Description of Different Advance Directives
An "advance directive," also called a “living will,” is a statement, usually in writing, where patients state what medical care they would like to receive or not receive at the end of their life, in case they become too sick to tell people what they want. The term "advance directive" also covers spoken statements made to family members or doctors, although spoken statements may not always carry the same legal force as written statements. Advance directives may include particular instructions about healthcare or assign a loved one to make medical decisions in case you can’t speak for yourself. Hospitals are supposed to ask patients whether they have a written advance directive and, if not, give information to new patients about advanced directives.
A living will is a document which can, but doesn't have to, be written with a lawyer while a person is well and of sound mind. It states a person's wishes about end-of-life treatment in case the patient loses the ability to make decisions for himself or herself. A living will cannot predict every possible treatment choice that one may be faced with in the future. Several choices, however, are common to most end-of-life sicknesses, including:
- Whether hospital staff should carry out Cardiopulmonary Resuscitation (CPR) if the heart stops (see CPR information sheet).
- Whether hospital staff should connect the patient to a breathing machine if the lungs fail.
A living will that is used to state a patient's wish not to be revived if breathing and the heart stop is also called a "do not resuscitate order" or DNR.
Almost all living wills state that people do not want CPR or breathing machines to be used if they are thought to be in a terminal condition by their doctors. The word "terminal" means that treatment will not improve the patient's condition, and that death is likely to occur with or without such treatments within a relatively short period of time. Unfortunately, when someone becomes very ill it is often impossible to say in the first couple days whether the patient is terminal. Thus, most living wills allow for a few days of a "trial of therapy," that is all treatments, including CPR and breathing machines are used until it becomes clearer whether the patient is terminal. Some patients, however, do not want CPR or breathing machines under any circumstances, even if their illness can be treated. The only way not to receive CPR or mechanical ventilation is to write in words to the effect: "I do not want CPR (and/or mechanical ventilation) under any circumstances, even if I have a condition that can be made better; instead, let me pass away."
Each state has its own living will/advance directives statutes. Accordingly, we present a list of web-based resources to help in writing your directives. This list was last updated in December 2007. Laws vary slightly between states and may evolve with time, so it is important to ensure that your living will is updated periodically to coincide with your state’s laws.
Family Members or Loved Ones as Substitute Decision-Makers
Unless a patient has asked the hospital staff not to share information with relatives, the staff tries to reach family members of critically ill patients and keep them updated on the patient's condition. If a patient is not able to state their wishes and does not have a living will, the doctor can ask family members whether a patient had made his or her wishes known before the illness. There are formal methods of picking a family member or other loved ones to make decisions for you if you become too sick to be able to do it for yourself.
Health Care Proxy often called “Healthcare Power of Attorney” or “Healthcare Agent:” A legal document can be written with or without a lawyer in which you can pick someone who will be allowed to make medical decisions for you if you are not able to make them on your own.
Note: This document is for general informational purposes only. It is not intended as and should not be relied on for medical advice. Please consult with the doctor providing treatment regarding any questions or concerns that you may have related to your (or your loved one's) care. The sample forms attached to this document were reproduced here with the permission of the State of Connecticut Attorney General's office. It is not intended as legal advice, but as an example of a document which can be used in the State of Connecticut to create written advanced directives. Different states have different requirements and the sample must be adapted to particular facts and circumstances of a situation and to state law. Please consult an attorney regarding any legal questions that you might have.
When there is no living will or health care agent and a patient has not made his or her wishes known to loved ones or doctors, family members in some states may be left to make these most difficult decisions. In some other states, however, family members may have to go to court to get permission to make these decisions. Whenever possible, all patients should try to make their wishes known to loved ones and make a legal document stating these wishes. In cases where family members have to make decisions, it can be very difficult because they also have to deal with the patient's sickness and possible death. Many family members are very uncomfortable about having to make these decisions. Furthermore, many family members are very reluctant to agree to take away machines or treatments that are maintaining the heart or lungs, even when things look hopeless, because they feel they would be responsible for causing the death of their relative. However, it is very important for family members left in this situation to think carefully about what their loved one, the patient, would want done. The best way to “honor the person” is to consider what he or she would say if they were there, hearing the doctors’ opinions, and making decisions for themselves. But, the best way to avoid causing such pain and guilt for family members is to talk about these issues before becoming ill and to create advance directives. Then your directive speaks for you when you can’t speak for yourself.