Advance Directives

What are advance directives?

Advance directives are written instructions about your future medical care. They do not go into effect until you are no longer able to make decisions. Advance directives have several functions:

• They allow you to decide ahead of time what medical procedures you do or do not want. This usually involves decisions about breathing machines, CPR, giving you food and water if you cannot take them by mouth, and whether or not to use certain medicines such as antibiotics.
• They help your family make decisions.
• They make sure your wishes are followed if they are different from your family's wishes.

Two types of advance directives are a living will and a durable power of attorney.

A living will is also called a healthcare treatment directive. It is a legal document. It states your desires about withholding and/or withdrawing treatment in the event you:

• have a condition that cannot be cured
• are not expected to live for more than a few months.

Living wills tell caregivers what to do in the future when you are not able to make healthcare decisions. It is called a "living will" because it must be signed formally like a regular will but its terms take effect before your death.

A living will may:

• Spell out the measures you do and do not wish to have taken to extend your life when you are clearly dying.
• State whether or not you want breathing machines, feeding tubes, oxygen, IV fluids, or other medicines to be used.
• List specific conditions (coma, fatal illness with no hope of recovery or cure, end-stage dementia) under which the terms of your living will are to go into effect.

For a living will to be legal, when you sign it there must be witnesses and you must be competent. All adults are presumed competent unless a judge has declared them incompetent. Requirements vary from state to state, but usually the witnesses must not be:

• your relatives
• creditors or heirs to your estate
• your doctor.

It is wise to prepare a living will at a time when you are healthy, not when you have been very ill or are in the hospital.

It is important to note that living wills only cover decisions about your healthcare when you have a terminal illness. This means an illness where death is expected in a relatively short time. Some illnesses, such as stroke, may not be covered by a living will. A living will is a good thing to have but you should also have other advance directives so that your wishes will be respected.

Most states have laws that recognize advance directives. Not all states do, however, and living wills may not always be binding. Some states do not recognize living wills that have been drafted in other states. Check the laws in your state.

A durable power of attorney for healthcare (DPAHC) appoints a family member or friend to follow your wishes. This person is called your agent. Your agent will make medical decisions for you if you cannot make them for yourself. Some people prefer the DPAHC to a living will because it is more flexible.

You must be competent at the time you sign a DPAHC for it to be legal. You are "legally competent" if you are of sound mind and at least 18 years old. If you have a brain disease that gets worse over time (such as Parkinson's disease or Alzheimer's disease), you may wish to draw up the DPAHC papers early in the illness. Your agent's duty is to follow your wishes. In states that recognize such documents, families and healthcare providers cannot override your living will or your agent's decision.

Once you have signed these documents, keep them in a safe place. But do not put them in a safe deposit box because others may not have access to them when the documents are needed. It is a good idea to discuss your wishes with your friends, family members, and your doctor. You should also give these people copies of your living will or DPAHC. That way, others will have access to the documents that express your wishes if you are no longer able to speak for yourself.

Sample forms for writing your living will, a durable power of attorney, and a Healthcare Treatment Directive are available with this handout. If you want copies of those sample forms and they were not provided with this handout, ask for them. They are only samples, however, and may not conform to the laws in your state.

The National Hospice and Palliative Care Organization will provide a copy of state-specific advance directives free. You can call 800-658-8898 or visit their web site at http://www.nhpco.org.

Your state health department, local hospitals, or state bar association also may be able to provide you with state-specific advance directives. You may wish to ask your lawyer to help draw up advance directives.

What happens if a person is already physically or mentally unable to manage his or her own affairs?

Some older people are unable to manage their own affairs due to a medical or a mental condition. A person can be confused about time and place but still able to understand choices if they are carefully explained. Can the person understand and make decisions about medical and financial choices?

Healthcare providers and mental health specialists can assess the ability to make decisions. A court must decide if the person is legally competent. Legal competence is based on whether the person:

• has a condition such as a mental illness or dementia
• is able to make or communicate decisions
• is able to manage money or make healthcare decisions.

The court may appoint a legal guardian if the person is not able to make informed decisions. Guardianship may cover all areas of someone's life, or it may cover only certain areas. For example, an older person may be able to make decisions about his or her health but not about money.

What is the meaning of "resuscitate" and "do not resuscitate (DNR)?"

If you are in a clinic, hospital, or nursing home, you may be asked to sign a code status sheet. This tells the staff what measures you want taken if your heart stops and you are not breathing. Code status may be changed at any time.

Cardiopulmonary resuscitation (CPR) is an emergency procedure that can save the life of someone whose heart has stopped beating and who is not breathing. CPR is not usually as helpful for people with severe chronic illnesses or where death is expected to occur soon. When CPR would be of no medical benefit, your doctor can explain why.

A full code means that you want everything possible done to revive you. This includes giving CPR, electrical shocks, medicine to start your heart, and putting you on a ventilator (a machine to keep you breathing).

A limited code may exclude being put on a ventilator, dialysis, or other kinds of support.

A no code order (DNR, for Do Not Resuscitate) may be written. A DNR order excludes only CPR and does not limit other types of treatment. You should receive all needed medical and nursing care, even when CPR would not benefit you.

Although death comes to everyone, many of us fear it and may avoid dealing with issues that concern the end of life. It is important for you to put your wishes in writing. Otherwise, those wishes might not be known and could not be honored. That can make it harder than need be for loved ones. Take care of yourself and your family by making decisions about medical care while you are able to do so.