What is an Advance Directive and Why Do You Need One?

A thorough advance care directive document will cover a range of different medical decisions that your doctors and caregivers could face. Addressing these possibilities now, in a legal document, ensures that those doctors and caregivers understand and can abide by your wishes. Try to include some of the most common medical situations and ask yourself how you would like to be treated in those circumstances. Consider your value system, which might consist of consulting any faith-based advisors you have or speaking with partners and loved ones. Ultimately, however, the decisions contained in your advance directive should be yours and yours alone.

Here are some of the medical decisions you can include in your advance directive:

CPR

CPR is cardiopulmonary resuscitation, a procedure that can be performed on someone by anyone, not just a medical professional. The purpose of CPR is to get the heart beating again if you have no pulse or an irregular heartbeat that could lead to death. In your advance directive, you can indicate whether or not you would want to be resuscitated this way. These procedures are life-saving and can extend your life, something for which you may wish to express your desire. Consider the fact that successful CPR can come with injuries to your ribs and lungs and, depending on how long your body went without oxygen; you could have long-lasting effects. You might also consider, under this heading, identifying how you feel about being treated with defibrillators or other electric devices designed to restart the heart as well as medications and other treatments. Some may want doctors and other caregivers to do all they can to resuscitate them, while some people prefer not to undergo these treatments. Your decision should be written down in straightforward language, and you are not required to explain why you arrived at your choice.

Ventilator Use

Ventilators can be required while fighting pneumonia, covid-19 and other diseases that target our lungs. When we cannot breathe on our own, a ventilator can take over for us. However, the process of accessing your lungs with the ventilator tube, known as intubation, can be quite painful and require painkillers. Tracheotomies are also a common way to connect patients to a ventilator and require a small incision in the neck to allow the ventilator tube to connect directly to the trachea. Though they sound painful and scary, these are life-saving medical procedures that you may want to exhaust in an effort to extend your life. However, you may also want to consider how long you would be willing to have a machine breathe on your behalf. When you are connected to a ventilator, you cannot speak, so it’s best to make your wishes clear beforehand in an advance healthcare directive.

Artificial Nutrition and Hydration

More commonly referred to as a feeding tube, artificial nutrition is when a tube is fed through your nostril to your stomach to deliver food if you cannot eat. The prolonged need for a feeding tube might mean that your tube has to be connected directly to your stomach with a small incision. To stay hydrated when you can’t drink, you will be connected to an IV that keeps a steady flow of fluids running to your body.

A feeding tube prevents malnutrition, and an IV will prevent dehydration. Both malnutrition and dehydration can exacerbate any pain you’re already in, as well as cause more. This may be reason enough for you to direct your healthcare providers to continue with both of these treatments as long as possible. However, neither artificial nutrition or hydration can effectively prolong your life in an end-of-life situation and can drag out painful and undignified scenarios that may not be how you envisioned you would spend your last days. Consider how you feel about these medical processes and decide whether or not you would want to be kept alive on feeding tubes and IVs if the situation is already terminal.

Dialysis

If your kidneys fail, dialysis can fill in. It’s a treatment that performs the kidney’s functions in a machine outside of the body. Kidneys filter waste and toxins out of the blood, so your body can circulate clean blood more efficiently. These bean-shaped organs help to control your blood pressure by maintaining a good balance of minerals, salts, and water in your blood.

A dialysis machine will pull your blood from your body, filter out everything that isn’t needed and send your blood back into your body cleaned up. An advance directive can indicate which situations you would want dialysis to continue or stop. Dialysis is a life-saving medical tool that can improve people's lives who can otherwise function normally, and it can prolong your life. You may want to live with the need for dialysis for as long as possible. Conversely, when a patient is no longer able to live independently and needs round-the-clock care, dialysis may just be prolonging pain and discomfort. If you’ve suffered brain damage, have no mobility or are experiencing a total loss of quality of life, you may want to ask for dialysis to stop.

Organ, Tissue, Brain, and Body Donation

Since the advent of organ transplants, the waiting list for much-needed organs has been heart-breakingly long. At any given time, there are over 100,000 people on the organ transplant list in the United States desperately awaiting the news that a life-saving transplant can finally be done. Many of us have chosen to take one final selfless act in death and give life to those who need it by becoming organ donors. However, there are many reasons not to donate your organs, such as cultural and religious beliefs, discomfort and fear. No matter what side of this issue you land on, your health care providers need to know if they can donate your organs after you pass. Including your organ donation preferences in your advance directive can accomplish that for you and ensure that nothing is done with your organs that you disapprove of.

