Advance directives could include:
Living will
A living will is a written, legal paper, called a document, that
includes details about the medical treatments you would and would not
want to be used to keep you alive. It's used when you are unable to
decide yourself. It also includes your choices for other medical
decisions, such as pain management or organ donation.
In deciding your wishes, think about your values. For example, think
about how important it is to you to be independent and self-sufficient.
Think about what situations might make you feel like your life is not
worth living. Would you want treatment to extend your life in any
situation or in all situations? Would you want treatment only if a cure
is possible?
You should list many possible end-of-life care decisions in your living
will. Talk to your healthcare professional about any questions you may
have about the following medical decisions:
-
Cardiopulmonary resuscitation (CPR). CPR restarts the heart
when it has stopped beating. Decide if and when you would want to be
revived by CPR or by a device that sends an electric shock to shock
the heart.
-
Pacemakers and implantable cardioverter defibrillators (ICDs). A
pacemaker keeps your heart beating steadily, while an ICD shocks
your heart if it beats irregularly. If you have one of these
devices, decide when you would want it to be turned off.
-
Mechanical ventilation. A machine that helps you breathe is
called a mechanical ventilator. It takes over your breathing if
you're unable to breathe on your own. Think about if, when and for
how long you would want a medical team to place you on a machine to
help you breathe.
-
Tube feeding. Tube feeding gives nutrients and fluids to
the body through a tube inserted in a vein or in the stomach. Decide
if, when and for how long you would want a medical team to feed you
in this way.
-
Dialysis. This process removes waste from the blood and
manages fluid levels if the kidneys no longer work. Decide if, when
and for how long you would want to receive this treatment.
-
Antibiotics or antiviral medications. Healthcare
professionals can use these medicines to treat many infections.
Think about if you were near the end of life. Would you want a
medical team to treat infections with many medicines, or would you
rather let infections run their course?
-
Comfort care, also called palliative care. Comfort care
includes many treatments that a medical team may use to keep you
comfortable and manage pain while following your other treatment
wishes. Treatment wishes may include choosing to die at home,
getting pain medicines or being fed ice chips to soothe mouth
dryness. It also may include avoiding invasive tests or treatments.
-
Organ and tissue donations. You can note if you plan to
donate organs or tissues in your living will. If the medical team
removes the organs for donation, they will keep you on treatment
that will keep you alive, called life-sustaining treatment, for a
brief time until the team has removed the organs. To avoid any
confusion from your healthcare agent, you may want to state in your
living will that you understand the need for this short-term
treatment.
-
Donating your body. You can state if you want to donate
your body to scientific study. Call a local medical school,
university or donation program for information on how to register
for a planned donation for research.
Durable power of attorney for health
care
A medical or healthcare power of attorney is a type of advance directive
in which you name a person to make healthcare decisions for you when you
are unable to do so. In some states this directive also may be called a
durable power of attorney for healthcare or a healthcare proxy.
Depending on where you live, the person you choose to make healthcare
decisions on your behalf may be called one of the following:
- Healthcare agent.
- Healthcare proxy.
- Healthcare surrogate.
- Healthcare representative.
- Healthcare attorney-in-fact.
- Patient advocate.
Choosing a person to act as your healthcare agent is important. Even if
you have other legal papers about your care, you can't anticipate all
situations ahead of time, such as emergencies and illnesses. And in some
situations, someone will need to decide about your likely care wishes.
Aim to choose a person who:
- Meets your state's requirements for a healthcare agent.
- Is not your healthcare professional or a part of your medical care
team.
- Is willing and able to discuss medical care and end-of-life issues
with you.
- Can make decisions that follow your wishes and values.
- Can speak up for you if there are disagreements about your care.
The person you name may be a spouse, other family member, friend or
member of a faith community. You also may choose one or more other
people in case the person you chose is unable to fulfill the role.
Physician orders for life-sustaining
treatment (POLST)
In some states, advance healthcare planning includes a document called
physician orders for life-sustaining treatment (POLST). This document
also may be called provider orders for life-sustaining treatment (POLST)
or medical orders for life-sustaining treatment (MOLST).
A POLST is meant for people who are diagnosed with a serious illness.
