Living wills and advance directives for medical decisions

Living wills and other advance directives include written, legal instructions that state the treatment you want for medical conditions when you're unable to make decisions for yourself. Advance directives guide choices for healthcare professionals and caregivers in certain situations. For example, a medical team may use advance directives when you're unable to talk and are terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

Advance directives aren't only for older adults. You can have unexpected accidents, illnesses or end-of-life situations happen at any age. So it's important for all adults to prepare these papers.

By planning ahead, you can get the medical care you want and avoid unnecessary suffering. You also can relieve caregivers of decision-making burdens during times of crisis or grief. And you help lessen confusion or disagreement about the choices you would want people to make on your behalf.

A medical or healthcare power of attorney is a type of advance directive in which you name a person to make healthcare decisions for you when you are unable to do so. In some states this directive also may be called a durable power of attorney for healthcare or a healthcare proxy.

Depending on where you live, the person you choose to make healthcare decisions on your behalf may be called one of the following:

• Healthcare agent.
• Healthcare proxy.
• Healthcare surrogate.
• Healthcare representative.
• Healthcare attorney-in-fact.
• Patient advocate.

Choosing a person to act as your healthcare agent is important. Even if you have other legal papers about your care, you can't anticipate all situations ahead of time, such as emergencies and illnesses. And in some situations, someone will need to decide about your likely care wishes. Aim to choose a person who:

• Meets your state's requirements for a healthcare agent.
• Is not your healthcare professional or a part of your medical care team.
• Is willing and able to discuss medical care and end-of-life issues with you.
• Can make decisions that follow your wishes and values.
• Can speak up for you if there are disagreements about your care.

The person you name may be a spouse, other family member, friend or member of a faith community. You also may choose one or more other people in case the person you chose is unable to fulfill the role.

A living will is a written, legal paper, called a document, that includes details about the medical treatments you would and would not want to be used to keep you alive. It's used when you are unable to decide yourself. It also includes your choices for other medical decisions, such as pain management or organ donation.

In deciding your wishes, think about your values. For example, think about how important it is to you to be independent and self-sufficient. Think about what situations might make you feel like your life is not worth living. Would you want treatment to extend your life in any situation or in all situations? Would you want treatment only if a cure is possible?

You should list many possible end-of-life care decisions in your living will. Talk to your healthcare professional about any questions you may have about the following medical decisions:

• Cardiopulmonary resuscitation (CPR). CPR restarts the heart when it has stopped beating. Decide if and when you would want to be revived by CPR or by a device that sends an electric shock to shock the heart.
• Pacemakers and implantable cardioverter defibrillators (ICDs). A pacemaker keeps your heart beating steadily, while an ICD shocks your heart if it beats irregularly. If you have one of these devices, decide when you would want it to be turned off.
• Mechanical ventilation. A machine that helps you breathe is called a mechanical ventilator. It takes over your breathing if you're unable to breathe on your own. Think about if, when and for how long you would want a medical team to place you on a machine to help you breathe.
• Tube feeding. Tube feeding gives nutrients and fluids to the body through a tube inserted in a vein or in the stomach. Decide if, when and for how long you would want a medical team to feed you in this way.
• Dialysis. This process removes waste from the blood and manages fluid levels if the kidneys no longer work. Decide if, when and for how long you would want to receive this treatment.
• Antibiotics or antiviral medications. Healthcare professionals can use these medicines to treat many infections. Think about if you were near the end of life. Would you want a medical team to treat infections with many medicines, or would you rather let infections run their course?
• Comfort care, also called palliative care. Comfort care includes many treatments that a medical team may use to keep you comfortable and manage pain while following your other treatment wishes. Treatment wishes may include choosing to die at home, getting pain medicines or being fed ice chips to soothe mouth dryness. It also may include avoiding invasive tests or treatments.
• Organ and tissue donations. You can note if you plan to donate organs or tissues in your living will. If the medical team removes the organs for donation, they will keep you on treatment that will keep you alive, called life-sustaining treatment, for a brief time until the team has removed the organs. To avoid any confusion from your healthcare agent, you may want to state in your living will that you understand the need for this short-term treatment.
• Donating your body. You can state if you want to donate your body to scientific study. Call a local medical school, university or donation program for information on how to register for a planned donation for research.

