What is a Living Will? Understanding Your Healthcare Choices

Planning for your future healthcare is one of the most considerate actions you can take for yourself and your loved ones. While it might seem daunting to think about medical decisions when you are unable to make them yourself, having a plan in place ensures your wishes are honored and alleviates stress for your family during challenging times. Among the essential tools for this planning are living wills and advance directives. These legal documents communicate your preferences for medical care should you become incapacitated due to severe illness or injury.

It’s a common misconception that advance care planning is only relevant to older adults. However, unexpected health crises can occur at any age. Creating these documents is a proactive step every adult can take to ensure they receive the medical care they desire, avoid unnecessary suffering, and provide clear guidance for their caregivers. By making these decisions in advance, you minimize potential confusion and disagreements among family members about your healthcare wishes.

What is a Living Will?

A living will is a formal, written legal document that outlines your specific instructions regarding medical treatment, particularly concerning life-sustaining procedures. It details the types of medical treatments you would consent to or refuse if you were diagnosed with a terminal condition or were permanently unconscious and unable to communicate your decisions.

Think of a living will as your voice when you are unable to speak for yourself. It allows you to express your values and preferences regarding various medical interventions. When drafting your living will, consider what aspects of life are most important to you. For instance, reflect on your desired level of independence and self-sufficiency. What circumstances might make you feel that prolonging life would not align with your values?

A comprehensive living will should address several critical end-of-life care decisions. It’s beneficial to discuss these points with your physician to gain a clearer understanding of the implications of each choice:

Cardiopulmonary Resuscitation (CPR): CPR is an emergency procedure to restart the heart and breathing when they have stopped. Your living will should specify under what conditions you would want CPR or electric shock therapy to be used.
Mechanical Ventilation: A ventilator takes over the breathing process if you are unable to breathe independently. Your directive should indicate if, when, and for how long you would want to be placed on mechanical ventilation.
Tube Feeding (Artificial Nutrition and Hydration): This involves providing nutrients and fluids intravenously or through a tube inserted into the stomach. Your living will should state your preferences regarding tube feeding, including the circumstances and duration for which you would want this intervention.
Dialysis: Dialysis is a treatment to filter waste products from the blood and manage fluid balance when the kidneys fail. Decide and document in your living will if, when, and for how long you would want to receive dialysis.
Antibiotics or Antiviral Medications: These medications treat infections. Consider whether you would want infections aggressively treated if you were nearing the end of life, or if you would prefer to allow natural processes to take their course.
Comfort Care (Palliative Care): Palliative care focuses on maximizing comfort and managing pain while respecting your other medical treatment wishes. This can encompass a range of interventions, such as pain medication, allowing death at home, providing ice chips for mouth dryness, and forgoing invasive procedures or tests.
Organ and Tissue Donation: Your living will can specify your desire to donate organs and tissues for transplantation. It’s important to note that if you choose organ donation, you will be maintained on life support temporarily until the donation procedure is completed. Clarifying your understanding of this temporary intervention in your living will can prevent confusion for your healthcare agent.
Body Donation for Scientific Study: You can also express your wish to donate your body to science in your living will. Contact local medical schools, universities, or donation programs to register for planned body donation for research purposes.

Alt text: Healthcare professional explaining living will document to patient, emphasizing informed medical decisions and advance care planning.

Living Will vs. Medical Power of Attorney

While a living will outlines your specific healthcare instructions for particular situations, a medical power of attorney (also known as a healthcare proxy or healthcare agent in some states) is another type of advance directive that appoints a person to make medical decisions on your behalf when you are unable to do so.

The key difference lies in their function. A living will provides direct instructions for specific medical scenarios, whereas a medical power of attorney designates a trusted individual to interpret your wishes and make broader healthcare decisions in situations that may not be explicitly covered in your living will.

The person you appoint as your healthcare agent should be someone you trust implicitly to understand your values and make choices aligned with your preferences. This person will act as your voice in situations where unforeseen medical complexities arise, requiring judgment and interpretation of your likely wishes.

When choosing a healthcare agent, consider the following criteria:

State Requirements: Ensure the person meets your state’s legal requirements to serve as a healthcare agent.
Not Your Doctor: Your healthcare agent should not be your physician or part of your direct medical care team to avoid conflicts of interest.
Willingness to Discuss End-of-Life Issues: Choose someone open to discussing sensitive topics related to medical care and end-of-life wishes.
Respect for Your Values: Select an individual who can be trusted to make decisions that honor your values and preferences, even if they differ from their own.
Advocacy Skills: Your healthcare agent should be capable of advocating for your wishes, especially if disagreements arise regarding your care.

Your healthcare agent can be a spouse, family member, close friend, or a member of your faith community. It’s also advisable to name one or more alternate agents in case your primary choice is unable to fulfill the role.

Do Not Resuscitate (DNR) and Do Not Intubate (DNI) Orders

You can also establish Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. These are specific medical orders written by your doctor that instruct healthcare providers not to perform CPR (DNR) or intubation (DNI) if your heart stops or you stop breathing.

While your living will can include your preferences regarding resuscitation and intubation, DNR and DNI orders are distinct in that they are direct medical orders placed in your medical record by your physician. To establish DNR or DNI orders, you need to discuss your wishes with your doctor, who will then write the orders if they align with your medical condition and wishes.

Even if you have a living will, it is still recommended to establish DNR or DNI orders whenever you are admitted to a hospital or healthcare facility to ensure your immediate wishes are clearly documented and readily accessible to medical staff.

