Advance Healthcare Directives are legal documents that stipulate a person’s wishes regarding the type of medical care they wish to receive or not receive should they be in a state where they cannot express their will. This may happen if you are in one of the following states:

• Seriously injured
• In a coma
• Vegetative state
• Terminally ill
• Severe dementia
• Severe Alzheimer’s disease
• Lost power of communication
• A lapse in mental health resulting in being of unsound mind

Advance healthcare planning is an integral part of keeping your affairs in order. Have you ever thought of what would happen if you got seriously ill or suffered incapacitating trauma? These documents help to express your wishes and ensure your voice is heard and wishes respected when you cannot do so.

As we’ll be discussing in this document, there are various types of advance healthcare directives, each with their objectives. It must be emphasized that Advance Healthcare Directives are not meant for senior citizens only or those who are already sick. Every adult should have them in place because a medical emergency can happen to anyone at any time. The best time to start advance healthcare planning is now. Waiting till a medical emergency happens may be too late. Check out this 2-minute video by Lee Health to see why you should be executing Advance Directives sooner, rather than later.

Advance Directives are recognized in all states in the United States and Washington, DC. Millions of Americans have them as part of their medical records. Retiree organizations, hospices, hospitals, healthcare professionals, and attorneys all recognize the different types of advance directives as legal documents and respect the wishes outlined in them as long as they are valid.

In this guide, we’ll talk about the different types of Advance Directives, how different states treat these documents, the benefits of having Advance Directives, important tips and other useful information that will help you know all about advance healthcare planning.

• Types of Advance Directives Documents

• Differences between a Living Will and a Last Will

• Medical Power of Attorney

• Physician orders for life-sustaining treatment (POLST)

• How to Create the Different Advance Directive Documents

• Changing your Advance Directives

• Important tips for Advance Directives

• Closing Thoughts

Types of Advance Directives Documents

There are different types of Advance Healthcare Directives. These documents differ depending on your situation and type of medical care you want or don’t want to receive. These documents are easy to fill out and sign. They don’t necessarily require legal advice. However, if your situation is complicated, it would be best to seek legal advice to ensure all your wishes are respected. In addition, state laws differ on how to make these Advance Directives valid.

Let us now look at the various type of legally recognized Advance Directive documents.

Living Will

A Living Will is the most common Advance Directive document. The reason for this is because it can cover almost all medical scenarios that other documents cannot cover. A Living Will is a written legal document that stipulates the type of treatments and medical interventions that a patient can and cannot receive. It can be as broad as the owner wants it. FreeAdvice.com offers this quick 2-minute overview of what a Living Will can cover.

Let us look at some scenarios it can cover. Most of these scenarios cover the end of life situations.

Cardiopulmonary Resuscitation

Commonly known as CPR, this is the medical intervention that healthcare workers use to revive a person’s heart after they suffer from a cardiac arrest or revive their breathing after they suffer from a respiratory attack. The interventions here are many, including ventilation, chest compressions, electric shocks, mouth to mouth, etc.

Depending on your situation and the chances of success, you may decide that you do not want any of these. For example, someone who is suffering from a terminal illness may wish to be allowed to die peacefully.

Check out this short discussion by Michelangelo Mortellaro on Do-Not-Resuscitate (DNR) orders to improve your understanding on how to execute this order as part of your Advance Directive.

Do not resuscitate orders is a legal document which prevents doctors and other medical responders from attempting to revive a person’s heart or breathing through CPR. DNR orders can be contained in a Living Will or can be a document of its own. The document goes to your medical record.

If you have a Living Will that has established DNR orders, it may still be good to have a DNR document when you are admitted to a hospital.

CPR can either happen in a hospital setting or outside the hospital. If in a hospital setting, the DNR orders are usually included in your medical record or prominently displayed where doctors and any emergency healthcare worker will easily see it. This will not revive you if you get a cardiac or respiratory arrest.

Mechanical Ventilation

Typically, doctors intubate someone for placing on a mechanical ventilator when there is a blocked airway or the patient's state of health is not well enough to support regular breathing. You may wish to be allowed to die peacefully when this need arises. You may address this in your Living Will and indicate the circumstances wherein you wouldn’t want to be put on a mechanical ventilator and when you would want to be. You may also specify the length of time you wish to be attached to the machine. You may also state added considerations such as when you are diagnosed to have a terminal illness.

Intravenous Feeding

Sometimes, when a patient cannot feed on their own, doctors may intubate them to pass down nutrients and fluids to the body. Some people may not want to be fed in this manner in their end of life care.

A Do-Not-Intubate order document informs your doctors that intubation should not be done in some circumstances. As with the DNR orders, this can be included in your Living Will or stand on its own.

Palliative Care

You can stipulate the treatments that cannot be administered to you while under palliative care.

Organ and Body Donation

A Living Will can help you specify which organ and tissues you want to donate. This helps doctors determine if they will keep you in a life-sustaining condition while arrangements are made for organ removal.

You can also specify in a Living Will whether you want to donate your body for scientific study.

Differences between a Living Will and a Last Will

These two documents express the wishes of the person who made the document. The Living Will express medical wishes while the Last Will expresses wishes in regards to the distribution of assets and other mementos.

The Living Will come into effect when you are still alive but sick.  A Living Will has no effect on your death save for the purposes of organ and body donation. A Last Will only come into effect once the testator dies.

Medical Power of Attorney

Medical Power of Attorney, also known as Durable Power of attorney or Healthcare Power of Attorney, is a legal document that names a person who will act and make medical decisions your behalf if you are unable to do. This person must be a mentally competent adult.

