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House Call: Advance Directives Make Patients’ Wishes Known

Most healthy people don’t spend much time thinking about how decisions would be made about their medical care if they were unable to communicate, but there are major benefits to being prepared for such an occurrence.

Considering what kind of medical care you would want if you were unable to make your wishes known and then completing legal documents to record your wishes can provide vital information to your family members and your health care providers.

Making these decisions is never easy, but delaying the process until you are seriously ill can make the task overwhelming. Taking these steps while you are healthy gives you time to consider your options and then discuss your wishes with your loved ones.

Types of advance directives

A written statement about the kinds of medical treatment a person does or does not want in the event he or she is not able to communicate is called an advance directive. Although the laws governing such documents vary from state to state, the most common types of advance directives are living wills, do-not-resuscitate (DNR) orders, and medical powers of attorney.

Living wills

A living will, also known as a directive to physicians and family or surrogates, is a legal document that describes the kinds of medical care, especially life-sustaining care, the patient wants or does not want if he or she becomes terminally ill. A living will takes effect only when the patient is unable to state his or her wishes.

Common issues addressed in a living will are whether the patient wants his or her health care provider to use life-sustaining equipment, such as a dialysis machine or ventilator, and whether the patient wants to receive artificial hydration and nutrition (tube feeding).

Do-not-resuscitate orders

A DNR order is a form signed by the patient and his or her doctor stating that the patient refuses cardiopulmonary resuscitation if his or her heart stops. There are two types of DNR orders. An out-of-hospital DNR order states that a patient who is not hospitalized does not wish to be resuscitated in a clinic or emergency center. Some people with out-of-hospital DNR orders wear bracelets that make this known to emergency personnel. An inpatient DNR order is discussed at the time of hospital admission and is included in the patient’s hospital chart.

Without a DNR order, health care providers are obligated to do everything medically possible to attempt to restart a patient’s heart if it stops.

Instructions not to resuscitate might also be included in a patient’s living will, but unlike a living will, which goes into effect when the patient is unable to make his or her wishes known, a DNR order is in force as soon as it is signed by the patient and doctor.

Medical powers of attorney

A medical power of attorney is an advance directive that lets the patient name another person to make decisions about the patient’s medical care if the patient is unable to communicate or make such decisions. The document is also called a health care proxy, durable power of attorney for health care, or appointment of health care agent.

Usually the person chosen to make medical decisions on a patient’s behalf is a close relative: a spouse, parent, son, or daughter. However, the patient may choose any adult he or she knows and trusts to be his or her agent. The agent has the same decision-making power the patient would have in agreeing to or refusing medical treatment or life support.

The patient can limit his or her agent’s decision-making authority by stipulating in the document his or her specific wishes, such as which medications or treatments the patient wishes to receive, which doctor the patient wants to be treated by, or which hospitals the patient prefers to be treated in. The agent is obligated to follow these guidelines. While the patient is able to communicate, he or she still has the power to make decisions about his or her own care and can take away the agent’s authority at any time, orally or in writing.

Although a medical power of attorney gives decision-making authority to one person, it cannot tell that person what to do in every possible situation. Similarly, while a living will can give the patient’s doctors and loved ones an idea of what the patient wants, it does not indicate what should be done in every circumstance. A good option for many people is to set up both a medical power of attorney and a living will. This allows the agent to make medical decisions based on the requests stipulated in the living will.

Preparing an advance directive

Anyone 18 years or older can prepare an advance directive. You can get the appropriate forms from your physician, hospital, or state health department; or you can simply write your wishes down yourself. These directives don’t have to be complicated or written by an attorney, but they must comply with the patient’s state’s laws.

Be sure to discuss your wishes with your family and health care providers, and provide them with copies of your advance directives. If you find it too hard to have this talk, it may help to plan a family meeting and invite a social worker or member of your faith community to help guide the discussion.

— K. Stuyck

For more information, ask your physician or call MD Anderson’s Department of Social Work at 713-792-6195.

OncoLog, July 2014, Volume 59, Issue 7 

© 2015 The University of Texas MD Anderson Cancer Center