Advanced Health Care Directives and Living Will

185568189As end-of-life health care services become more complex and patient-centric, both medical professionals and legal experts are now recommending advanced heathcare directives be completed by all adults. These documents help ensure your wishes are respected if you should become unable to communicate; they also help reduce confusion and stress among your next-of-kin who may otherwise be called upon to make difficult decisions on your behalf.
Advocates of advanced care planning say that by discussing one’s end-of-life wishes with caregivers, physicians and family members the patient can be assured that their personal preferences will be respected and their loved ones are relieved of the burden of making important health care choices for another person.

In the United States, a number of terms are often used interchangeably to describe written documents regarding end-of-life medical care preferences; these include Living Will, Advanced Health Care Directive, and DNR (do not resuscitate) orders as well as a Durable Power of Attorney (DPA) for Health Care.

Each document is slightly different with unique limitations and inclusions; a living will provides basic instructions regarding end-of-life care, a DPA (also known as a health care proxy) assigns the power to make medical decisions on your behalf to one or more people, while an advanced health care directive (AHCD) includes both a living will and a DPA in a single document. A DNR order can be included as part of a living will or an advanced healthcare directive; it lets medical providers know that you do not wish to have extreme life-saving measures performed (such as cardiac defibrillation or CPR) in order to prolong your life if your heart stops or you stop breathing naturally.

Living Wills

According to the American Bar Association, a living will “is simply a written instruction spelling out any treatments you want or don’t want if you are unable to speak for yourself and (you are) terminally ill or permanently unconscious (such as when there is no detectable brain activity). Generally speaking, a living will is a basic document that provides medical staff and family members with a clear outline of what type of life-sustaining interventions you want and do not want should you be unable to communicate your wishes. Depending on which state you live in, the term “living will” may refer to an advanced healthcare directive; it may or may not include the designation of a power of attorney for healthcare, so it is important to seek out state-specific information from your state Department of Health Services or your Secretary of State. The National Hospice and Palliative Care Organization provides a complete list of links to free, state-specific documents on their Caring Info website here.

Advanced Healthcare Directives

iStock_000009802555XSmallAn advanced health care directive is a legal document that both outlines your specific wishes regarding your medical care (as covered in a living will) and provides you with the option of appointing a durable power of attorney for health care/health care proxy. It only comes into effect in the event of your incapacitation combined with a medical condition which is likely to result in your passing.

While the exact contents of each advanced healthcare directive vary depending on each person’s personal preferences and beliefs, the basic information always includes the individual’s name, the name and address of the person being appointed as the health care proxy and an alternate. It also includes details about end-of-life care such as wishes about life-sustaining treatments like hydration and nutrition as well as details about comfort care including the use of pain medication.

Laws and Regulations Regarding Advanced Healthcare Directives

Each state has legislation which covers end-of-life care, living wills and advanced healthcare directives, although the general format and contents remain consistent throughout the country. No person in the United States is currently required by law to have a living will or advanced healthcare directive and forcing a person to sign one under duress is a criminal act.

In accordance with the Federal Patient Self-Determination Act, any healthcare facility that participates in Medicare must provide patients and their families with written information about advanced health care directives and the patients’ rights regarding health care choices . The Act also specifies that these facilities must provide ongoing education and training to both their staff and the general public regarding advanced healthcare directives. The Act, which came into effect on December 1, 1991 aims to improve informed consent and end-of-life care for all patients of Medicare-funded facilities.

It is not necessary to hire a lawyer to assist with an advanced directive, however, some people may wish to involve an attorney in the process to ensure they fully understand their rights and the limitations and inclusions of their directive. In most states, an individual can complete their own advanced healthcare directive using free state-approved forms that are signed and witnessed.

Copies of completed directives should be provided to your primary health care provider, any caregivers, close family and friends as well as your health care power of attorney (if one has been named). Note that in every state a person who has completed a living will, advanced directive, health care proxy and/or a do not resuscitate order has the right to revoke or change these documents at any time so long as they are competent to do so.

Inclusions and Limitations in Living Wills and Advanced Directives

452563585An advanced healthcare directive, living will or medical power of attorney only becomes effective in certain situations; the patient must be unable to communicate their own wishes and any conditions outlined in the documents must be met, such as the presence of a terminal illness. Each state has regulations which determine if and when and advanced directive becomes active.

People are free to include or exclude as much information as they wish in their advanced directive provided that their requests do not break any laws or pose any medical ethics issues.

For example, some choose to include details about hospitalization, pain medications and specific treatments that may either delay or expedite death like tube feeding. A directive can also include directions regarding organ donation, tissue removal and post-death examination (autopsy).

Benefits of Advanced Healthcare Directives

A study of over 4,000 people by researchers at the University of Michigan found that “advanced directives are important tools for providing care in keeping with patients’ wishes” and that over one-quarter of all adults over the age of 60 required assistance from a surrogate decision maker (health proxy or power of attorney for medical) to make arrangements for end-of-life care.

Advanced directives have been supported by medical professionals and national organizations such as the American Cancer Society as valuable tools for ensuring a person’s quality of life during times of terminal illness or impending passing. By communicating your end-of-life wishes to your family members, caregivers and loved ones you will retain greater control over your care and relieve your survivors of the burden of making vital health care decisions on your behalf.

To learn more about advanced healthcare directives, speak with your doctor, contact your local hospice or review the following online resources on living wills, advanced directives and durable healthcare power of attorneys.

Additional Resources

American Academy of Family Physicians (AAFP) - Sample Advanced Directive Form. This webpage includes a complete ready-to-use Advanced Directive Form which also serves as a Living Will/Durable Healthcare Power of Attorney in some states. It includes detailed information about common inclusions and exclusions on a living will such as specifics regarding life-sustaining and comfort care treatments, organ donation and autopsies.

National Healthcare Decisions Day - This not-for-profit organization is dedicated to educating both caregivers and the public “about the importance of advance care planning” through a one-day annual awareness day, held in April each year. Their website includes a 3 1/2 minute video that outlines the importance of advanced healthcare planning as well as an extensive list of resources.

New York Times - A personal account of how an advanced health care directive helped one man spend his final days exactly as he wished - surrounded by family members and friends in the comfort of home written by Dr. Pauline W. Chen, M.D.

Cleveland Clinic Department of Social Work - An example of a print-ready, state approved “Living Will Declaration” along with a
plain-language explanation of what is covered and excluded by this document.

PBS - A basic explanation of advanced directives, how to prepare one and the legal implications of this document. Includes links to state-specific advance directives forms.

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