Advance Medical Directives

Advance directives are documents that discuss treatment preferences a patient may choose if they become unable to make medical decisions on their own.

Autonomy is a pillar of medical ethics. Patients have the right to make informed decisions about their medical care. This involves obtaining consent before procedures or treatment can take place. It assumes the patient is competent to decide.

In some cases, especially near the end of life, patients may not understand their situation and make decisions. Advance medical directives provide guidance to family and caregivers when the patient cannot decide.

Please note that advance medical directives may vary by state and country. Healthcare providers, hospitals, and attorneys can assist with information and provide necessary forms to help patients express their care wishes.

What are advance medical directives?

Advance directives discuss treatment preferences a patient may choose if they become unable to make medical decisions on their own. The documents may also name a proxy to make decisions and act on the patient’s behalf.

The most common types of advance medical directives are the living will and the power of attorney for healthcare.

Living will (POLST: physician orders for life-sustaining treatment)

A living will specifies desired medical treatments if the individual becomes incapacitated. It is usually activated when death is near.

A typical beginning statement of the living will may be:

"If I have an incurable, irreversible illness, disease, or condition and my attending physician determines that my condition is terminal, I direct that life-sustaining measures that would only prolong my dying be withheld or discontinued."

The document discusses specific acceptable or unacceptable treatments, including a "do not resuscitate" order. For example, the patient may choose not to receive CPR or artificial breathing.

The living will can also address:

• IV fluids if the patient cannot drink.
• Feeding tubes if the patient cannot eat or swallow.
• Antibiotics for infection.
• Life support machines to maintain blood pressure, breathing, or kidney function.

The living will is typically signed by the patient, healthcare provider, and often a family member and witness. Copies are kept in the patient’s medical record, healthcare provider’s office, and given to the proxy.

If the patient’s health or understanding changes, the living will terms may be modified. Healthcare providers will seek clarification from family or friends if the patient’s choices have been recently reconsidered. Otherwise, providers will follow the patient’s written guidance.

Power of Attorney for Healthcare (health care proxy)

A power of attorney for healthcare designates another person to make decisions if the individual becomes incapable. The designated person has the same rights to request or refuse treatment. Activation usually requires evaluation by two physicians.

What is the importance of advance medical directives?

Advance medical directives address concerns about unwanted treatments or procedures that aim to preserve life at any cost. They allow patients to decide on their care when they cannot express their decisions. This reduces the burden on family and healthcare providers while preserving patient autonomy and dignity.

Advance medical directives are completed while a patient has decision-making capacity. They become effective when the patient loses capacity or cannot communicate. If the patient regains decision-making ability, the proxy’s authority is revoked.

When are advance medical directives used?

Advance medical directives are used when a patient cannot make health care decisions due to injury, illness, or incapacitation. Prior to that, the patient has the ultimate authority.

Examples of situations where advance medical directives provide guidance include:

• Critical illness affecting mental capacity.
• Coma.
• Severe brain injury.
• Stroke.
• Advanced Alzheimer’s disease or dementia.
• Persistent vegetative state.

Advance medical directives can also help overwhelmed patients decide whether to accept or decline treatment. Thinking about medical decisions outside of a crisis can clarify care goals.

How to prepare advance medical directive forms

Advance medical directives can be written at any time and modified as circumstances change. Discussion with healthcare providers and family is crucial to ensure understanding and clear decision-making.

Advance medical directive documents are available online and elsewhere. However, they are more than just documents. They require thoughtful consideration of implications and open conversations.

Selecting a healthcare proxy is an important decision. It does not have to be a family member; anyone the patient trusts to act in their best interests can be designated.

Talking about terminal illnesses and end-of-life care is difficult but important. Even with proper documentation, family members and caregivers need to understand the patient’s preferences and know where the documents are located in emergencies.

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Montanari VG. Advance Healthcare Directives: Binding or Informational Value? Cambridge Quarterly of Healthcare Ethics. 2020. 29(1):98-109

Montanari VG. Advance Healthcare Directives: Binding or Informational Value? Cambridge Quarterly of Healthcare Ethics. 2020. 29(1):98-109