This form doesn't replace your other directives. Instead, it serves as
healthcare professional-ordered instructions — not unlike a
prescription. A POLST ensures that, in case of an emergency, you get the
treatment you prefer. Your healthcare professional will fill out the
form. To fill out the form, your healthcare professional will use the
information in your advance directives, the talks you have with your
healthcare professional about the likely course of your illness and your
treatment preferences.
A POLST stays with you. If you are in a hospital or nursing home, staff
post the POLST near your bed. If you are living at home or in a hospice
care facility, staff clearly place the POLST where emergency staff or
other medical team members can easily find it.
Forms vary by state, but a POLST lets your healthcare professional
include details about your care. These details can include what
treatments a medical team should not use, under what conditions a
medical team can use some treatments, how long a medical team may use
some treatments and when the medical team should stop treatments.
Issues
covered in a POLST may include:
- Resuscitation.
- Mechanical ventilation.
- Tube feeding.
- Use of antibiotics.
- Requests not to transfer to an emergency room.
- Requests not to be admitted to the hospital.
- Pain management.
A POLST also states what advance directives you have written and who
serves as your healthcare power of attorney. Like advance directives,
you can cancel or update POLSTs.
Do not resuscitate (DNR) order
A do-not-resuscitate (DNR) order can also be part of an advance
directive. Hospital staff try to help any patient whose heart has
stopped or who has stopped breathing. They do this with cardiopulmonary
resuscitation (CPR). A DNR order is a request not to have CPR if
your heart stops or if you stop breathing. You can use an advance
directive form or tell your doctor that you don’t want to be
resuscitated. Your doctor will put the DNR order in your medical chart.
Doctors and hospitals in all states accept DNR orders. They do not have
to be part of a living will or other advance directive.
Other possible end-of-life issues that may be covered in an advance
directive include:
-
Ventilation – if, and for how long, you want a machine to
take over your breathing.
-
Tube feeding – if, and for how long, you want to be fed
through a tube in your stomach or through an IV.
-
Palliative care (comfort care) – keeps you comfortable and
manages pain. This could include receiving pain medicine or dying at
home.
-
Organ donation – specifying if you want to donate your
organs, tissues, or body for other patients or for research.
Do not intubate (DNI) order
A Do Not Intubate (DNI) Order is a medical order written
by a doctor indicating that intubation and mechanical
ventilation should not be performed if a patient experiences
respiratory failure. This order is intended to prevent
unwanted or unnecessary invasive respiratory support.
A DNI order is often used in conjunction with a Do Not
Resuscitate (DNR) order, but it specifically addresses the
use of breathing tubes and ventilators. As a result, some
healthcare systems use the term Do Not Ventilate (DNV)
interchangeably with DNI.
The decision to create a DNI order typically results from
discussions between the doctor and patient (or patient’s
Medical Power of Attorney). This order can be revoked at any
time by the patient if they are mentally competent or by
their Medical Power of Attorney.
Do not hospitalize (DNH) order
A Do Not Hospitalize (DNH) Order is a medical order that
instructs healthcare providers not to transfer a patient to
a hospital for treatment, even if their condition worsens.
This order is typically used for individuals in long-term
care facilities or receiving end-of-life care at home who
prefer to avoid hospital-based interventions.
A DNH order does not mean the patient will receive no care.
Instead, it indicates that care will be provided in their
current setting, focusing on comfort and symptom management
rather than curative treatments that would require
hospitalization.
Out-of-hospital DNR order
An Out-of-Hospital Do Not Resuscitate (OOH-DNR) Order is
a medical order that instructs emergency medical services
(EMS) and other healthcare providers not to attempt
cardiopulmonary resuscitation (CPR) on a person outside of a
hospital setting. Also known as a Prehospital DNR or EMS-DNR,
this order ensures a person’s wishes regarding resuscitation
are respected in community settings.
An OOH-DNR requires a physician’s signature and may involve
special identifiers like bracelets or necklaces. It can be
part of a broader Advance Directive or POLST form. While it
prevents CPR, other forms of care and comfort measures are
still provided.
Implementation varies by jurisdiction, so consult healthcare
providers or legal professionals for specific guidance.