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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 can help in several ways:

  • They record what medical procedures you do and do not want. This usually involves decisions about breathing machines, cardiopulmonary resuscitation (CPR), feeding, and the use of certain medicines, such as antibiotics.
  • They help your family make decisions about your care.
  • 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
  • durable power of attorney for healthcare
  • code status sheets or DNR orders.

It is best to prepare advance directives when you are healthy rather than when you have been very ill or are in the hospital.

What is a living will?

A living will is a legal document that states your wishes for treatment when you have a terminal illness. Terms in the living will may go into effect when:

  • You have a condition that cannot be cured.
  • You 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 yourself. It is called a living will because it must be signed formally like a regular will but its terms go into effect before your death.

A living will may:

  • Spell out what you do and do not wish to have done to extend your life when you are clearly dying.
  • State if you want breathing machines, feeding tubes, oxygen, IV fluids, or medicines to be used.
  • State when the terms of your living will are to go into effect—for example, coma, fatal illness with no hope of recovery or cure, or end-stage dementia.

Living wills cover decisions about your healthcare only when you have a terminal illness. Some illnesses, such as stroke, may not be covered by a living will.

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

What is a durable power of attorney for healthcare?

A durable power of attorney for healthcare (DPOA-HC) is another legal document regarding medical care. It appoints a family member or friend to make medical decisions for you if you cannot make them for yourself. This person is called your agent. Your agent should be someone who will follow your wishes. In states that recognize these documents, families and healthcare providers cannot override your stated wishes or your agent's decisions. 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 create and sign 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 healthcare provider. Give these people copies of your living will or DPOA-HC. Then they will have easy access to the documents if they are needed.

There are various ways to get forms for advance directives. For example:

  • Your healthcare provider or lawyer.
  • The National Hospice and Palliative Care Organization, which can be contacted by calling-1-800-658-8898 or visiting their Web site at http://www.nhpco.org.
  • Your state health department, local hospitals, or state bar association.

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 you want to be done if your heart stops and you are not breathing.

  • 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. It includes putting you on a machine to keep you breathing (a ventilator). CPR is an emergency procedure that can save your life if your heart has stopped beating and you are not breathing. CPR is not usually as helpful if you have a severe chronic illness or you are expected to die soon. Your healthcare provider can explain when CPR will not help.
  • A limited code may exclude being put on a ventilator, kidney dialysis, or other kinds of support. However, if something simple can be done to restart your heart or your breathing, it will be done.
  • A “no code” means that nothing will be done, other than helping you be as comfortable as possible if stop breathing or your heart stops. If you have very-advanced cancer or some other life-ending disease and you tell your healthcare provider that nothing should be done to rescue you, your provider will write a “Do Not Resuscitate” (DNR) order in your medical chart. A DNR order means that medical staff should not try to save your life with CPR or cardiac shock.

    A DNR order applies only to emergency treatment in case of collapse. Having a signed DNR order does not keep healthcare providers from doing other types of treatment, such as more antibiotics for an infection or more treatments for advanced cancer.

It can be helpful to have nonhospital DNR orders 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 if you stop breathing. Emergency medical teams that come to your home by ambulance are not allowed to stand back and not treat you unless they have DNR orders for you. In some states you are expected to keep a copy of the DNR order by your bedside, on your refrigerator, or on the inside of your bedroom door. Emergency medical staff are trained to look in these places for your instructions. In other states, you wear a DNR bracelet.

To create DNR orders for places other than a hospital, talk to your healthcare provider. Special forms called Orders for Life Sustaining Treatment can be prepared for you to keep at home and at your provider’s office.

What happens if I am already physically or mentally unable to manage my affairs?

Advance directives are legal only if you signed them when:

  • You were legally competent, and
  • Witnesses were present.

You are legally competent if you are of sound mind and at least 18 years old. All adults are presumed competent unless a judge or a court has declared them incompetent. A person can be confused about time and place but still be able to understand choices if they are carefully explained. Legal competence is based on whether you:

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

Healthcare providers and mental health specialists can help assess your ability to make decisions. Requirements for competency vary from state to state.

Usually the witnesses to the signing of your directives must not be:

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

The court may appoint a legal guardian if you are not able to make informed decisions. Guardianship may cover all areas of your life, or it may cover only certain areas. For example, you may be able to make decisions about your health but not about money.

Who should have copies of my advance directives?

Give copies to your family and to your primary healthcare provider. If you see several providers 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 treatment.

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, your wishes might not be known and then cannot 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.

Developed by Harriet Berliner, MSN, ANP, and Daniel L. Swagerty, MD, MPH, for RelayHealth.
Published by RelayHealth.
Last modified: 2011-07-08
Last reviewed: 2011-01-17
This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
© 2011 RelayHealth and/or its affiliates. All rights reserved.
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