Trusts & Estates
March 24, 2022
Advance Healthcare Directives: Document Your Wishes
According to the National Institute on Aging, people who document their emergency medical wishes through advance healthcare directives1 are more likely to get the end-of-life care they want than people who do not.2
What is an advance healthcare directive?
An advance healthcare directive is a legal document that communicates your treatment preferences and end-of-life wishes to healthcare providers when you are unable to speak for yourself. The most common are the living will and healthcare power of attorney (POA), but there are other advance healthcare directives that address specific situations. Advance healthcare directives are governed by state law and often go by different names in different states. Not all types are recognized by every state.
What are the benefits of having an advance healthcare directive?
Along with a current will, a revokable trust and a financial POA, an advance healthcare directive is an essential component of a comprehensive estate plan. In addition to providing the peace of mind that comes from knowing your wishes will be respected, an advance healthcare directive relieves your loved ones of the burden of making life-or-death decisions on your behalf without clear authority or guidance.
Which advance healthcare directives do I need?
At a minimum, every adult should have a current living will and healthcare POA.
Living will: The master advance healthcare directive
A living will dictates to healthcare providers which medical interventions you do and do not want if you are dying and unable to communicate your wishes. A living will typically includes:
- A statement that you do not want life-prolonging procedures administered if there is no probability you will survive.
- Specific directions about what care you do or do not want and the conditions under which your choices would apply. Common treatment options include dialysis, life support, ventilation, feeding tubes, artificial hydration and CPR.
- Organ and tissue donation instructions, if applicable.
- Palliative care decisions, such as dying at home, pain management or avoiding invasive procedures.
- Any spiritual and religious considerations.
Healthcare POA: Empowering your healthcare surrogate
A healthcare POA is a legal document authorizing another person to make medical decisions for you if you are unable to do so. That person may be called your agent, attorney-in-fact, healthcare proxy, patient advocate or something similar, depending on your state law. Your healthcare POA also identifies alternate choices if your primary agent is not available to fulfill their duties.
While a living will addresses terminal situations, your healthcare POA kicks in any time you are unable to participate in your medical decision-making. Since your agent takes an active role in determining your care and treatment options, it is important to select someone you trust, who is familiar with your wishes and who is willing to assume this responsibility.
What other advance healthcare directives should I consider?
In addition to a living will and healthcare POA, you might need additional advance healthcare directives to address specific circumstances or chronic medical conditions. The most common are summarized below.
Do not resuscitate (DNR)
A DNR directive tells hospital or nursing facility staff that you do not want them to perform CPR or other life-support measures. Even if your living will states you do not want CPR, a DNR provides an additional layer of assurance. In an emergency, hospital staff will make every effort to restore normal heart rhythms, and they may not have the time to consult a living will. A DNR attached to your hospital chart or posted next to your bed can clear up any confusion about your wishes.
Do not intubate (DNI)
Like the DNR, a DNI directive tells medical staff in a hospital or nursing care facility that you do not want to be put on a breathing machine.
A nonhospital DNR directive covers emergency treatment in noninstitutional settings such as your home or a public venue. It tells emergency medical technicians, paramedics and first responders that you do not want them to perform CPR or other life support measures. If you execute a nonhospital DNR, be sure to carry it with you when you leave your home.
Portable medical orders for advanced illness
A Physician Orders for Life-Sustaining Treatment (POLST) form is a legal document designed for people with serious progressive illnesses or advanced frailty. Different states use different names for these forms, including POST, MOLST and MOST. A POLST supplements, but does not replace, a living will. While a living will communicates your end-of-life care preferences in a variety of hypothetical situations, the POLST is a medical order about the use of life-sustaining interventions likely to arise in the context of your specific illness.
You doctor fills out the POLST form after a comprehensive discussion about your medical status, what to expect in the future, your values and goals for care and the risks and benefits of various treatment options. Once you and your doctor sign the form, the POLST becomes an out-of-hospital medical order that instructs all healthcare providers on what treatments you do and do not want.
POLSTs are portable and in force wherever you receive care. Most states will recognize a valid POLST from another state, but it is a good idea to carry both your living will and your POLST with you when you travel.
