Advance Directive

October 7, 2020

Written by the Open Caregiving Team. Editorial review by Joyce O. Murphy RN, MSN.

What is an advance directive?

An advance directive is a written legal document that lets others know your loved one’s medical preferences for when they are unable to do so. Advance directives may include a living will, healthcare power of attorney documents, DNR and DNI.

How does an advance directive work?

An advance directive is part of advance care planning. These are the steps taken by your loved one to assure that their healthcare preferences are legally documented. An advance directive includes:

  • Who will make decisions about your loved one’s health and medical care when they are unable to do so.
  • Details associated with end-of-life care.
  • A living will that details your loved one’s preferences about a number of medical care options.

Why are advance directives important?

Advance directives are important in multiple scenarios:

  • Whether your loved one is in the prime of life or older, you want to ensure that their medical care wishes are met. By having advance directives in place, there will be a plan in place if they:
    • Are seriously injured.
    • Develop a life-threatening illness.
    • Are in a coma because of an accident or health event.
    • Are in the end stages of life.
  • Your loved one has dementia or a degenerative illness that will eventually affect their ability to make decisions for themself. It is important to document:
    • What they want for treatment and care for the remainder of their life.
    • Their choices for end-of-life care, such as pain management and where they prefer to pass.

What are the different types of advance directives?

Advance directive is an overarching term that applies to these legal documents:

  • Do not resuscitate (DNR) and do not intubate (DNI) orders. Your loved one may choose one or both.
    • These are discussed with their doctor, signed, and kept in their medical record.
    • They should also be kept together with your loved one’s other advance directive documents.
  • A medical power of attorney for sometimes called a durable power of attorney for healthcare.
    • These are both considered advance directives.
    • The different terms used often varies because of state guidelines.
  • A living will that specifies wishes for your loved one’s care for:
    • A serious or life-threatening illness.
    • End-of-life care.
    • Options for after they have passed.

What are advance healthcare directives?

Advance healthcare directives are written, legal documents that state your loved one’s choices about medical and healthcare decisions.

  • These state who your loved one has chosen to be their healthcare agent or proxy.
  • These offer general and specific details of what they do and don’t want to be part of their treatment and care.
  • What their choices and priorities are about curative treatments, palliative care, and hospice.
  • Guidelines for these documents vary by state so it is important to access the right information.

What is a healthcare agent?

A healthcare agent is the person your loved one picks to be their durable power of attorney. Other terms may be used based on the state where your loved one lives. These include:

  • Healthcare proxy
  • Medical power of attorney

This person is responsible for following your loved one’s written medical care decisions. This happens when they are unable to state those for themself.

How to pick a healthcare agent?

First and foremost, it is important for your loved one to pick a person they trust to be their healthcare agent. That person is:

  • A family member or close friend.
  • An attorney, although it is typically not required to have one as a healthcare agent.
  • Someone they know well in a spiritual community.
  • Willing to assure that your loved one’s wishes are followed. This means taking responsibility to assure that:
    • Family members know about and are able to accept your loved one’s decisions about medical care and end-of-life decisions.
    • Medical providers have copies of your loved one’s advance directives and ensure those are met.

Note: Your loved one should not have their doctor or any other professional on their healthcare team as their healthcare agent.

What is the difference between a living will and advance directive?

A living will is a detailed document that gives instructions about specific medical procedures. Your loved one includes what they do and don’t want done medically when they are seriously ill and/or dying. Examples of living will content are:

  • Decisions about heart resuscitation and intubation for breathing support.
  • Whether or not they want tube feedings, kidney dialysis, or antibiotics if any of those become treatment options.

An advance directive has broader guidelines than a living will. It names the person your loved one has chosen to be their healthcare agent. The person in that role:

  • Makes healthcare decisions for your loved one when they are unable to do so.
  • Discusses the choices your loved one has made with family members and healthcare professionals.

Living wills and advance directives can be changed at any time, as long as your loved one is capable of doing so. A doctor may need to determine if your loved one is still capable if they have dementia or a dramatic change in physical or mental health.

What happens if you don’t have an advance directive?

When a person does not have an advance directive, medical providers determine the best course of treatment. This means that:

  • In an emergency doctors will provide the care that is immediately needed to treat your loved one. An example is that medical personnel will attempt resuscitation if your loved one has a cardiac arrest.
  • Interventions put in place can be changed later on. An intervention is a form of care that helps a person to recover from an injury or illness.
    • Examples include:
      • When breathing is helped by a ventilator.
      • A feeding tube needed to get liquids into the stomach.
    • Forms of treatment like these and others can be changed once:
      • Your loved one’s preferences are made available.
      • It’s assured that changes adhere to medical ethics, such as your loved one’s current ability to make sound decisions.

How to get an advance directive?

Your loved one can complete their advance directive on their own.

  • They can also do so with your help or the help of others whom they trust.
  • They can work with a lawyer too, although this isn’t usually necessary.
  • Find your state’s advance directive form from the National Hospice and Palliative Care Organization.
    • Although they vary, each one includes what each state currently requires.
    • Your loved one can ask their doctor what else they recommend including.
  • Consider the importance of having a living will be part of your loved one’s advance directive.

Where to store your advance directives?

Advance directive documents belong to your loved one. They can share them with others as part of storage options that include:

  • With you and other family members.
  • With their primary doctor.
  • Securely on their computer.

Always make note of the original document’s location on each copy.

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