Comfort Care

Comfort care is also known as palliative care and is, simply put, the management of pain and comfort in the final months and days of your life. Palliative care is often used for terminal patients, and there are a few decisions to be made that fall into this category. First, you can decide when the medical poking and prodding stops. There comes the point when tests and treatments for a condition that will not improve are causing more discomfort than eliminating. You may also wish to remain at home until the end so you can be surrounded by the people and things you love. To that end, you may choose to limit or specifically define who can see you in such a condition, as you may wish to keep any children in the family from the trauma it may cause, or request that certain loved ones be present to bring comfort and support. Decisions should also be made about what pain medications you’re open to and how much and when to change the focus from prolonging life to increasing comfort.

Not only does everyone’s advance directive look different, but yours may change and adapt in the years to come. When you first create your advance directive, it can be simple and list your preferences on a single page. As you get older, learn more and understand how you want your final days to look, you may consider adding more details. That could mean more documents for specified purposes and include orders for who to consult and what to do in certain situations. A few different types of documents can be included in your advance directive that serve various purposes. Let’s take a look at some of these specified documents you can have in your advance directive:

Living Will

Unlike your last will and testament, a living will does nothing after you have passed. Instead, a living will is a document containing all of your instructions, preferences, and wishes for medical care if you cannot speak for yourself. A living will is a type of advance directive, which is an umbrella term that includes medical decisions and the power of attorney, healthcare surrogates and proxies, non-medical care directives and more. Your living will is strictly for listing your wishes regarding medical procedures, treatments and medication.

Your living will should be a separate document included in your advance directive and signed by witnesses or notarized. Most states have a living will form that you can download and fill out and then take it to your local notary to legalize it. Your living will is one of the documents in your advance directive that should be copied and given to your health care providers.

Durable Power of Attorney

Your durable power of attorney is someone who you have selected to become your health care proxy. That means that the person you have chosen will be able to legally make decisions on your behalf in the event you are unable to do so on your own. It is a good idea to speak to the person you want to serve as your power of attorney and confirm that they are willing and able to fulfill the role for you. Your state may have specific requirements for anyone you might select to be your health care surrogate, so make sure your choice meets those qualifications before making your final decisions on who will play that role. You’ll also want to choose someone you trust who understands and respects the values that have informed your advance directive decisions. Most states will have downloadable power of attorney forms that you can fill out, sign, and notarize if required. These papers should be included in your advance directive to cover any scenarios not addressed by your living will and other documents. It’s also good practice to give a copy of your power of attorney forms to the person you have chosen to be your healthcare proxy.

DNR and DNI Orders

DNR stands for Do Not Resuscitate, and a DNR order is a legal document that covers your preferences in the event you stop breathing or your heart stops beating. This order requests that doctors and other caregivers not perform CPR or use defibrillator technology to restart your heart and bring you back to life. You may want to include this order in your advance directive when you are facing a painful terminal illness; you’ve suffered brain damage or struggle with debilitating dementia and other conditions that completely strip all quality of life. In these scenarios, some feel it is more humane to let a patient pass peacefully than to bring them back to a life they can no longer enjoy. A DNI order is similar to a DNR, but it deals with intubation when you require a ventilator to breathe. The forms for these orders can be downloaded from many different places across the internet, quickly filled out and included in the rest of your legal advance directive documents.

POLST and MOLST Forms

POLST stands for Portable Orders for Medical Treatment, and MOLST stands for Medical Orders for Life-Sustaining Treatments. A POLST form is valid in and out of medical settings and can communicate your wishes regarding specific scenarios. For instance, it can instruct caregivers not to take you to the hospital under certain circumstances or identify medical treatments you do and don’t want. A MOLST form is an approved legal form available in some states that covers many of your medical decisions addressed in your living will. You can download both forms from state government websites and nonprofit organizations.

Organ and Tissue Donation Forms

Organ and tissue donation forms are available in most states, and some will indicate your preferences on your government-issued ID. You can find out how to become an organ donor and where to download the forms in your state by visiting this user-friendly website and selecting your home state. Follow the instructions for the state you reside in, and be sure to include any of the legal documents required by your state for organ donation in your advance directive.

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