Advance directives: What you should know

Imagine that you’ve been in a life-threatening accident and are now unable to make clear decisions about your medical treatment. If you don’t have an advance directive, what happens next?

Do you want your care team to do everything in their power to keep you alive? Would that include the use of a ventilator or feeding tubes? Or would you not want lifesaving interventions?

These are important questions. Yet in some situations, you may not be able to provide the answers. That is why most health care providers strongly suggest their patients participate in advance care planning.

Advance care planning requires you to think through situations and draw up an advance directive. An advance directive is made up of multiple legal documents that clearly state what actions should or should not be taken if you are in a life-threatening or end-of-life situation.

Types of advance directives

The goal of advance care planning is to help you create an advance directive. These documents will eliminate any confusion if you are unable to communicate your wishes because of a physical injury or physical or mental impairment.

Many health care and legal experts advise that anyone over the age of 18 should have some sort of advance directive.

The most common types of advance directives are living wills, durable powers of attorney for health care and written medical orders.

Living will

A living will is a legal document that tells health care providers which interventions they should and shouldn’t use to keep you alive under specific life-threatening or end-of-life circumstances.

For instance, you may allow the use of antibiotics in the event of infection but not want CPR during cardiac arrest.

Durable power of attorney for health care

This legal document names a health care proxy. This is someone who will make care decisions for you if you are unable to. Usually a trusted family member or a very close friend, the health care proxy should know your wishes.

One of the key benefits of this approach is that the health care proxy will have the flexibility to make decisions in real time, as the event is happening. It also offers a good solution for those who are not comfortable making these decisions or committing them to a legal document in advance.

DNRs, DNIs and ANDs

While you may explain your wishes in a living will or in conversations with your health care proxy, you or your proxy may be asked to sign a Do-Not-Resuscitate order (DNR), a Do-Not-Intubate order (DNI) or an Allow Natural Death order (AND) if you go to the hospital.

These orders will then be filed and posted in your room. This helps prevent confusion and mistakes among your care team.

• The DNR tells your physicians not to restore your breathing or restart your heart in the event of cardiac arrest.
• The DNI prevents them from putting you on a ventilator, which would breathe for you if you lost the ability to breathe naturally.
• The AND is a broad order that doesn’t allow the use of life-extending measures if death is near.

If on home health or hospice care, your clinician can also assist you through the advance care planning process. 

POLST and MOLST forms

Some states allow the use of Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) forms. These forms supplement advance directives with condition-specific orders.

Like DNRs and DNIs, they can help the care team know exactly what to do or not do in a life-threatening situation.

Additional questions and answers about end-of-life planning

It’s normal to feel overwhelmed in this process. Answering a few common questions about advance care planning might help you feel more comfortable.

Can you change your advance directive after it’s executed?

As long as you have mental capacity, you have the right to update or revise your advance directive as often as you wish.

Can a doctor override your advance directive?

Advance directives are legally binding documents. Physicians should respect your wishes as you wrote them.

However, if a physician can’t follow the instructions of your directive, they do have the right to remove themselves from your care team.

Can a family member override or change your advance directive?

Family members do not have the right to override your living will or other advance directive. However, they can advise the care team if you don’t have a directive and are unable to speak for yourself.

Additional resources on advance directives and end-of-life planning

Choosing to enter into advance directive documents like the ones discussed here is a very personal decision, and those choices can have important legal consequences. We recommend consulting a lawyer of your choice who has expertise in the law of the state where you live, because state laws in this area can vary in important ways. 

For additional information on advance directives, you can also visit:

• Creating an advance directive: A step-by-step guide (deathwithdignity.org)
• Free advance directive forms by state (aarp.org)
• Advance care planning: Health care directives (nih.gov)
• Living wills and their role in end of life planning (aarp.org)

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At Enhabit Home Health & Hospice, we are committed to fulfilling patients’ needs and delivering care that is consistent with a patient and their loved one’s wishes. Although we cannot provide you with legal advice, a member of our home health or hospice team can speak with you about decisions you can address through advance care planning.

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