ADVANCE DIRECTIVES: What Hospitals and Doctors Need to Know

Advance directives? What are they? What do they mean? Hospitals and doctors always ask about them; do you have them? Two terms people often hear, but what do they mean? Are they required or necessary?

Several quotes I discovered in my reading highlight the definition of AD’s and give us a base for discussion of the various Advance Directives. They are:

“A written statement of a person’s wishes for medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate to the doctor.”

“Advance Directives (AD) are documents in which an individual makes provision for healthcare decisions in the event that, in the future, he/she becomes unable to make those decisions.”

“Oral and written instructions about future medical care should the patient become unable to communicate those decisions at the time of the illness.”

“…planning for health care in the future is an important step toward making sure you get the medical care you would want, if you’re unable to speak for yourself..”

“…avoid unnecessary suffering and relieve caregivers of decision-making burdens during moments of crisis or grief..”

Advance Directives are written legal documents in which, before it becomes a necessity, individuals express their feelings about what kind of medical care they want to receive, and the extent to which they want it to be taken. It most often is used when people are near death or are physically or mentally unable to make those decisions. It’s all decided well in advance.

The most frequently used Advance Directives are two documents:

The Living Will

The Durable Power of Attorney for healthcare decisions

They will be discussed in detail, while other, less frequently used AD’s, will also be discussed.

Living will—a written document that is signed, witnessed, and notarized stating your wishes about the use of artificial life support measures to keep you alive if you are terminally ill or permanently unconscious. It becomes effective when you are no longer able to make healthcare decisions for yourself, and you are diagnosed with a terminal illness, an end-stage condition, or are in a permanent vegetative state. It tells your healthcare provider, your family, and friends how you wish to die. It tells them your decision to receive or not receive food, water, or pain medication. A Living Will clarifies for the physician the wishes of the patient. Family members, or other individuals, have no legal standing to interpret or alter the intent of the individual expressed in this document.

Issues that should be specifically addressed in the Living Will are as follows:

CPR (Cardiopulmonary resuscitation)

Mechanical ventilation

Tube feeding

Kidney Dialysis


Narcotic pain medication

Organ donation

Donation of your body

The signer of the document should decide which of these procedures he/she desires be done and which ones not, thus giving providers specific knowledge of the signer’s end-of-life wishes.

Durable Power of Attorney for Health Care Decisions—also known as “Healthcare Surrogate,” is a signed, witnessed, and notarized document in which the signer designates an individual to make healthcare decisions for him/her. It takes effect when the signer is temporarily or permanently unable to make such decisions. The patient does not have to be terminally ill as is the case in a Living Will. The individual chosen for this role must have a clear knowledge and understanding of the wishes, values, and intent of the signer and should have discussed these issues with him/her. The designee has considerable power and authority over the signer and must not abuse the role.

Many terms are used for the person who has the authority to make medical decisions on another person’s behalf. These terms are as follows:

Health care proxy

Health care agent

Health care surrogate

Health care representative

Health care attorney-in-fact

Patient advocate

They all mean this is the designated person of authority, but are called different names.

Combination Advance Directive—a signed, witnessed, and notarized document that contains specific written directions to be followed by a designated individual. This document gives the individual flexibility in decision-making should an unusual circumstance arise. The designee has the authority to issue a new document based on changed decisions the signer has expressed. This individual must be chosen carefully and be known to have the patient’s best interest at heart.

Durable power of attorney—this differs from the Health care POA. It is a written document that authorizes someone to make decisions about your life, not just medical decisions. It remains in effect whether or not you become unable to make decisions yourself. The chosen representative has discussed your wishes and represents you and your decisions. It becomes active as soon as it is signed, witnessed, and notarized. It gives someone you know and trust the power to “step into your shoes” and make decisions about items such as banking, check writing, bill paying, investment management, and other personal, financial transactions. Upon your death, this document “dies with you,” and the proxy can no longer act on your behalf. Durable means this arrangement continues if the individual becomes unable to make such decisions.

Do not resuscitate—DNR out of hospital—a statement of your wishes for the use of artificial life support to keep you alive if you are not in a hospital and are found to be unable to communicate those wishes. To have a DNR order, it is not necessary to have a Living Will, but having one clarifies one’s wishes.

Do not resuscitate—DNR in the hospital—a written order that tells a hospital staff your decision to not use CPR if your heart stops or if you stop breathing. This may also pertain to the use of a ventilator, tube feedings, palliative care, or organ donation should those situations arise. A Living Will is not required for this designation, either, but the doctor needs to write an order in the patient’s chart specifying this decision.

Do not intubate—DNI order tells medical providers you do not want to be put on a ventilator. It is treated the same as the DNR order.

Protective Medical Decisions Document—is a protective Durable Power of Attorney for Healthcare in which the signer names a trusted person to make healthcare decisions for them, just as mentioned above, but this version specifically prohibits assisted suicide and euthanasia. This document is not used very often as assisted suicide is legal in only seven states and is not a common practice. But some individuals want a safeguard against that decision being made.

POLST, MOLST (Physician/Medical Orders for Life-sustaining Treatment)—is intended for patients already diagnosed with a serious illness. It is a form that serves as “doctor-ordered” instructions to ensure, in case of emergency, your end-of-life decisions are known. The order is based on treatment decisions provided by one’s Living Will. POLST does not replace other Advance Directives, but increases provider awareness of their contents. This document remains in force while hospitalized, in a nursing home, or the ER, should these situations arise. Issues covered by POLST are CPR, mechanical ventilation, tube feeding, antibiotics, narcotic analgesics, and requests to be sent to the ER or the hospital.

Organ and tissue donation—an AD that tells hospitals and doctors upon your death what organs or body tissues you would like to donate to people who need them. In the event of death, it may be necessary to keep the donor alive by mechanical means until the donated organs can be harvested. The organ donation order then “supersedes” a DNR order.

Pregnancy—a document stating that if you become pregnant, and something happens during the pregnancy, to what degree the patient wants her life, and the viability of her fetus, preserved. This is an infrequently used AD.

What else should I know about Advance Directives?

AD’s are valid throughout the United States, but some states do not honor AD’s from another state.

If you spend considerable time in other states, you should have Advance Directives for

those states as well as your home state. Each state regulates AD’s differently.

You do not need a lawyer to fill out an AD. They are legally valid as soon as you sign

them in front of a witness and a notary.

They are “not set in stone.” They can be revised as often as needed when conditions change.

Emergency medical technicians (EMT’s) cannot honor Living Wills or Medical powers of

attorney. Once summoned, EMT’s must do what is necessary to stabilize a patient.

AD’s do not expire. They remain in effect until you change them. They should be reviewed

periodically to update one’s current wishes.

Dr. G’s Opinion: Advance Directives are both good and bad. The good thing is they spell out clearly what the patient wants for “end-of-life care.” Doctors, nurses, hospitals, and family members have written proof of the dying patient’s wishes and can carry out those orders as requested. The bad is that once a patient is determined to be a “DNR,” the little things called “TLC” get overlooked, forgotten, neglected and patients aren’t given the close attention they all deserve. Providers know not to call a “Code Blue” on Mr. Smith, but they may also neglect to give him oral care, clean his messes, and spend time with him.

Still, it is important for everyone to have a Living Will and have a Health care Power of Attorney proxy. These are items essential to good communication and medical care.


“What are Advance Directives” The Legal Aid Society of Orange County Bar Association, Orlando, FL

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