorney addresses difficult issues including Terminal Illness, Permanent Disability, Determining Permanence or Irreversibility, Ordinary and Extraordinary Care. (University of Buffalo)
  • End-of-Life Care: Advance Care Planning – Provides free brochures and state-specific advance directives to provide you with information and resources for advance care planning (National Hospice & Palliative Care Organization (NHPCO))
  • 10 Legal Myths About Advance Medical Directives – A compiled list of common myths about advance directives and the facts that dispel them. (American Bar Association Commission on Law and Aging)

Decision-Making Tools

  • Consumer’s Tool Kit for Health Care Advance Planning – Contains 10 “tools” (pdf documents) that provide a variety of self-help worksheets, suggestions, and resources to help you “discover, clarify, and communicate” what is important to you in the face of serious illness. (American Bar Association Commission on Law and Aging)
  • End-of-Life Decision-Making – Outlines issues to consider when you or a loved one is faced with end-of life decision-making and provides resources for additional assistance. (Family Caregiver Alliance)

Advance Health Care Directive Forms

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