Medical release of information (HIPAA release form)
This gives your doctor prior authorization to share medical information with persons you have identified in writing. You may want to include your healthcare agent, financial POA, caregivers or other advisors who help manage your medical affairs. If there is a question about a bill or an insurance claim, they may not be able to get the information they need without your prior authorization.
You will need a separate HIPAA (Health Insurance Portability and Accountability Act) release form for each of your medical providers. Medicare provides a prior authorization form that lets members name persons or third parties who may have access to their personal account information.
Hospital visitation form
This allows nonfamily members to visit you in the hospital. The visitation form may be important if you are in a domestic partnership, are not legally married or have friends you want to have visitation rights.
How do I set up advance healthcare directives?
Once you have decided which types of directives will best protect your care preferences and end-of-life wishes, discuss your options with your attorney and execute the appropriate documents in accordance with applicable state laws. If you have seasonal residences or routinely seek out-of-state medical care, you may need to execute advance healthcare directives in multiple states.
Who should have copies of my advance healthcare directives?
At a minimum, your agent and alternates, your doctor and your hospital or care facility should have a copy of your living will and your healthcare POA. Your attorney should maintain a copy of all advance directives. If you are admitted to a hospital or other care facility, ask them to put a copy of all your advance healthcare directives in your chart, including your DNR/DNI, if applicable.
Where should I keep my advance healthcare directives?
Keep the original documents in a secure place in your home. Be sure your agent, family and advisors know where to find them in case of an emergency, since some hospitals and providers may require originals. Advance healthcare directives such as a DNR/DNI or POLST should be carried on your person whenever you leave your home. You might also carry a card with your agent’s name and contact information and a list of the advance healthcare directives you have and where you keep them. The American Hospital Association has an advance directive wallet card you can download here and print.
When should I update my advance healthcare directives?
As with any estate planning document or beneficiary designations, you should periodically review your advance healthcare directives to be sure they still reflect your circumstances and wishes. The American Bar Association Commission on Law and Aging suggests you do so whenever one of the following events occurs3:
- You start each new decade of your life.
- You experience the death of a loved one.
- You experience a divorce or other major family change. In some states, a divorce may revoke the authority of a spouse who had been named as a healthcare agent.
- You are diagnosed with a serious medical condition.
- You experience a significant decline in your health or your ability to live independently.
How do I make changes to an advance healthcare directive?
To change one or more of your advance healthcare directives, ask your attorney to prepare a new document in accordance with current state law. Discuss the updates with your doctor, loved ones and healthcare agent to be sure everyone is clear on what has changed.
Old directives should be destroyed. A copy of the new advance directive should be distributed as appropriate and filed with your doctor, hospital and assisted living facility or nursing home as part of your permanent medical record.
Advance healthcare directives are powerful tools that set the terms for how you want to live and die. Contemplating end-of-life care and clarifying treatment preferences can take time, which is why early engagement with family, friends and trusted advisors is critical. We urge you to reach out for support and leverage the experience and expertise a firm like Glenmede provides.
1 Some states use the term “advance directive” to refer to a document that combines the living will and healthcare POA. Here we use the term “advance healthcare directives” to refer to all types of documents to avoid confusion with the shorter designation.
2 U.S. Department of Health and Human Services. National Institute on Aging/National Institutes of Health. Advance Care Planning: Health Care Directives. https://www.nia.nih.gov/health/advance-care-planning-health-care-directives. Accessed Nov. 1, 2021.
3 Harvard Health Publishing. Keep Your Health Care Directives Up to Date. Jan. 17, 2018. https://www.health.harvard.edu/staying-healthy/keep-your-health-care-directives-up-to-date.
This presentation is intended to provide a review of issues or topics of possible interest to Glenmede Trust Company clients and friends and is not intended as investment, tax or legal advice. It contains Glenmede’s opinions, which may change after the date of publication. Information gathered from third-party sources is assumed reliable but is not guaranteed. No outcome, including performance or tax consequences, is guaranteed, due to various risks and uncertainties. Clients are encouraged to discuss anything they see here of interest with their tax advisor, attorney or Glenmede Relationship Manager.