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Advance Healthcare Directives

(Please read The Most Important Conversations page first)

Your advance directive is the way you tell the medical world and your family what your wishes are at the end of life. 

All states authorize an advance directive, or its precursor, the living will combined with a power of attorney for health care (which is really what an advance directive is; the term advance directive will be used here). There are no limitations on the content of an advance directive. Your wish might be that all heroic efforts be brought to bear keep you alive. At the other extreme you can say you want your life to end under certain circumstances. In between these extremes you can say you want no heroic efforts – let you die a natural death or that you don’t want to be resuscitated or intubated (fed by tube). Or that you do want all medical treatments (heroic efforts), but if it appears after a reasonable time that such efforts are not going to restore you to some level of health (which you specify), then stop such efforts, and let you die a natural death. In The Most Important Conversations there are some references that will help you sort things out. 

DocumentsPhoto.jpgThe most important section of your advance directive is the one in which you appoint someone to speak for you when you can’t speak for yourself – called your agent, or proxy. It’s good idea to appoint someone who lives near you, which means your agent may not be a family member. The reason is the person needs to be with you as soon as possible when you are so ill you can’t speak for yourself. 

And, as discussed under The Most Important Conversations you need to have an in depth conversation with this person before designating him or her.

While you can say just about anything you want in an advance directive, there are strict rules about how to execute it. Unfortunately, these rules vary from state to state. A few states require a specific form to be used. A few states require you to use its mandated form, but you can add to it or modify it. There is no federal law in this regard in part because U.S. Supreme Court decisions basically say controlling dying is a state issue (e.g., Vacco v. Quill, 521 U.S.  703 (1997)).

Typically, your advance directive needs to be officially notarized or be witnessed by two persons. If witnessed, be aware that some states have extensive limitations as to who can be witnesses. To find out the execution requirements of your state, do an internet search for “advance directive form for [your state]” or go to one of these websites:

Most people choose to follow a standardized form, either state-specific or generic. To find generic ones, do the web search just mentioned but leave off your state. In some states, such as California, the form is specified in the law (but need not be used except as to method of execution, as just discussed). A form for your state can be found at the web sites above. A very popular (but not necessarily the best) non-state-specific form is Five Wishes, which gives information on each state’s method of finalization. 

A typical form provides options for “do not resuscitate” and other medical procedures. A few forms don’t refer to medical procedures but instead focus on quality of life. For such a form, go to The author of this site is a member of Conscious Elders Network and developed the form in consultation with hospice doctors and nurses. 

There can be subtle and not-so-subtle differences in the forms. For example, the second wish in Five Wishes says that “I do not want anything done or omitted by my doctors or nurses with the intention of taking my life.”  That’s fine if that’s your wish, especially if it reflects your religious view (Five Wishes is written by Aging with Dignity, a Catholic-connected organization).   In fact, doctors do make decisions that have the effect of taking the patient’s life. This is done in the guise of pain relief (death is a “secondary” or indirect effect). Typically such treatments are compassionate and supported by the patient (if still competent) and/or the family. If this language is not your wish, or if you think your agent/proxy should make this kind of decision rather than you in advance, don’t use such language. In short, read any standard form very carefully to be sure you agree with its printed provisions.  Cross out and initial any you don’t agree with.