Advance Directives

Advance directives center around the principles of your right to die and death with dignity. With an advance directive, you can express how much or how little you want done for you when you are no longer able to make these decisions.

• Advance directives are a way of making your voice heard when you can no longer speak. They allow you to appoint someone to make your health care decisions for you when you no longer can and to administer or withhold treatment and procedures. Advance directives are not just for the elderly. All people who desire to direct their medical care in the future should complete an advance directive.
  
  
• All 50 states and the District of Columbia have laws regarding advance directives. Authorities also agree that no difference exists between withholding life-saving treatment and withdrawing life-support treatment. This is especially important in a situation where someone is resuscitated despite his or her wishes because the advance directive could not be found and the person is put on life support. Once the advance directive is shown to health care providers, life-support measures can be withdrawn.
  
  
• An advance directive does not mean, "do not treat." This is a common misperception and not correct. Of course, if you want it to mean do not treat, then that is something that your surrogate needs to know.

Advance directives: An advance directive is a written document or series of forms. You sign it to make it binding. The document indicates your choices about medical treatment. In the document, you can also name someone to make decisions about your medical treatment if you are unable to make these decisions or choices yourself. By completing the appropriate advance directives, you can predetermine end-of-life decisions about your future medical care in a legally sound way.

Two types of advance directives are generally completed: a living will and a medical power of attorney (also referred to as designation of a health care surrogate or health care proxy).

• Living will: This written statement tells health care providers what type of life-prolonging treatments or procedures to perform if you have a terminal condition or are in a persistent vegetative state. Living wills should not be confused with a regular will. A living will only deals with and addresses issues regarding your medical care while you are still living.
  
  
• Medical power of attorney (or designation of a health care surrogate): This legal document allows you to select any person to make medical decisions for you if you should become temporarily or even permanently unable to make those decisions for yourself. This person is also referred to as your attorney-in-fact, but it is not necessary for them to be a lawyer.

Life-prolonging treatments: These procedures are not expected to cure your terminal condition or make you better. They only prolong the dying process. Examples include a ventilator (breathing machine), kidney dialysis, and cardiopulmonary resuscitation (CPR).

Terminal condition: If you have an incurable condition of this type, medical treatment will only prolong the dying process. And without such treatment or procedures, death will occur in a short period of time.

Persistent vegetative state: This permanent coma or state of being unconscious is caused by injury, disease, or illness. You are unaware of your surroundings, and no reasonable expectation of recovery exists.

Do not resuscitate (DNR): Your doctor discusses this form or document with you, and it tells health care providers and emergency personnel that if your heart stops beating (cardiac arrest) or if you stop breathing (respiratory arrest) that they are not to attempt to revive you by any means. A DNR is not the same as a living will.

Artificial nutrition and hydration: This procedure is the invasive administration of nutrition and fluids through IV lines and feeding tubes. It is not the natural process of eating food or drinking liquid.

An advance directive is purely optional. All health care facilities such as hospitals that accept federal funding are required by law to ask if you have one and offer you the appropriate information and documents to sign one, if you so choose. Of course, the fact that you are reading this puts you one step ahead of the game.

• You should consider an advance directive if any of the following are true:
  
  
  • You want to be sure your voice is heard when you can no longer speak.
    
    
  • You want to be sure that your wishes are respected and followed in the event that you are unable to make medical decisions for yourself.
    
    
  • You want to be sure that you are not placed on life support machines or receive other life-prolonging treatment if you suffer from a terminal condition.
    
    
  • You want to be sure that, if you fall victim to a cardiac arrest after you have suffered with a long-term, end-stage medical condition, cardiopulmonary resuscitation (CPR) or other heroic measures will not be performed.
  
  
• No doctor or health care provider can force you to complete an advance directive.
  
  
• If you do not complete an advance directive, then you will receive medical care to the fullest extent appropriate for your condition. However, a greater chance exists that you will receive more treatment or more procedures than you would want performed.
  
  
• If you cannot speak for yourself and you do not have an advance directive, then health care providers will look to the following people, in the order listed, for guidance with your care:
  
  
  • Your guardian (if court appointed)
    
    
  • Your spouse
    
    
  • Your adult child (or the majority of adult children who are reasonably available)
    
    
  • Either of your parents
    
    
  • Your adult brother or sister (or the majority who are reasonably available)
    
    
  • Other adult relatives
    
    
  • A close friend who is familiar with your activities, health, or religious or moral beliefs

You can select just about any adult to be your attorney-in-fact (surrogate). Select someone who is aware of your wishes and values and whom you trust will be able to make the decisions (regardless of how difficult) at a time when needed. You should discuss all your wishes with your surrogate and be certain that they clearly understand what you desire. Be sure they are willing to accept this responsibility.

You can select a spouse, adult child or sibling, or even a close friend. You should not select your doctor, your doctor’s employees, or any staff of a facility where you live (such as a nursing home, hospice, or assisted living facility) because of a possible conflict of interest regarding the type of care you would or would not receive.

• The surrogate can only make decisions for you when you are temporarily or permanently unable to make your own health care decisions. As long as you have the ability to make your own decisions, you retain the right to do so. If you are temporarily unable to make decisions and then regain the ability to do so, then your surrogate no longer has decision-making capability.
  