Creating Your Living Will and Advance Directives

Advance directives, including living wills and medical power of attorney documents, must be in writing to be legally valid. The specific forms and legal requirements for creating these documents vary by state. Some states may require witness signatures or notarization.

While legal assistance is available, it is generally not mandatory to involve a lawyer in creating your advance directives. Numerous resources offer state-specific forms and guidance, such as the American Bar Association, AARP, and the National Hospice and Palliative Care Organization.

Once you have drafted your advance directives, it’s crucial to review them with your doctor and your chosen healthcare agent to ensure they are correctly completed and accurately reflect your wishes. After finalizing your documents, take these essential steps:

Store Originals Safely: Keep the original documents in a secure but easily accessible location, where they can be found when needed.
Provide Copies to Your Doctor: Give a copy of your advance directives to your primary care physician to include in your medical records.
Share with Your Healthcare Agent: Provide copies to your healthcare agent and any alternate agents, so they are aware of your wishes and have the necessary documentation.
Keep a Record of Distribution: Maintain a list of individuals who have copies of your advance directives for easy reference.
Discuss with Loved Ones: Have open conversations with family members and other significant people in your life about your advance directives and healthcare wishes. These discussions ensure they understand your preferences, minimizing potential conflicts and guilt during difficult times.
Carry a Wallet Card: Carry a wallet-sized card indicating that you have advance directives, identifying your healthcare agent, and stating where copies of your directives can be located. This is especially useful in emergency situations.
Take Copies When Traveling: Keep copies of your advance directives with you when traveling, particularly for extended trips.

Reviewing and Updating Your Advance Directives

Your healthcare wishes may evolve over time, and it’s essential to review and update your advance directives periodically. You can change or revoke your directives at any point. To make changes, you must create a new document, distribute new copies, and destroy all old copies to avoid confusion. State-specific regulations may apply to amending directives.

It’s advisable to discuss any changes with your primary care physician to ensure your medical file is updated with the most current directive. New directives should also be added to your medical chart if you are admitted to a hospital or nursing home. Furthermore, communicate any updates to your healthcare agent, family, and friends.

Consider reviewing and revising your advance directives in the following circumstances:

New Diagnosis: A diagnosis of a serious, chronic, or terminal illness can significantly alter your perspectives on medical treatment. Discuss potential care decisions related to the disease’s progression with your doctor and adjust your living will accordingly.
Change in Marital Status: Marriage, divorce, separation, or becoming widowed may necessitate selecting a new healthcare agent.
Periodic Review (Every 5-10 Years): Even without major life events, regularly review your directives, ideally every 5 to 10 years, to ensure they continue to reflect your current values and healthcare preferences.

Physician Orders for Life-Sustaining Treatment (POLST)

In some states, Physician Orders for Life-Sustaining Treatment (POLST), also known as MOLST or provider orders for life-sustaining treatment, are used in conjunction with advance directives. A POLST form is specifically designed for individuals with serious illnesses.

Unlike advance directives, which are general guides, a POLST is a doctor’s order set based on your current health status and treatment preferences. It translates your wishes from your advance directives into actionable medical orders. Your physician completes the POLST form based on discussions with you about your illness, prognosis, and treatment choices.

A POLST form is portable and travels with you. If you are hospitalized or in a nursing facility, it is prominently displayed. At home or in hospice care, it should be readily accessible to emergency medical personnel and healthcare providers.

POLST forms vary by state but generally include details about:

Resuscitation preferences
Mechanical ventilation
Tube feeding
Antibiotic use
Preferences regarding hospital transfer or admission
Pain management

The POLST form also indicates the existence of your advance directives and identifies your healthcare agent. Like advance directives, POLSTs can be updated or canceled as your health condition or wishes change.

By proactively engaging in advance care planning and creating a living will, you empower yourself to make informed decisions about your future healthcare, ensuring your wishes are respected and providing invaluable peace of mind for both you and your loved ones.

References

AskMayoExpert. Advance directives. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017.
AskMayoExpert. Do not resuscitate/do not intubate order. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2016.
Advance care planning: Healthcare directives. National Institute on Aging. https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives. Accessed Nov. 17, 2018.
Give peace of mind: Advance care planning. Centers for Disease Control and Prevention. https://www.cdc.gov/aging/advancecareplanning/. Accessed Nov. 17, 2018.
Frequently asked questions: Advance directives. American Cancer Society. https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-financial-and-legal-matters/advance-directives/faqs.html. Accessed Nov. 19, 2018.
Toolkit for health care advance planning. American Bar Association. https://www.americanbar.org/groups/law_aging/resources/health_care_decision_making/consumer_s_toolkit_for_health_care_advance_planning.html. Accessed Oct. 2, 2018.
Myths and facts about health care advance directives. American Bar Association. https://www.americanbar.org/publications/bifocal/vol_37/issue_1_october2015/myths_and_facts_advance_directives.html. Accessed Oct. 2, 2018.
Living wills, health care proxies, & advance health care directives. American Bar Association. https://www.americanbar.org/groups/real_property_trust_estate/resources/estate_planning/living_wills_health_care_proxies_advance_health_care_directives.html. Accessed Oct. 2, 2018.
POLST for professionals. National POLST Paradigm. http://polst.org/professionals-page/?pro=1. Accessed Nov. 19, 2018.
Patient FAQs. National POLST Paradigm. http://polst.org/faq/?pro=1. Accessed Nov. 19, 2018.