Advance care directives

Definition

Advance care directives are specific instructions, prepared in advance, that are intended to direct a person's medical care if he or she becomes unable to do so in the future.

Alternative Names

Power of attorney; DNR; Do not resuscitate; Living will

Information

Advance care directives allow patients to provide instructions about their preferences regarding the care they would like to receive if they develop an illness or a life-threatening injury and are unable to express their preferences. Advance care directives can also designate someone the patient trusts to make decisions about medical care if the patient becomes unable to make (or communicate) these decisions. This is called designating ?power of attorney (for health care).?

Federal law requires hospitals, nursing homes, and other institutions that receive Medicare or Medicaid funds to provide written information regarding advance care directives to all patients upon admission.

Advance care directives can reduce:

• Personal worry
• Feelings of helplessness and guilt by family members
• Futile, costly, specialized interventions that a patient may not want
• Overall health care costs
• Legal concerns for everyone involved

However, advance care directives cannot predict what situations may arise in the future or what new modes of care may be available for situations considered nearly hopeless today.

EXAMPLES OF ADVANCE DIRECTIVES

Verbal instructions. These are any decisions regarding care that are communicated verbally by an individual to health care providers or family members.

Organ donation. This may be accomplished by completing an organ donation card and carrying it in your wallet. A second card may be placed with important papers (such as a living will, insurance papers, and so on). Most hospitals or other major health care centers have organ donor information available.

Many states offer people who are applying for new or renewed driver's license the opportunity to make a decision regarding organ donation and have it recorded on the driver's license. More information may be obtained by calling 1-800-24-DONOR.

Living will. This is a written, legal document that conveys the wishes of a person in the event of serious illness. This document can speak for a patient who is unable to communicate. A living will may indicate specific care or treatment the person does or does not want performed under specific circumstances. This may include specific procedures, care, or treatments such as the following:

• CPR (if cardiac or respiratory arrest occurs)
• Artificial nutrition through intravenous or tube feedings
• Prolonged maintenance on a respirator (if unable to breathe adequately alone)
• Blood cultures, spinal fluid evaluations, and other diagnostic tests
• Blood transfusions

State laws vary regarding living wills. Information specific to individual states usually may be obtained from the state bar association, state medical association, state nursing association, and most hospitals or medical centers.

A living will is not to be confused with a last will and testament that distributes assets after a person's death.

Special medical power of attorney. A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make or communicate such decisions personally.

NOTE: This document provides for power to make medically related decisions only and does not give any individual power to make legal or financial decisions.

DNR (do not resuscitate) order. This states that CPR (cardiopulmonary resuscitation) is not to be performed if your breathing stops or your heart stops beating. The order may be written by the person's doctor after discussing the issue with the person (if possible), the proxy, or family.

RECOMMENDATIONS

• In the event you choose to create a living will or special medical power of attorney, know specific state laws that may apply. Write the document to be consistent with your state's laws.
• If you have a living will or special medical power of attorney, provide copies for your family members and health care providers. Carry a copy with you in a wallet, glove compartment of a car, or similar location. If you have a planned admission to a hospital, take copies for the hospital to include in your medical chart and tell all medical personnel involved with your case about the documents.
• Consider the possibilities of the future, and plan ahead. Studies have shown that although the majority of people believe having some form of advance directive is a good idea, most people have not actually developed advance directives for themselves. Many people state that they want their families to make health care decisions. However, less than half of these people have ever discussed the issue and their specific desires with family members.
• These decisions can be changed at any time. However, if a living will is changed, everyone involved -- including family or proxies and all healthcare providers -- must be informed and new copies of instructions made and distributed.

SUMMARY

The process of creating advance care directives may be difficult. It requires you to think about your priorities regarding quality of life and your death. Treatment options, and their possible influence on your quality of life, need to be fully understood and considered. Know the potential implications of choosing or refusing specific forms of care.

Discuss your wishes regarding advance care directives with your health care providers, family members, and friends. Review your wishes from time to time to remind everyone.

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References

Kapp MB. Ethical and legal issues. In: Duthie EH, Katz PR, Malone ML, eds. Practice of Geriatrics. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 6.