  
• An attorney-in-fact (surrogate) can make just about any treatment or procedure decision that is consistent with accepted medical practice. Some states have restrictions in which a surrogate cannot make decisions regarding experimental treatment, sterilization, abortion, or electroshock therapy.
  
  
• You should only appoint one person to be your surrogate, but others may be selected to serve as alternates in the event the person you have chosen is unavailable or unable to make decisions.
  
  
• Surrogates cannot be held liable for decisions made regarding your care or for costs associated with medical care.

You can select just about any adult to be your attorney-in-fact (surrogate). Select someone who is aware of your wishes and values and whom you trust will be able to make the decisions (regardless of how difficult) at a time when needed. You should discuss all your wishes with your surrogate and be certain that they clearly understand what you desire. Be sure they are willing to accept this responsibility.

You can select a spouse, adult child or sibling, or even a close friend. You should not select your doctor, your doctor’s employees, or any staff of a facility where you live (such as a nursing home, hospice, or assisted living facility) because of a possible conflict of interest regarding the type of care you would or would not receive.

• The surrogate can only make decisions for you when you are temporarily or permanently unable to make your own health care decisions. As long as you have the ability to make your own decisions, you retain the right to do so. If you are temporarily unable to make decisions and then regain the ability to do so, then your surrogate no longer has decision-making capability.
  
  
• An attorney-in-fact (surrogate) can make just about any treatment or procedure decision that is consistent with accepted medical practice. Some states have restrictions in which a surrogate cannot make decisions regarding experimental treatment, sterilization, abortion, or electroshock therapy.
  
  
• You should only appoint one person to be your surrogate, but others may be selected to serve as alternates in the event the person you have chosen is unavailable or unable to make decisions.
  
  
• Surrogates cannot be held liable for decisions made regarding your care or for costs associated with medical care.

• A lawyer may be helpful with the completion of these matters, but one is not required.
  
  
• You can designate information regarding organ donation in most advance directive documents.
  
  
• You can withdraw or revoke your advance directive at any time you choose.
  
  
• The laws regarding advance directives vary from state to state. If you plan to spend an extended period of time in another state, complete the necessary papers for that state regarding your medical wishes. Legal experts agree, however, that most states will honor an out-of-state advance directive if it meets legal requirements in the state that it was executed.
  
  
• Give copies of your advance directive to as many people as you can.
  
  
  • In the untimely event of a medical emergency, those closest to you will need to know where the papers are in order to provide them to the medical personnel.
    
    
  • Give copies to your family, neighbors, clergy, doctor, lawyer, and the staff of the facility where you live.
    
    
  • Too often a person with a terminal condition goes into cardiac arrest at home, and the family cannot find the paperwork to relate the person’s wishes to the emergency personnel. This situation frequently results in excessive resuscitation efforts—despite your wishes and desires. Unfortunately, without the legal paperwork, emergency personnel must do everything possible to attempt to revive someone.
  
  
• A living will does not mean the withholding of pain medications. The whole purpose of completing a living will is so that you can express your wishes for medical treatment and, if the situation warrants, die with dignity. For this reason, pain medication would be provided whenever appropriate to minimize any suffering and make you as comfortable as possible.

The best place for information on advance directives is to start with your family doctor. Your doctor is able to discuss your medical condition, treatment options, and procedures, as well as outline what would happen in certain situations. Your doctor should also be able to supply you with the necessary paperwork to properly complete an advance directive.

• Other resources available include your local hospital, library, attorney, hospice, or long-term care facility.
  
  
• The Internet is an excellent resource for information on advance directives. In fact, the necessary forms for each state can be obtained online from Partnership for Caring or call (800) 989-9455 for assistance by phone.

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3. Emanuel LL, von Gunten CF, Ferris FD. Advance care planning. Arch Fam Med. Nov-Dec 2000;9(10):1181-7. [Medline].

4. Health Care Financing Administration, US Dept of Health and Human Services. Advance Directives. Accessed 2001.

5. Marco C. Ethical issues of resuscitation. In: Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A Comprehensive Study Guide. 5^th ed. McGraw-Hill; 2000:76-79.

6. Michaels HE. Paramedic dilemmas in nursing home care. Emerg Med Serv. Sep 2000;29(9):85. [Medline].

7. Partnership for Caring Inc. Partnership for Caring: America's Voices for the Dying. Accessed 2001.

8. Sabatino CP. Commission on Legal Problems of the Elderly: 10 Legal Myths About Advance Medical Directives. American Bar Association. Accessed 2001.

9. Veatch RM. The topic of potential conflict between advance directives and surrogate decisions. J Clin Ethics. Fall 2000;11(3):284. [Medline].

Author: Scott D Fell, DO, FAAEM, Medical Director, Emergency Care Center, Bon Secours Venice Hospital.

Coauthor(s): Christina L Kukula, DO, Consulting Staff, Walk-in-Care Center, Bon Secours Venice Hospital.

Editors: Patrick Taylor, MD, FAAEM, Medical Director, Department of Emergency Medicine, CHRISTUS St Frances Cabrini Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.