Living wills and advance directives: Tools for medical wishes

Living wills are one part of advance directives and describe your medical treatment preferences in end-of-life situations. Find out what else you can do.

The issues surrounding serious illness and death aren't easy to discuss. But it's far easier on everyone if you have a living will and other advance directives in place before you're faced with a serious accident or illness. If you don't, you may find yourself in a situation in which you're unable to communicate your wishes regarding the extent of treatment efforts, such as resuscitation and life-support machines.

Living wills and other advance directives aren't just for the elderly. Unexpected end-of-life situations can happen at any age, so it's important for all adults to have advance directives.

Living wills are just one part of advance directives — forms that tell your doctor what kind of care you'd like to have if you become unable to make medical decisions. Learn more about living wills and other advance directives, how to create them, and how valuable advance directives can be to both you and your family.

Advance directives: More than just living wills

Advance directives are written instructions regarding your medical care preferences. Your family and medical professionals will consult these instructions if you're unable to make your own health care decisions. Anyone age 18 or older may prepare an advance directive.

Advance directives can include:

Living will. This written, legal document spells out the types of medical treatments and life-sustaining measures you do and don't want, such as mechanical breathing (respiration and ventilation), tube feeding, resuscitation. In some states the living will may be known by a different name, such as health care declaration or health care directive.
Medical power of attorney (POA). This is also called a durable power of attorney for health care or a health care agent or proxy. The medical POA form is a legal document that designates an individual to make medical decisions on your behalf in the event you're unable to do so. These forms allow your health care agent or proxy to use a living will as a guide, but interpret your wishes when unexpected developments aren't specifically addressed by your living will. The medical POA document is different from the power of attorney form that authorizes someone to make financial transactions for you. If you don't appoint a medical POA, the decisions about your care default to your spouse. If you aren't legally married, decisions fall to your adult children or your parents.
Do not resuscitate order (DNR). This is a request to not have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. A DNR order can be put in your medical chart by your doctor.

Living wills and medical power of attorney each have limitations. For instance, you can't possibly plan ahead for every situation, so what you include in your living will might not apply in certain instances. Your medical POA isn't given a set of instructions on what to do in every situation, so you have to trust that this person will make decisions based on what's best for you.

The ideal approach to clarify your wishes is to combine the advance directives with a conversation with your loved ones. Talk about what's in your living will and explain how your values shaped your decisions. This gives your loved ones greater insight into what you'd want in medical situations.

Planning option	What does it do?	Benefits	Limitations
Living will	Details your feelings on certain medical treatments and interventions.	Gives your doctors and loved ones an idea of the care you'd prefer if you can't speak for yourself.	Used as a guide, but does not spell out each possible situation.
Medical power of attorney	Appoints whom you want to make medical decisions about treatment for you if you aren't able to do so.	If there's any question about what type of care you would want, your doctors and your family know who to go to for answers.	Doesn't expressly tell that person what to do. You have to trust this person has your best interests in mind.
Talking with your loved ones	Lets you elaborate on your feelings about medical treatment.	Helps your family better understand your wishes. Gives a greater understanding of your approach to each situation.	A conversation isn't as legally binding as written instructions.

Choose a decision maker

Carefully choosing and authorizing a person to act for you by naming him or her in a medical POA document is possibly the most important part of your discussion. That person doesn't necessarily have to be a family member. You may want to have your health care decision maker be different from the person you choose to handle your financial matters. Some people are willing to make health care decisions but not financial decisions, and the reverse also may be true.

You don't have to choose a health care agent, but it's usually a good idea to do so, because he or she can make decisions in situations not anticipated in your written advance directive.

"Be sure to avoid picking someone out of feelings of guilt or obligation," says Paul Takahashi, M.D., a specialist in geriatrics at Mayo Clinic, Rochester, Minn. "You need to feel comfortable that he or she is going to do what you would want."

When selecting a health care agent, choose someone you trust and who you're comfortable with. He or she should understand fully your medical care philosophy and wishes. It may be helpful, but not necessary, if this person lived in the same city or state as you do.

"The person should be levelheaded, mature and calm in a crisis," adds Edward Creagan, M.D., a cancer specialist at Mayo Clinic, Rochester, Minn.

Once you've chosen a health care agent, let your family and close friends know.

Treatments to discuss

In determining your wishes, think about your values, such as the importance to you of independence and self-sufficiency and what you feel would make your life not worth living. Is the treatment lifesaving or life sustaining? Does that make any difference to you?

Although an infinite number of medical situations can arise, be sure to discuss the following treatments. It may help to talk with your doctor about these and other issues and terminology.

