Advance Directives and Do Not Resuscitate (DNR) Orders

What is an advance directive?

An advance directive is a legal document. It tells your doctor and family what kind of medical care you want to have if you can’t tell them yourself. This could happen if you:

• Are in a coma.
• Are seriously injured.
• Are terminally ill.
• Have severe dementia.

If you are admitted to the hospital, the hospital staff will probably talk to you about advance directives.

Path to improved well being

A good advance directive describes the kind of treatment you would want, depending on how sick you are. It could describe what kind of care you want if you have an illness that you are unlikely to recover from. It could also describe the care you want if you are permanently unconscious. Advance directives usually tell your doctor that you don’t want certain kinds of treatment. They can also say that you want a certain treatment no matter how ill you are.

Types of advance directives

Advance directives could include:

Living will

A living will is one type of advance directive. It is a written, legal document. It describes the treatments you would want if you were terminally ill or permanently unconscious. These could be medical treatments or treatments that will help you live longer. A living will doesn’t let you select someone to make decisions for you.

Durable power of attorney for health care

A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom you have chosen to make health care decisions for you. It becomes active any time you are unconscious or unable to make medical decisions (and may be called Medical Power of Attorney, or MPOA). A DPA is generally more useful than a living will. But a DPA may not be a good choice if you don’t have another person you trust to make these decisions for you.

Laws about advance directives are different in each state. Living wills and DPAs are legal in most states. The law in your state may not officially recognize these advance directives. But they can still guide your loved ones and doctor if you are unable to make decisions about your medical care. Ask your doctor, lawyer, or state representative about the laws in your state.

Physician orders for life-sustaining treatment (POLST)

A POLST is for people who have been diagnosed with a serious illness. A doctor fills out the form. It doesn’t replace your other advance directives. Instead, it stays with you to ensure you get the medical treatment you want.

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.

Should I have an advance directive?

Creating an advance directive is a good idea. It makes your preferences about medical care known before you’re faced with a serious injury or illness. This will spare your loved ones the stress of making decisions about your care while you are sick. Any person 18 years of age or older can prepare an advance directive.

People who are seriously or terminally ill are more likely to have an advance directive. For example, someone who has terminal cancer might write that they do not want to be put on a respirator if they stop breathing. This action can reduce their suffering. It can increase their peace of mind and give them more control over their death.

Even if you are in good health, you might want to consider writing an advance directive. An accident or serious illness can happen suddenly. If you already have a signed advance directive, your wishes are more likely to be followed.

How can I write an advance directive?

You can write an advance directive in several ways:

• Use a form provided by your doctor.
• Write your wishes down by yourself.
• Call your health department or state department on aging to get a form.
• Call a lawyer.
• Use a computer software package for legal documents.

Advance directives and living wills do not have to be complicated documents. They can be short, simple statements about what you want done or not done. Remember, anything you write by yourself or with a computer software package should follow your state laws. You may also want your doctor or a lawyer to review what you have written. They can make sure your directives are understood exactly as you intended. When you are satisfied with your directives, have the orders notarized. Then give copies to your family and your doctor.

Things to consider

Can I change my advance directive?

You may change or cancel your advance directive at any time, as long as you are of sound mind to do so. This means you can think rationally and communicate your wishes clearly. Again, your changes must be made, signed, and notarized according to the laws in your state. Make sure that your doctor and family members are aware of the changes.

If you change your mind, you can also make your changes known while you are in the hospital. Tell your doctor and any family or friends who are present exactly what you want to happen. Usually, wishes that are made in person will be followed in place of the ones made earlier in writing. Be sure your instructions are clearly understood by everyone you have told.

Questions to ask your doctor

• I’m not sick. Do I need an advance directive?
• What kinds of things should I include in my advance directive?
• How do I go about getting a DNR order?
• Do I have to pay a lawyer to draw up an advance directive?
• What happens if I change my mind on the kind of care I want to receive?

Resources

National Institute on Aging, Advance Care Planning: Healthcare Directives

U.S. National Library of Medicine: Advance Directives