Advance Care Directives: Preparations for the Unforeseeable Future
An advance directive is a legal document that spells out a person’s health care preferences for use in the event they become incapacitated or otherwise unable to make decisions for themselves. Drafting one provides invaluable guidance and peace of mind for family members and medical professionals.
Who Needs an Advance Directive?
It’s impossible to know if/when a car accident, stroke, heart attack or other serious illness may strike, rendering someone incapable of making their own medical decisions. Drafting an advance directive is highly recommended for older adults and individuals with chronic medical conditions. However, advance care planning isn’t reserved for seniors. Life is unpredictable, so these legal documents are important for people of all ages even if they do not have any existing medical conditions. (This includes family caregivers!)
Why Is Advance Care Planning Important?
Without the instructions that advance directives provide, family members are often conflicted over what kind of treatment their loved ones would have wanted in emergency and end-of-life situations. In the absence of any specific preferences, doctors are legally required to pursue all viable life-sustaining treatment options. These measures can be very extreme, and many frail and chronically ill individuals choose to opt out of specific interventions that may do more harm than good.
Advance directives can provide guidance in the following health care decisions:
- The use of equipment such as ventilators and dialysis machines.
- The use of cardiopulmonary resuscitation (CPR).
- The use of artificial nutrition via tube feeding and/or artificial hydration via IV.
- Treatments for pain, even if a person is unable to make other decisions (this may be called comfort care or palliative care).
- The decision to donate organs or other body tissues.
Components of an Advance Directive
Advance directives go by different names in different states, but they are usually comprised of two main components: a living will and a durable power of attorney for health care. Add-ons like do-not-resuscitate (DNR) orders, physician orders for life-sustaining treatment (POLST) forms, and organ and tissue donation requests may also be part of a person’s advance directive.
Living Will
A living will states a person’s wishes that will guide their health care if they become mentally or physically unable to make decisions. The difference between this and a regular will is that a living will guides medical decisions before death while a standard “last will” guides estate decisions after death. A living will is used to declare which life-prolonging measures a person wants and does not want if they are dying or permanently unconscious.
Durable Power of Attorney for Health Care
A durable power of attorney (POA) for health care, or health care proxy, designates someone to act on the incapacitated person’s behalf to ensure they are cared for in accordance with the wishes explained in their living will.
Discussing Health Care Wishes
It’s crucial to discuss health care options, possible scenarios and personal preferences with a physician prior to executing an advance directive. Once the document has been drafted, its contents should be reviewed in detail with the person selected to act as power of attorney for health care.
Broaching such a heavy topic with a loved one can be difficult, but it’s crucial to find opportunities to talk about advance care planning. According to The Conversation Project (TCP), a public engagement initiative aimed at helping people talk about their wishes for care through the end of life, most are willing to discuss their preferences, but only a fraction actually follow through. A recent study published in Health Affairs found that only about one-third of Americans have completed some type of advance directive.
Surprisingly, though, a 2018 TCP survey found that more than half (53 percent) of Americans say they would feel relieved if a loved one started “the Conversation.” If you plan to go this route, try using an example, such as a newspaper article about advance care directives or the experience of a friend or relative, to broach the topic. You can also try mentioning that you are considering drafting an advance care directive for yourself.
In instances where a loved one resists talking about this subject, ask their doctor for help. Medical professionals, especially those who deal with older or seriously ill patients, are usually well versed in these matters. You can write the doctor a note requesting that they address the topic during your loved one’s next appointment. Medicare Part B now covers advance care planning as part of a beneficiary’s yearly “wellness” visits, so there is no need to worry about additional charges.
Where to Get an Advance Directive
An attorney can assist with drafting a valid advance care directive but is not necessary. Local hospitals and seniors’ organizations, such as Area Agencies on Aging, should be able to direct you to the right forms. The American Bar Association has also compiled a helpful document with links to generic state-specific advance directive forms.
Ensure Advance Directives Are Valid and Up to Date
Desires for health care and end-of-life care cannot be followed if they haven’t been clearly communicated to key people. Keeping an open dialogue with all parties involved will ensure everyone is informed and on the same page.
As a caregiver, check that the following steps are taken to ensure your loved one’s documentation is both current and valid:
- Make sure the documents have been signed in front of witnesses and/or a notary public. Requirements vary by state.
- Provide all doctors caring for the patient with a copy of the advance directive. Keep a copy handy for yourself.
- Make sure anyone named as an agent in a health care proxy has a copy of that document and knows the patient’s goals for medical care.
- Explain the patient’s health care wishes to other family members as needed.
- Realize that more than one discussion with doctors and family is warranted. Revisit the advance directive annually or whenever big changes occur in your loved one’s health to be sure the document still accurately reflects their needs and wishes.
- When a person is admitted to a hospital or long-term care facility, request to review their advance directive with their physician and have a copy added to their medical chart.
Having these instructions expressed in writing removes the uncertainty of what medical care is desired and what is not. If we don’t spell out our wishes in a health care directive, these decisions are up to doctors who may not know us, or conflicts may arise among our loved ones over what our wishes might have been.
Sources: Most Americans “relieved” to talk about end-of-life care: New Survey by The Conversation Project finds cultural shift over five years (https://theconversationproject.org/wp-content/uploads/2018/07/Final-2018-Kelton-Findings-Press-Release.pdf); Advance care planning (https://www.medicare.gov/coverage/advance-care-planning); Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care (https://doi.org/10.1377/hlthaff.2017.0175); Advance Care Planning: Health Care Directives (https://www.nia.nih.gov/health/advance-care-planning-health-care-directives#official)
https://www.agingcare.com/articles/what-are-advance-care-directives-140690.htm