This person can be referred to by any of the flowing names all meaning the same thing:

• Healthcare Proxy
• Healthcare Agent
• Patient Advocate
• Medical Attorney-in-fact
• Healthcare Surrogate
• Healthcare Representative

Different states and different healthcare organizations may prefer one name or another, but it doesn’t change the meaning of this person nor his role in making medical decisions on behalf of the patient as outlined in the Advance Directive.

This person may be a different person to the person you chose to act as the financial Power of attorney or maybe the same person as well. This role is usually fulfilled by someone close to you. It can be a spouse, adult child, another close relation, friend, attorney, colleague, etc. The best practice is to choose more than one person if one is unable to perform their function.

This document in itself is an Advance Directive as it tells your healthcare provider who to talk to in terms of making key decisions on your care. Check out this short discussion on what a medical power of attorney is made by e-Forms.

Other best practices to follow:

• Checking if the person meets any defined criteria in your state
• Should not be a member of your medical team
• Can make the right decisions in the case of an emergency
• Should be willing to respect and follow your wishes

It is highly advisable to talk with the person you intend to grant a medical power of attorney beforehand. If they do not want to talk about end-of-life decisions, they are probably not the best-suited person. Your talk should be open, realistic, and explore all options without fear. This person should be open-minded enough to accommodate your wishes.

Medical decisions that a proxy/agent can make

The scope of decisions that your appointed agent can make can go as far as you allow them or limit them in writing. Usually, you’ll give them broad authority to make any healthcare decision which can include:

• Consenting or refusing any diagnostic procedure or medical treatment
• Hire or fire medical providers for you
• Authorize admission to a medical or care facility
• Consent to any comfort measures or pain relief medication
• Have access to all your medical records
• Granting waivers and releases to healthcare providers in furtherance of your wishes
• Move to court to seek judicial remedy if any of your express written wishes is in danger of being contravened

If you do not wish to give your agent broad authority, you can specify what you want them to do and not do. The orders in your Advance Directive will always take precedence over the decisions of your chosen medical proxy.

Physician orders for life-sustaining treatment (POLST)

This is one of the documents involved in advance care planning. It can also be referred to as medical orders for life-sustaining treatment (MOLST). A doctor prepares this document. It is done when you have already been diagnosed with a serious illness. It doesn’t replace your other wishes but serves as a guide to the type of treatment that should be administered to you. The doctor will take any Advance Directives you had before the illness and further discuss any other treatment preferences. You’ll discuss the likely course of your illness and the best approach to take.

CoalitionCCC presents a 6-minute discussion on POLST forms, when such forms apply and how to use it to your advantage when you wish to take any treatment that can extend your life.

A POLST form goes into your record and stays with you even if you change hospitals or go to a nursing home. The document usually is prominently displayed close to you at all times. A POLST will stipulate what treatments should not be used when specific treatments should be withdrawn, how long some interventions should last etc. Other areas that may be covered include:

• CPR
• Mechanical ventilation
• Intubation
• Administration of Antibiotics
• Pain management
• Hospital admissions
• Transfer to an emergency room

How to Create the Different Advance Directive Documents

In most states, the different Advance Directives need to be in writing and signed to be valid. A witness may also need to be present. It is not a requirement to have the form notarized or drafted by an attorney.

Before filing, it is essential to review the document with your doctor to be sure that the form is filled correctly and any wishes you may have been clearly captured as they should.

Once you have written and signed the Advance Directives, you should keep the original safe. Then have a few copies. One should be given to your doctor to be included in your medical records. One copy should be given to your nominated proxy and any other alternative proxy.

It is also important to discuss with family members about the wishes expressed in your Advance Directives.

Use the checklist we have prepared to guide you while drafting your Advance Directives.

Changing your Advance Directives

You are allowed to change your Advance Directives at any time. If you wish to make changes, you should create a new form and destroy old copies. Distribute all new copies to the relevant people, just as you had done with the old copies. This ensures that your new directives are updated in your medical file. There are some instances where you need to change your Advance Directives:

• A new diagnosis
• Change of marital status
• Change residences across states
• After a period to time, say every ten years
• Retirement
• Your wishes changed

Important tips for Advance Directives

• Always carry a small card in your wallet that shows you have a Living Will or Advance Directives to carry with you all the time. The card should contain the name and contacts of your designated medical proxy
• All Advance Directives, including POLSTS, can be revoked, updated, or modified at any time. The only requirement here is that the author needs to be mentally competent to do so
• Different states have different regulations regarding Advance Directives. Most online forms will vary by state, so pick the appropriate one. It may be a good idea to consult an attorney if unsure about anything
• If you change residencies across states, you should look at your existing Advance Directives for compliance with regulations in the new state
• Ensure that your doctor and your medical proxy understand your wishes and have a copy of your Advance Directive in your medical file

Closing Thoughts

Advance Directives are a significant part of healthcare planning. They help everyone involved make the best decision that reflects your wishes when you are incapacitated. They know precisely what you’d have wanted. This gives them peace of mind.

End of life scenarios and advance healthcare planning are not very nice discussions to have but are necessary. In some states, even your spouse cannot be allowed to access your medical records. Having Advance Directives stipulating your wishes and the person to act on your behalf is very important.

If you ever get into a serious medical situation without Advance Directives, your family may find it hard to make the best decisions. They may end up in court, fighting some decisions amid the stress of the medical circumstance. All this can be avoided by having prepared valid Advance Directives.

As you plan your other affairs such as finances, do not shy away from healthcare planning.