What are Advance Directives?
When someone is very sick or close to dying, they might not be able to decide about their medical care or talk about their choices.
Advance directives are legal papers that tell doctors and family members what kind of medical care a person wants before they get too sick to decide. These papers help make sure the person gets the care they want and doesn't get care they don't want.
Advance directives only start working when the sick person can't make decisions anymore.
Surrogate in Healthcare Decisions
A very sick person might need someone else to make decisions for them. They can choose a person called a "surrogate" decision-maker. The surrogate's job is to do what the sick person wants, as much as possible. They should make the choices that the sick person would make if they could still decide for themselves.
Your expressed wishes are legally and ethically more important than what others want for you, even if they feel that they are acting in your best interests.
Types of Advance Directives
Two common types of advance directives for health care are:
- Living wills
- Durable power of attorney for healthcare.
States have different names for this, including healthcare proxy or healthcare declaration.
Living Wills
Living wills let someone tell healthcare professionals how they want to be treated if they can't stay alive on their own. Some treatments that help people stay alive include:
- CPR (which helps if the heart stops)
- A machine that helps with breathing (mechanical ventilation)
- Getting food in a special way (such as through a tube)
In some places, a person can choose their surrogate decision-maker with a living will. Doctors and caregivers who follow a legal living will won't get in trouble with the law.<
Durable Power of Attorney for Healthcare
This legal document is more flexible than a living will. The person who is sick chooses a surrogate decision maker (such as a friend or relative) to make their medical decisions when the person can’t.
The best surrogate decision-maker is someone who:
- Knows the person’s choices about health
- Is able and willing to act in the person’s best interests
Physician Orders for Life-Sustaining Treatment (POLST)
POLST is for people who have a serious illness, are frail, or are very old. This document gives healthcare providers orders they need to follow based on the person’s choices about health care.
POLSTs can go from one health care setting to another. For example, when a POLST form is shown, a person’s advance care plans will be honored by the:
- Emergency Medical Service team (ambulance or fire personnel),
- Staff in the emergency room
- Hospital team,
- Nursing home staff.
The POLST contains a set of legal orders. So, it needs a discussion with the physician and this professional’s signature to be legal.
The POLST is usually on a brightly colored form. Keep it at home in a visible spot, like the refrigerator, so emergency responders can easily find it.
Visit the National POLST Program website to find more information and to locate community or state-based POLST programs.
Changes to Advance Directives
Advance directives need to be revisited when a person:
- Experiences a change in their health
- Enters or leaves a nursing home
- Enters or leaves a hospital
- Has a change in surrogate decision-maker
A person can stop or change any advance directive at any time, as long as the person is capable of making decisions.
Legally, healthcare providers must follow these advance directives to the extent possible.
Family Role in Decision-making
Advance directives help very sick people and their families. Advance care planning helps people by:
- Giving them a better life and care
- Letting them choose where to die and have fewer treatments when they are close to dying
- Having fewer trips to the hospital at the end of their life
- Making family members feel less stressed, sad, and worried after the person passes away
Rules for Surrogate Decision-making
Most states and the Department of Veterans Affairs have rules about who makes health care decisions for people who can’t make their own, in the following order:
- Legal guardian
- Surrogate decision-maker with a Durable Power of Attorney for Health Care
- A spouse, followed by other family members. Some states require total or majority agreement of all family in a category, such as adult children
Some states allow for non-family surrogate decision-makers who know the sick person well.
When no legal surrogate decision-maker exists, the healthcare provider may decide that family members are unable to make medical decisions. For example, families may have:
- Different personalities, values, or interests
- Estranged family members
- Disagreements among family
- Lack of ability or willingness to make decisions
These are some of the reasons why it’s so important to make an advance directive and choose a surrogate before you become ill.
If a person has no advance directive and no one to speak for them, the healthcare provider may ask a court to appoint a guardian to act as a surrogate (see: Guardianship)
Limits of Advance Directives
Advance directives have limitations. A person:
- May not fully understand treatment options or choices they have.
- May change their minds and forget to tell others.
- Have advance directives that are too vague to guide medical decisions or may not be useful when situations change.
People can help avoid these problems by discussing advance directives with each other and their healthcare providers.
Importance of Communication
Good communication with the health care provider and surrogate decision-maker can solve many problems when doing advance directives.
A question you can ask to open the topic is: "Can we talk about how decisions will be made for my medical care in case I become too sick to talk to you directly?"
Ask or tell your healthcare provider about:
- Situations that commonly develop with your specific illness or condition.
- Various treatments and treatment options.
- Your wishes, including who you choose as a surrogate decision-maker.
- The limits of the decision-maker’s power and how you will let your surrogate know if you change your mind about something.
Last Updated May 2023