4 Types of Advance Directives Explained

Updated

Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

Most people think of advance directives as something that older and frail people need, but anyone 18 and over should consider advance directives. The truth is, advance directives are a crucial part of long-term planning for anyone at any age. Life can change in a heartbeat, and a sudden accident or illness can happen to anyone.

With that said, age does matter for some of these advance directives. If you are younger and in good health, your decisions can be different than if you are older and in poor health.

Advance directives can be difficult to understand since there is no uniform document across states. Each state has its unique forms, and some of these forms incorporate several types of advance directives together.

Jump ahead to these sections:

Despite the different documents, advance directives share this in common: the ability to document your preferences for treatment and end-of-life care that only go into effect only if you are incapacitated and unable to speak for yourself. Advance directives can also serve the purpose of permitting assigned people access to your medical information should they need to advocate for you.

Here are the different types of advance directives listed below, with different uses and applications depending on the situation.

1. Living Will

A living will is a type of advance directive. In some states, an advance directive can include questions related to the purpose of a living will. A living will is a crucial document to complete because it dictates what care you want if you become incapacitated, whether temporarily or permanently. Incapacitated means you are unconscious or mentally incapacitated and unable to make reasonable decisions about your care and treatment.

It can be hard to think about situations that might or might not occur, but life is unpredictable. To clarify what we mean by “care,” consider the following cases.

  • Would you want a ventilator (breathing machine) to keep you alive? And under what circumstances would that be acceptable to you? Some people state that if there is no hope of meaningful recovery, they do not want a ventilator. The same decision applies to kidney dialysis.
  • If you would want liquid (usually by IV) and or food (tube feeding into your stomach) if you cannot drink or eat independently. In some situations, a person would not be able to survive without these interventions. With your health care provider’s help, you can be very specific under what conditions you would be willing to have life-sustaining treatments occur.
  • Do you want active, aggressive treatment for pain or other medical problems? Would you prefer palliative care or hospice if there is very little likelihood that such interventions would extend your life in any meaningful way?
  • What about Cardiopulmonary resuscitation (CPR)? If you have a terminal condition and do not want medical personnel to restart your heart if it stops, you have to make that known through your living will.  
  • Is organ donation something that you would like to do? You would need to designate this as a choice before you become unable to state that preference.

A living will needs to be a legal, written document that complies with state laws and requirements. Just telling someone what you want will not be enough to honor your wishes should you become incapacitated. A living will dictates your decisions, and without it, other people may have to make those decisions for you. 

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2. Durable Power of Attorney for Health Care/Medical Power of Attorney

To complicate things, each state has an individual term for durable medical power of attorney and medical power of attorney. Other names for these documents might be the following:

  • Health care proxy
  • Health care surrogate
  • Health care attorney-in-fact
  • Health care representative

Regardless of the name used, the central idea behind a medical power of attorney is choosing someone to act as your healthcare agent. This person can either be appointed to help make decisions and access medical care immediately or only in the case of your inability to do so due to incapacity or unconsciousness. 

The person you name could be a spouse, partner, friend, or relative, but choose the person very carefully. In some states, the power of attorney document allows you to designate a guardian if you become mentally incapacitated.

If possible, the person you select should meet these criteria:

  • Understand their responsibilities and be willing to serve as your power of attorney. Avoid naming someone before you have had a chance to discuss the situation with them. Don’t assume that this is something they are wanting or willing to do.
  • Be willing to openly discuss personal health care and end-of-life wishes with you.
  • Be trusted to not only carry out your wishes but advocate for you if there is a disagreement about your medical care. It is not unusual for family conflicts to arise during the stress of end-of-life and other medical decisions. Your healthcare proxy should be willing to fight for your expressed wishes.
  • Inform other family members about who you have chosen.

3. Physician’s Order for Life-Sustaining Treatment (POLST)

A POLST is part of advance directives in some states and a separate document in others. It is not uncommon for people to be confused about why a POLST is needed if you have other advance directives like a living will.

