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Estate Planning: Advance Health Directives
Proper Planning for your End-of-Life Decisions

It's a fact that most people avoid planning for end of life affairs. For whatever the reason, we are reluctant to face that inevitable part of life. Yet, if you start today to think about your end-of-life choices, from a healthy perspective, you're able to wisely visualize how you want the end of your life to play out.

The family is grateful for your planning which eases their burden. Or, if you talk to your parent about their wishes and they prepare advance health directives, it takes the pressure off future tough ones. What a relief for all involved - you've reduced stress for both the family and yourself.

What is an Advance Health Directive?

End of life health directive

End of life affairs are confusing, so let's look at what an Advance Health Care Directive is and what it does for a person doing the planning. First, the directive gives the best assurance that a person's decision regarding the future medical care will reflect their true values and desires. Advance directives are legal documents giving people the opportunity to make decisions about their own future medical care. For many seniors and their loved ones, these documents provide a sense of comfort. At the end of the day, those involved can relax because important medical and health decisions are in compliance.

Throughout the years, an advance health care directive acquired several names such as living will, personal directive, advance directive, or advance decision. The directive is a group of written instructions that stipulate the actions to take in regards to a person's health, if they are no longer able to make the healthcare decisions due to illness or incapacity. These written instructions may include:

DNR (Do Not Resuscitate Order)

A DNR is a Do Not Resuscitate Order that covers two very specific situations. If you or your loved one suffers from a heart attack or stops breathing, medical personnel cannot revive you. Your doctor can generate a DNR and to include with your medical records.

Health Care Proxy

Creating a Health Care Proxy allows you to assign an agent that makes important decisions for you in the event that you are unable to make the decisions yourself. Family members are most commonly chosen as agents, because they have a great deal of knowledge concerning a loved one's personal wishes and religious beliefs. Health Care Proxies are only related to medical care. It is not a Power of Attorney document.

Living Will

Every state is different, but in most states a Living Will is a legal document that assures that your doctors are not liable for following a patient's wishes concerning medical care. They only apply for patients with terminal conditions that are not permanently unconscious. It states that you do NOT want life-sustaining care, including things like being placed on a respirator.

Items Covered by Advance Directives

The Family Caregiver Alliance offers the following decisions and questions advance directives can address:

  • What person; relative, friend, or professional do you want to make decisions for you (if you are not able to make them on your own?) These decisions include financial and health care matters. Remember: The same person for both is not a good idea.
  • What medical treatments and care are acceptable to you? Are there some that you would absolutely not choose? Which treatments are acceptable to you?
  • Do you wish to be resuscitated (revived), if you stop breathing and/or your heart stops? This is a DNR (Do Not Resuscitate). All hospitals have policies which describe circumstances under which CPR are withheld. Here are two situations which justify withholding CPR: (from University of Washington School of Medicine).
    • 1) When CPR provides no medical benefit "medical futility" when it offers the patient no clinical benefit and a physician is then justified in withholding resuscitation. To "be of benefit" - shows a 0% probability of success in circumstances like: Septic shock, Acute stroke, Metastatic cancer, Severe pneumonia, Hypotension (2% survival), Renal failure (3%), AIDS (2%), Homebound lifestyle (4%), Age greater than 70 (4% survival to discharge from hospital).
    • 2) When the patient's decision-making is intact (or when lacking such capacity, someone designated to make decisions for them - an advanced medical health directive) indicates that s/he does not want CPR, should the need arise.
  • If you are seriously or terminally ill, do you want to remain in the hospital or to stay home? State specifically "where" you want to stay?
  • How is the healthcare paid? Do you have adequate insurance?
  • What happens when you die? Do you want to know more about what might happen?
  • Will your loved ones be prepared for the decisions they may have to make?

Popular Resources for Advance Directives

Two well-known comprehensive guides used today regarding care are:

  • Five Wishes. Five Wishes speaks to all a person's concerns, not just the medical and legal ones. The matters addressed are comfort, dignity, pain management, personal and spiritual issues, family reconciliation and memorial matters. It's easy to use and understand and meets the legal requirements and is one of the closest thing available to a national advance directive. You can obtain a sample copy of Five Wishes.
  • MyDirectives.com is a digital (online) advance medical directive service, allowing people to create, store, update and retrieve directives at any time from any location. It is a standalone website and offers a module to connect with electronic medical record systems; helping hospitals improve access to directives at the time of a health crisis.

History of Advance Directives

Advanced directives came about in response to the aggressive revolutionary medical technology. More and more medical technologies, surgeries, medications, and treatments (medical care) keep severely and terminally ill patients alive through unnecessarily prolonged, painful, expensive, and emotionally burdensome managements.

Today in the United States, aggressive medical intervention leaves:

  • Nearly two million patients confined to nursing homes
  • Over 1.4 million patients remain medically frail, surviving on feeding tubes
  • 30,000 persons are kept alive in comatose and permanently vegetative states

The burden of cost relies on the patient and family members.

A national study found:

  • In 20% of cases, a family member had to quit work
  • 31% lost "all or most savings" (even though 96% had insurance)
  • 20% reported loss of major source of income

Studies report that 70-95% of people would refuse aggressive medical treatment if that meant their lives have poor and limiting prognosis.

Stages of Advance Directives

Living Will

The Living Will is the oldest form of advance directive and devised for a person when s/he is no longer available to speak for themselves and express healthcare desires. It's called "living will" because it is a form of "will" used while an individual remains alive (but no longer able to make decisions).

Next Stage - Advance Directives

The next generation is a result of business law; "durable powers of attorney for health care" and "health care proxy appointment" documents allow individuals to appoint an agent to make health care decisions in their behalf, if incapable of making their wishes known.

The next generation advance directive appoints someone to make real-time decisions (in actual circumstances), as opposed to a "hypothetical situations" (recorded in a living will.)

The Third Stage - Advance Directives

The third stage of advance directives is the Values History by Doukas and McCullough at the Georgetown University School of Medicine. It's intended to assist individuals, appointed agents, family members, and physicians to honor and better understand the wishes of a person.

It has two-parts that elicit patient values about terminal medical care and therapy-specific directives. The Values History focuses strictly on a patient values and personal goals, not on specific treatments and medical procedures.

Additional Third Stages - Advance Directives

Five Wishes directive is the best known advance directive in the third stage generation - designed by experts with funding from the Robert Wood Johnson foundation and endorsed by Mother Teresa of the Sisters of Calcutta.

The Medical Directive is a widely used advance directive - a six-page document that provides six case scenarios for decision-making. The scenarios are medical procedures and interventions, giving individuals the ability to choose treatments and under what circumstances.

Lifecare is a recent advance directive. Researchers studied 6,500 plus medical, legal, sociological, and theological sources. They found that advance directives need to look at "health outcome states" rather than medical treatments and legal jargon.

Many agree, maybe even you, that expressing one's "advanced" wishes is tricky but most rely upon their state's standard directive format. To make your best choice, review several advance medical health directive documents and discover which meets your personal needs.

Carol Marak
Carol Marak

After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.