You don't need an advance directive or living will to have do not resuscitate (DNR) and do not intubate (DNI) orders. To make DNR or DNI orders, tell your healthcare professional about your preferences. Your healthcare professional will write the orders and put them in your medical record. Keep a copy of these orders at home too.

You may already have a living will that includes your choices about resuscitation and intubation. But it's still a good idea to set up DNR or DNI orders each time you stay at a new hospital or healthcare facility.

Advance directives need to be in writing. Each state has different forms and requirements for filling out legal documents. Depending on where you live, you may need to have the form signed by a witness or notarized. You can ask a lawyer to help you with the process, but you don't generally need a lawyer.

You can find links to state-specific forms on the websites of many organizations such as the American Bar Association, AARP, and the National Hospice and Palliative Care Organization.

Look over your advance directives with your healthcare professional and your healthcare agent to be sure you have filled out forms correctly. When you have finished your documents:

• Keep the original advance directives in a safe place that's easy to reach.
• Give a copy of your advance directives to your healthcare professional. Make sure they know about your DNR or DNI orders and your healthcare power of attorney.
• Give a copy of your advance directives to your healthcare agent and any other agents.
• Keep a record of who has your advance directives.
• Talk to family members and other important people in your life about your advance directives and your healthcare wishes. By talking to your family members now, you help ensure that they clearly understand your wishes. Having a clear understanding of your choices can help your family members avoid conflict and feelings of guilt.
• Carry a wallet-sized card that notes you have advance directives and names your healthcare agent. The card should also state where a copy of your directives can be found.
• Keep a copy of your advance directives with you when you are traveling.

You can change your directives at any time. If you want to make changes, you must fill out a new form. Give new copies to your healthcare professional and others, and get rid of all old copies. Specific requirements for changing directives may vary by state.

You should talk with your primary healthcare professional about any changes. Make sure a new directive replaces an old directive in your medical file. New directives also must be added to medical charts in a hospital or nursing home. Also, talk to your healthcare agent, family and friends about changes you have made.

Think about checking your directives and filling out new ones in the following situations:

• New diagnosis. A diagnosis of a disease that is terminal or that majorly changes your life may lead you to make changes in your living will. Talk with your healthcare professional about the kind of treatment and care decisions that might be made during the expected course of the disease.
• Change of marital status. When you marry, divorce, become separated, or become a widow or widower, you may need to choose a new healthcare agent.
• About every 10 years. Over time your thoughts about end-of-life care may change. Check your directives from time to time to be sure they reflect your current values and wishes.

In some states, advance healthcare planning includes a document called physician orders for life-sustaining treatment (POLST). This document also may be called provider orders for life-sustaining treatment (POLST) or medical orders for life-sustaining treatment (MOLST).

A POLST is meant for people who are diagnosed with a serious illness. This form doesn't replace your other directives. Instead, it serves as healthcare professional-ordered instructions — not unlike a prescription. A POLST ensures that, in case of an emergency, you get the treatment you prefer. Your healthcare professional will fill out the form. To fill out the form, your healthcare professional will use the information in your advance directives, the talks you have with your healthcare professional about the likely course of your illness and your treatment preferences.

A POLST stays with you. If you are in a hospital or nursing home, staff post the POLST near your bed. If you are living at home or in a hospice care facility, staff clearly place the POLST where emergency staff or other medical team members can easily find it.

Forms vary by state, but a POLST lets your healthcare professional include details about your care. These details can include what treatments a medical team should not use, under what conditions a medical team can use some treatments, how long a medical team may use some treatments and when the medical team should stop treatments. Issues covered in a POLST may include:

• Resuscitation.
• Mechanical ventilation.
• Tube feeding.
• Use of antibiotics.
• Requests not to transfer to an emergency room.
• Requests not to be admitted to the hospital.
• Pain management.

A POLST also states what advance directives you have written and who serves as your healthcare power of attorney. Like advance directives, you can cancel or update POLSTs.