A POLST is also referred to as a MOLST (Medical Orders for Life-Sustaining Treatment) in some states. Here are some of the differences between a POLST and other advance directives:

  • A POLST is used for specific life-threatening or emergency situations. For example, you may be a healthy person with advance directives. Still, a medical circumstance dictates that you and your healthcare provider need to decide treatment and care for this specific situation.
  • Your healthcare provider must sign your POLST. For most advance directives, a physician’s signature is not necessary.
  • You do not need a healthcare proxy or surrogate for a POLST because you and your healthcare provider have already decided on your treatment and care under these unique circumstances.
  • A POLST stays with you whether you are in the hospital, nursing home, home, or in hospice. POLST forms may be printed on a special colored paper to alert medical emergency personnel of its existence. An advance directive may not be accessible when first responders arrive.
  • A POLST form is typically a front and back page only, whereas an advance directive might be many pages long.
  • A POLST form is recommended for people who may be in their last year of life or have some other form of an irreversible condition. The POLST form is for keeping individuals from receiving unwanted treatments. Any younger person could have advance directives, but a POLST may not be necessary if they are healthy. 
  • Many nursing homes and hospitals now require a POLST form upon admission. 

4. A Do Not Resuscitate Order (DNR)

A Do Not Resuscitate (DNR) can be a part of a living will or any other type of advance directive. Designating a DNR is not as easy as it sounds. A DNR means that you will not be resuscitated if your heart stops, and you could die. At the end of life, people who have a terminal condition often designate a DNR because the procedure is unlikely to improve their condition and might make it worse.

Even if you have an advance directive with instructions on resuscitation, having a DNR if you are admitted to a healthcare facility is a good idea.

You can’t assume that just because you have told emergency responders or healthcare workers that you have a DNR that it will be followed. There have been lawsuits against hospitals regarding this very specific issue. In these cases, although there was a DNR in the patient’s chart, resuscitation was attempted anyway.

If you are home, you will want the DNR displayed in a prominent place so that emergency personnel can see it and follow the directive. A DNR is flexible in the sense that you can revoke it at any time.

Reviewing and Changing Advance Directives

The first step in creating any of the advance directives listed above is to make certain they are accurate and legal. Consulting with an elder law or estate planning attorney is the best way to do this, as you want to ensure that the documents you sign are legal.

Not every advance directive will require a lawyer, and in some states you can fill out the form yourself. If you have a financial advisor, many of them have secure online portals to store your documents. Here are some other things to keep in mind:

  • Review all of your advance directives at least every ten years or if there is a new medical diagnosis. If you need to change your healthcare power of attorney due to divorce, separation or for any other reason, do so as soon as possible.
  • Make sure your healthcare providers have copies. Otherwise, your healthcare proxy will not be able to advocate for you or obtain critical healthcare information about your treatment. 
  • Have a secure place to keep advance directives and tell others where to find them. 
  • Give copies to family members and any other trusted sources. Have conversations with those that you provide the documents to so that everyone knows what your wishes are.
  • You can change any of your advance directives at any time by destroying the current copy and completing new ones. Life changes, and your advance directives should reflect those changes. 

Advance Directives for End-of-life Planning

Advance directives should be the foundation of long-term planning. The task may seem daunting and overwhelming at first, but the process of deciding what is most important to you will ensure your wishes are honored. 


Sources:
  1. “Hospital Ordered to Pay $400,000 in Do-Not-Resuscitate Lawsuit.” The Associated Press 24 May 2019, apnews.com/article/d2e3b975b83640dd87276df7a559d559.
  2. “Living Wills and Advance Directives for Medical Decisions. Mayo Clinic, 22 Aug 2020, www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/living-wills/art-20046303.
  3. “Types of Advance Directives.” American Cancer Society, 13 May 2019, www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-financial-and-legal-matters/advance-directives/types-of-advance-health-care-directives.html.

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