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 and 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.

Three examples of advance directives are a living will, a durable power of attorney for healthcare, and DNR orders.

A living will is a type of advance directive called a healthcare treatment directive. It is a legal document. It states your desires about withholding 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 if you become unable 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 medicines to be used.
• List specific conditions (such as coma, fatal illness with no hope of recovery or cure, or end-stage dementia) under which the terms of your living will are to go into effect.

A living is legal only if you sign it in the presence of witnesses and you are legally competent. You are legally competent if you are of sound mind and at least 18 years old. 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 cover decisions about your healthcare only 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 (DPOA-HC) 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. Your agent's duty is to follow your wishes. In states that recognize these documents, families and healthcare providers cannot override your living will or your agent's decision. Some people prefer the DPOA-HC to a living will because it is more flexible.

You must be legally competent at the time you sign a DPOA-HC for it to be legal. 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 DPOA-HC papers early in the illness.

Once you have signed a living will and DPOA-HC, keep them in a safe place. 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 DPOA-HC. 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 the sample forms and they were not provided with this handout, ask for them. Note that they are just samples and may not conform to the laws in your state.

The National Hospice and Palliative Care Organization provides free copies of state-specific advance directives. 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 are code status sheets and DNR orders?

If you are in a clinic, hospital, or nursing facility, you may be asked to sign a code status sheet. The code status sheet 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.

A full code means that you want everything possible done to revive you. This includes giving CPR, electrical shocks, or medicine to start your heart, and putting you on a ventilator (a machine to keep you breathing). 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. Your healthcare provider can explain when CPR would be of no medical benefit.

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. In plain terms, do not resuscitate means do not try to save your life with CPR or cardiac shocking if you start to die suddenly. A DNR order does not limit other types of treatment.

Nonhospital DNR orders are important if you live at home alone or in a nursing home or adult care home and you do not want to have emergency treatment if your heart stops or you stop breathing. They are instructions to not give you emergency CPR or other treatments if you suddenly collapse or stop breathing. Emergency medical teams that come to your home by ambulance are not allowed to stand back and not treat you unless they find your nonhospital DNR orders. In some states you put a copy of these DNR instructions by your bedside, on your refrigerator, and on the inside of your bedroom door. Emergency medical people are trained to look in these places for your instructions. In other states, you wear a DNR bracelet. To create nonhospital DNR orders, talk to your healthcare provider.

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

Some older people cannot manage their own affairs because of a medical or mental condition. However, a person can be confused about time and place but still able to understand choices if they are carefully explained. Healthcare providers and mental health specialists can assess a person's 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, a person may be able to make decisions about his or her health but not about money.

Who should have copies of my living will and DPOA-HC?

Give copies to your family and to your primary doctor. If you see several doctors regularly, like an internist and a cardiologist, give them both a copy. Put a copy in a bright envelope in your home; then put notes by your bedside and on the refrigerator or on your bedroom door telling people where to find your documents. Always take copies with you if you go to a hospital or surgery center for treatments.

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 even harder for loved ones when you are very ill. Take care of yourself and your family by making decisions about medical care while you are able to do so.