Resuscitation. Restarts the heart when it has stopped beating (cardiac death). Determine if and when you would want to be resuscitated by cardiopulmonary resuscitation (CPR) or by a device that delivers an electric shock to stimulate the heart. Would it matter what stage of an illness or injury you were in? There are medical forms called do not resuscitate (DNR) orders that can be filled out to indicate your desire not to be resuscitated. These forms can be placed in your medical record to alert medical staff.
Mechanical ventilation. Takes over your breathing if you're unable to do so. Consider if, when and for how long you would want to be placed on a mechanical ventilator. Would it matter what your prognosis was or if your condition was improving?
Nutritional and hydration assistance. Supplies the body with nutrients and fluids intravenously or via a tube in the stomach. Decide if, when and for how long you would want to be fed in this manner. Would it matter what your prognosis was or if your condition was improving?
Dialysis. Removes waste from your blood and manages fluid levels if your kidneys no longer function. Determine if, when and for how long you would want to receive this treatment. Would it matter whether the treatment would be permanent rather than temporary?
Treatments in the end stages of life. Examples include but are not limited to antibiotics, pain medication and mechanical ventilation. Would you want to receive these as comfort (palliative) care if your prognosis was that it would only delay imminent death?

In general, these types of medical interventions can be helpful in temporary situations — situations you're expected to recover from. But in end-of-life situations, medical interventions may only prolong discomfort. Many situations fall somewhere in between — where your chances for recovery are unknown or unclear. It's these gray areas that are difficult to plan for.

Treat- ment	What does it do?	When it might be consid- ered	Benefits	Limita- tions	What happens if it's not used?
CPR	Restarts heart and breathing	Heart attack	For younger, healthier people, revives heart and breathing	Not as effective in older adults and the terminally ill, may only temporar- ily prolong life	Coma leading to death within five to 10 minutes
Breath- ing machine (venti- lator or respir- ator)	Assists in breathing or completely takes over breathing	Injury or illness that weakens lung function or disables ability to breathe	Temporar- ily takes over breathing while doctors treat illness affecting lungs	Can't reverse disease or illness, simply sustains life	Slowed breathing until it stops; use of medica- tions to ease discomfort
Tube feeding	Administers nutrition in a vein or through a tube in stomach	Injury or illness that prevents swallowing	For a temporary condition, alleviates hunger and confusion from dehydra- tion	For terminally ill, may not extend life, but prolongs the dying process	Coma leading to death in one to three weeks
Dialysis	Takes over for kidneys, removes waste and excess fluid from body	Kidney failure	Prevents excess waste from damaging other organs	May require long-term use; difficult to predict whether kidneys will recover	Waste buildup in body, leading to coma and heart failure

Organ donation
Determine whether you'd like to donate your organs, eyes and tissues for transplantation or your body for scientific study. If you wish to donate your body for scientific study, contact the medical school closest to your home for details.

Fill out the forms for your state

Put everything in writing. Each state has its own laws regarding advance directives. Your doctor can give you the proper forms. Or, state-specific forms are available from a variety of Web sites. The National Hospice and Palliative Care Organization offers free forms on its Web site.

Though not necessary, you may consider consulting an attorney about this process. "This can be wise, especially if you move to a different state," says Dr. Creagan.

Once you've filled out the forms, give copies to your doctor, the person you've chosen as your medical POA, and other friends and family members. Your instinct might be to put your advance directives away somewhere safe, like a safe deposit box, but that will only make it difficult for your loved ones to find the forms when they need them.

"Advance directives can be very powerful," says Dr. Takahashi. "It's important to make sure they're both accessible and utilized."

Revisit and revise your wishes from time to time

As your health changes or your perspective on life changes, you might reconsider some of your advance directives. Read over your advance directive forms from time to time to see if you need to revise any of the instructions. You can change your mind about your advance directives at any time.

You'll follow the same steps to revise your advance directives as you did when you first wrote them. Get new advance directive forms to fill out. Discuss your changes with your friends, family and doctor. Then distribute copies of your new advance directives and ask your loved ones to destroy their earlier version.

If there isn't time to redo the paperwork, you can always cancel your advance directive by telling your doctor and your family. As long as you're able to understand your health condition, weigh the risks and benefits of treatment, and communicate your wishes, you're in charge of what happens to you.

How to talk about end-of-life issues

Injury, illness and death aren't easy subjects to talk about. But the bottom line is that by planning ahead you can ensure you receive the type of medical care you want.

The best approach to discussing the subject is probably to be matter-of-fact and reassuring. If you want an advanced directive for yourself, explain to your family, friends and doctor what your medical care philosophy is and what you'd want done in specific instances. If your family is morally opposed to some of your wishes or is divided over the issue, you might consider choosing someone more in keeping with your personal philosophy as your medical POA.

If you're approaching parents or other family members with the suggestion that they create an advance directive, explain that it's important for you and the family to know what they'd want done.

"Without advance directives, families can be torn apart trying to decide what is best for you," says Dr. Creagan. "Discussing and deciding what you want in advance can take the burden off your family, who would otherwise have to guess at what you'd want done. And no one wants a court to decide his or her fate."