What Is an Advance Directive?

An advance directive is important, no matter your age. If you can’t speak for yourself due to an illness or accident, it specifies the medical care you want.

Noone wants to think about the possibility they could suffer a terrible accident or illness one day, resulting in the inability to communicate. Especially if you are young and healthy, your senior years and potential illnesses could be the farthest thing from your mind.

No matter your age or health circumstances, however, it’s important to face the fact that you are mortal. Even the youngest and healthiest people can suffer brain injuries and unexpected diseases affecting consciousness and thinking abilities.

An advance directive is a legal agreement that lets you decide about your health decisions and who you want to carry out your wishes, including end-of-life decisions, in case you can’t communicate your preferences one day.

While, hopefully, you’ll never need it, your advance directive ensures you’ll receive the medical care you would want — and none you don’t want — if you are unable to speak for yourself and doctors, family members, or a close friend must make decisions for you.

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What is an advance directive?

There are two primary parts to an advance directive, the National Institute on Aging (NIA) explains:

• A living will. In this written legal document, you can list procedures you would want, and any you do not want, under specific conditions. For example, if there is no chance for survival, do you want life support to be discontinued? If you are in a coma, do you want all medical treatment possible to support your body indefinitely or for a specific length of time?
• A durable power of attorney for healthcare. This legal document can be used instead of a living will, or in addition, and it becomes part of your advance care directive. A durable power of attorney for healthcare names a proxy. This is a family member, close friend, or doctor whom you designate to make medical decisions for you at any time you are unable to do so. Your proxy (also sometimes called an agent, surrogate, or representative) should be familiar with your specific values and concerns about your healthcare so they can make the decisions you would want in case you are unable to make them yourself at some time.

It’s important to understand that you do not have to list your specific health decisions in writing. Instead, if you feel comfortable that your proxy understands your values related to medical care and end-of-life issues, you can opt to give your proxy the authority to evaluate and make decisions themselves about any health situation or treatment that comes up, if you are incapacitated.

It's important to talk about your thoughts, beliefs, and values with the person you designate as your healthcare proxy. You should also talk to multiple people in your life you are close to about how you want to be cared for in a medical emergency or at the end of life. Those conversations can help you think through everything you want to put in your advance directive, the NIA notes.

Medical treatments and issues to consider in your advance directive

As you think about what an advance directive is going to specifically mention to align with your values and concerns about medical decisions, it’s a good idea to consider your personal feelings about common artificial or mechanical ways (below) that can keep you alive after a severe injury or a medical crisis (such as cardiac arrest or a severe stroke).

Cardiopulmonary resuscitation (CPR) can restore your heartbeat if it has stopped or is beating out of control due to a life-threatening arrhythmia (ventricular fibrillation, which is always deadly if not halted abruptly). A person doing CPR pushes forcefully on your chest while blowing air into your lungs. CPR can save lives but has risks, such as broken ribs or collapsed lungs.

A defibrillator, a device that uses electric shocks to restore a heart rhythm, may also be used. CPR and defibrillation can often trigger a stopped or fibrillating heart to resume normal beating. In very elderly adults, however, especially those with multiple health problems, CPR may not be effective.

A ventilator is a machine that connects a tube down through your throat and into your windpipe (the trachea) to force air into your lungs. The procedure, called intubation, is uncomfortable and even painful, so drugs are typically used to keep patients on ventilators sedated.

If long-term treatment with a ventilator is expected, a hole may be cut through your neck to attach the tube directly to your trachea. The procedure, called a tracheotomy, doesn’t require sedation while on a ventilator.

The use of the breathing tube means you can’t speak without special help because air doesn’t reach your vocal cords. Amyotrophic lateral sclerosis (Lou Gehrig's disease) is an example of a terminal condition that often involves intubation and a tracheotomy as the disease progresses.

Artificial nutrition (tube feeding) and artificial hydration with IVs (intravenous fluids) are used if a person cannot eat otherwise, due to an injury, stroke, or a terminal illness. Feeding may take place through a tube threaded from your nose into your stomach or, if you need artificial nutrition long-term, through a tube surgically inserted into your stomach. Fluids are delivered through tubes inserted into a vein if a person cannot drink.

As people with dementia, especially Alzheimer's disease, have worsening symptoms, they may not be able to eat without artificial nutrition and IVs.

Research shows, however, that artificial nutrition and hydration toward the end of life does not meaningfully prolong survival and can be harmful if a person who is terminally ill cannot digest and process food and nutrients properly.

In addition to considering how you feel about those specific treatments being used if you are unable to agree to them, you should also consider whether you would want comfort care if you are in a terminal condition.

Comfort care is anything that can relieve pain and discomfort, while staying in line with your other care decisions wishes. It includes:

• Drugs for pain, anxiety, constipation, and nausea
• Managing shortness of breath
• Limiting invasive medical testing
• Providing emotional and spiritual counseling

If you already have an organ donor card or are listed as a donor on your driver’s license, you can also choose to note in your advance directive if you want that to happen, or not, at your death.

What to do after you have an advance directive

Make sure you give copies of your advance directive to your healthcare proxy (the person you designated to make decisions for you) and to an alternate proxy. An alternative proxy is someone you choose to take over if you have an emergency health situation and your original proxy is not available or incapacitated. Your doctor should also receive a copy of the advance directive for your medical records.

Keep a record of everyone who has a copy of your advance directive so, if you make changes in the future, you’ll have a list of people who need an updated copy.

Make sure your partner or spouse, other family members, and close friends know where you keep your copy of the advance directive. If you go to the hospital, you or a friend or relative should take a copy of the document and give to the ER or other medical staff.

You can also carry an advance directive notification card in your wallet. It indicates you have an advance directive and indicates where you keep it. You can also have an advance directive card in your wallet.

An advance directive is worth your effort

An attorney can help you prepare an advance directive, but it’s not required. The NIA advises that you talk to your doctor as you start the planning process, so you don’t have to depend on an attorney to help you understand and decide on different medical treatments you may list in the directive.

While laws differ somewhat from state to state, in general a person’s expressed wishes in their advance directive are typically honored, according to the American Hospital Association.

Some states have their own advance directive forms. Your local Area Agency on Aging, a service of the Administration on Aging, can help you find out where to obtain the forms. For information, call 1-800-677-1116. Depending on the state in which you live, signing your advance directive may need a witness. Some states require your signature to be notarized.

An advance directive goes into effect only if you are incapacitated and unable to communicate for yourself due to a severe illness or injury. You may never need it, but having it in place can give you and your family members peace of mind if you can’t speak for yourself about life and death health decisions.

An advance directive is not written in stone. In fact, the NIA advises that you think about an advance directive as a living document. You can change the document if your health situation changes, or you ammend your wishes. You can also change your proxy.

It’s a good idea to review your advance directive decisions at least every decade to see if you want to make revisions. You will also need to change the document if:

• You’ve married or divorced
• Your spouse has died
• Something happens to your proxy or alternate
• You’ve changed doctors

Let your doctor, proxy, close friends, and family members know about the changes, and make sure they receive updated copies of your advance directive.

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