Advance Directives

Taking care of yourself and your family means making decisions about medical care while your health allows you to do so.

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 may not be known and cannot be honored. That can make it harder than need be for loved ones.

What are advance directives?

Advance directives are written instructions in the form of a living will and/or durable power of attorney for health care. Advance directives do not go into effect until you are no longer able to make decisions.

A living will (health care treatment directive) is a legal document. It states your desires about withholding and/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 set out in advance the treatment choices and instructions to be followed by caregivers if you cannot take part in making health care 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
• may state whether or not you want breathing machines, feeding tubes, oxygen, IV fluids, or other medications to be used
• may list specific conditions (coma, fatal illness with no hope of recovery or cure, end-stage dementia) under which the terms of your living will are to go into effect.

For a living will to be legal, when you sign it there must be witnesses and you must be competent. Requirements vary from state to state, but usually the witnesses must not be:

• your relatives
• creditors or heirs to the 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.

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. You need to know the laws in your state.

A durable power of attorney for health care (DPAHC) appoints a family member or friend to follow your wishes. This person (the agent) will make medical decisions for you if you can't make them for yourself. Some people prefer the DPAHC to a living will because it is more flexible.

You must be competent at the time you sign a DPAHC for it to be legal. Anyone with a brain disease that gets worse over time (such as Parkinson's disease or Alzheimer's disease) may wish to draw up the DPAHC papers early in the illness. Your agent's duty is to follow your wishes. In states that recognize such documents, families and physicians cannot override your living will or a decision by the agent of your DPAHC.

Once you have signed these documents, keep them in a safe place. But 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 DPAHC. 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 Health Care Treatment Directive are available with this handout. If you want copies of those sample forms and they were not provided with this handout, ask for them. They are only samples, however, and may not conform to the laws in your state.

Partnership for Caring will provide a copy of state-specific advance directives free to anyone who writes (Partnership for Caring, 1620 Eye Street, NW, Suite 303, Washington, DC 20006) or calls (800-989-WILL, or 800-989-9455). You can also go to the Web site: http://www.partnershipforcaring.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 about advance directives and drawing up a durable power of attorney for health care or a living will that conforms to the laws in your state.

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

Some older people are unable to manage their own affairs due to a medical or a mental condition. The important thing is whether that person can understand and make decisions involving medical and financial choices. A person can be confused about time and place but still able to understand his or her choices if they are carefully explained. It is also possible for an older person to be capable of making decisions about his or her health but not about money. Doctors are often asked to assess the competence of a patient, but a doctor can only make a medical judgment about someone's ability to make decisions. A court must decide whether someone is competent.

All states allow the courts to establish limited guardianships (also called conservatorships) and unlimited guardianships.

A limited guardianship allows the appointed guardian to make decisions for someone in areas where the court has determined that the person lacks the ability to function. This type of arrangement is often made for managing finances. Someone judged incompetent for financial purposes is still able to make decisions regarding his or her health.

An unlimited guardianship removes all rights of the person to vote, to decide where to live, and to manage his or her money and health. That person is said to be incompetent for all purposes and gets the protections generally given to a child.

What is the meaning of "resuscitate" and "do not resuscitate (DNR)?"

If you are in a clinic, hospital, or nursing home, you may be asked to sign a code status sheet. This will tell the staff what measures, if any, you want taken should you be found not breathing and without a heartbeat. Code status may be changed at any time.

Cardiopulmonary resuscitation (CPR) was developed in the 1960s as a way to prevent sudden and unexpected death. When done quickly, it is often effective for heart attacks, drownings, drug overdoses, and similar situations. However, CPR is not usually as effective for people with chronic and severe illnesses or where death is expected to occur soon.

A full code means that you want everything possible done to revive you. This includes giving chest compressions, electrical shocks, and medication (to start your heart) and putting you on a ventilator (a machine to keep you breathing). This type of CPR has the most success but is still less successful for people with chronic medical conditions. Some people request a limited code, which usually excludes being put on a ventilator and is much less often successful.

When CPR would be of no medical benefit, your doctor should explain why. In such cases, a no code order (DNR, for Do Not Resuscitate) may be written. A DNR order excludes only CPR and does not limit other types of treatment. You should receive all needed medical and nursing care, even when CPR would not benefit you. A talk with your doctor about CPR is a good time to review your overall medical condition and treatment plan.