Although most people realize they should have some sort of advance healthcare directive in place, there is often a lot of confusion as to what type they need, and for what reason.
First, it’s important to understand why advance healthcare directives came into being. They were created in response to increasingly sophisticated medical technology. A century ago, before recent technological breakthroughs and advancements in modern medicine, the dying process looked quite different than it does today. While modern advancements can make dying much easier and less painful in many cases, the reverse can also be true – the medical care of the dying can instead become unnecessarily prolonged, painful, expensive, and emotionally burdensome to both patients and their families.
In the late 1960s, the idea of a living will was proposed as the first type of advance healthcare directive. Also known as a personal directive, advance directive, medical directive, or advance decision, this is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. It usually provides specific directives about the course of treatment healthcare providers and caregivers are to follow. In some cases, a living will may forbid the use of certain medical treatments. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices.
A living will can be either very general or more specific, such as providing information regarding an individual’s desire for such services such as analgesia (pain relief), antibiotics, blood transfusions, dialysis, hydration, feeding, dying at home, and the use of ventilators or cardiopulmonary resuscitation. An example of a statement sometimes found in a living will is: “If I suffer an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would serve only to prolong my dying be withheld or discontinued.” Being clear about your wishes in your living will means your loved ones don’t have to guess about what you would want. It is used only if the individual has become unable to give informed consent or refusal due to incapacity.
You can usually find free living will forms at local senior centers and hospitals, your physician’s office, or your state’s medical association. While you can also get a living will form from a lawyer, you don’t need an attorney to make one. The living will should exist in physical form, so be sure to print a hard copy. You should sign your living will, and have it witnessed and notarized according to your state’s laws. (Most states require two witnesses to a living will, and some also require a notary’s seal.) Make sure you give copies of your living will to family members, your health care proxy, your doctor(s), and your hospital or care facility, since it only becomes effective if those treating you know about it.
You may also want to consider filling out a Physician Order for Life-Sustaining Treatment (POLST) form, which is an order signed by your doctor that describes the end-of-life medical treatment you want to receive in an emergency.
While putting together a living will is a great place to start, it can be insufficient on its own because it tends to be limited in scope and often fails to fully address possible problems and needs. It reflects a moment in time, and so it needs regular updating to ensure that the correct course of action can be chosen. Also, individuals sometimes write out their wishes in ways that might conflict with quality medical practice. For these reasons, it’s also important to have a “second-generation” advance healthcare directive called a health care proxy, or medical power of attorney.
A healthcare proxy document appoints a person (usually an individual related by blood, adoption, or marriage) who can make decisions on behalf of the granting individual in the event of incapacity. The appointed healthcare proxy has, in essence, the same rights to request or refuse treatment that the individual would have if still capable of making and communicating health care decisions. The appointed representative is authorized to make real-time decisions in actual circumstances, as opposed to the advance decisions being framed in hypothetical situations, as is typically the case with a living will.
A best practice is to fill out both the health care proxy and living will forms. A conventional healthcare proxy may be too vague for meaningful interpretation in specific instances, which is where the living will would be beneficial. Another alternative is also filling out a medical directive, which is a document that describes six case scenarios involving common medical procedures and interventions, allowing the individual to decide in advance which treatments are wanted or not wanted under the circumstances. People are often encouraged to complete both, or all three, documents (although they may be combined into a single form) to provide comprehensive guidance regarding their care.