A Guide to Advance Health Care Directives

If you provide care for a parent or another loved one, you may have heard of advance health care directives (AHCDs). Sometimes known as "living wills," these documents ensure that your senior's wishes are known to their medical team and others in case of medical emergencies. If they cannot speak for themselves, the AHCD does it for them.

Living wills vary from state to state, but generally, they outline the types and levels of emergency or end-of-life care your loved one wishes to receive. They are often used in conjunction with a medical power of attorney, which directs a trustworthy individual to speak on behalf of the senior. 

Living wills are increasingly popular — 45% of people have them — and in this guide, we take away the mystery and explain what you need to know to ensure your loved one's wishes are always observed.

Advance care planning is the process of preparing for when your aging loved one might not be able to make their own medical decisions. This process ensures that, should they become unable to speak for themselves or make their own decisions about treatments or interventions, their health care professionals and loved ones know what they want.

Simply put, this process is an essential part of medical care and a gift to your loved one and family.

Advance directives are legal instructions ensuring people receive their desired medical care if they can't decide for themselves. These documents serve as guides for medical professionals and help you make decisions for your aging loved one's care.

These directives can refer to various documents, including living wills, medical power of attorney, and organ donation instructions. Depending on local and state laws, they may refer to a single directive or multiple documents. However, it's most common for people to use the term "advance health care directive" when referring to a document that lists the medical treatments a person does or does not want.

Although AHCDs are legal documents, health care providers may reject the instructions included in the form without risking legal action. This occurrence should be rare and generally only occurs when:

• The instructions go against the health care provider's conscience
• The instructions aren't allowed according to the health care institution's policies
• The instructions violate accepted health care standards.

In these cases, the provider or facility has an obligation to transfer your senior's care to someone who will follow the instructions.

An advance health care directive goes into effect when a person is incapacitated, for example in a coma, in the late stages of dementia, or near the end of life, and can no longer make their own decisions regarding medical care. When your parent or loved one can't communicate their wishes, their AHCD helps ensure they get the care they need.

Firstly, AHCDs specify your loved one's desired and undesired health treatments, such as their preferences on life-saving measures and nourishment, including CPR, intubation, or tube feeding. Your loved one may have instructions for general medical care and end-of-life scenarios.

Secondly, AHCDs may appoint a medical proxy to make decisions on the patient's behalf if they're incapacitated. This proxy ensures the patient's wishes are carried out and makes the decisions during unexpected situations.

Depending on state jurisdictions, these protections may be in one document or split into two; the latter is often called a medical power of attorney.

Although medical power of attorney (MPOA) and the AHCD work together, you may have one without the other. In some states, both are included in the standard living will form. In other regions, the AHCD is a stand-alone document that covers medical care instructions. 

An AHCD outlines your parent's preferences in various medical situations, often through a checklist of common treatments. It should provide precise instructions on handling their healthcare, especially regarding life-sustaining treatments in terminal or irreversible conditions.

A medical power of attorney (MPOA), on the other hand, gives someone else the power to make decisions about a patient's health care. The person making the decisions is often known as the medical proxy or durable power of attorney for health care. A medical proxy should make decisions in line with your loved one's wishes but is often needed in situations not covered by the AHCD.

AHCDs and MPOAs take effect only when your loved one is incapacitated. Until then, doctors follow their current decisions. If incapacitated, the AHCD guides medical decisions, overriding even a proxy's opinions and decisions. The law on this varies by state, which emphasizes the need for a proxy who understands and respects your parent's wishes.

Although living wills are a good idea for people of all ages, they become more important as your loved one ages. If they currently experience poor health or reside in an assisted living facility, nursing home, or memory care facility, exploring advance directives with them is a loving and compassionate way to show your care. Even vibrant, healthy seniors living at home or in independent living residences can benefit from discussions with their families on their future wishes.

Writing an advance directive is a proactive step in managing your senior's health care and ensuring their wishes are respected and carried out. The following list covers some key reasons why you should write an advance directive:

• Autonomy: It allows your loved one to control their health care decisions, even if they cannot communicate or make decisions for themselves later in life.
• Clarity: It provides clear instructions about your parent or other loved one's health care preferences to your doctors and caregivers, minimizing ambiguity during moments of crisis.
• Reduced Burden: An advance care directive alleviates the burden on family members and loved ones. They will be spared from making tough decisions without knowing your loved one's preferences.
• Preventing Conflicts: These documents help prevent potential conflicts or disagreements among family members about the right course of action regarding medical care.
• Peace of Mind: Your loved ones will know that their preferences and wishes will be respected.

Contrary to popular belief, an advanced care plan (ACP) benefits all adults at any age, regardless of their current health status. After all, unexpected medical situations can occur at any time. However, it is particularly important for certain groups of people:

• Older Adults: As we age, we're more likely to be inflicted with serious health issues. An ACP provides clear instructions for situations (e.g., injuries, illnesses, post-treatment, etc.) where older adults may not make decisions for themselves.
• People With Severe Or Chronic Illnesses: For those with conditions like heart disease, cancer, Alzheimer's, diabetes, or kidney disease, an ACP can help guide treatment decisions and ensure their wishes are respected.

• People Undergoing High-Risk Procedures: If you are about to undergo a major surgery or a procedure that might temporarily impair your decision-making abilities, an ACP can ensure your wishes are fulfilled.
• People With Strong Feelings About Certain Treatments: If you have specific feelings about treatments such as resuscitation, ventilation, or tube feeding, an ACP can ensure your preferences are met.

Choosing an agent for end-of-life decisions is an important decision that should not be taken lightly. Although a family member may seem like the logical choice, it should be someone who can remain calm and objective in an emergency situation to prioritize the senior's wishes rather than their own. 

Without an agent in place, many states require decisions to be jointly made by family members, which could lead to disagreement or dissension. The section below covers some factors to consider when choosing an agent.

To choose an agent to implement your loved one's advance health care directive, start by researching your state's rules about eligible appointees. The person you name may be a spouse, family member, friend, or member of a faith community. Typically, doctors can't be proxies due to potential conflicts of interest. Also, your agent should be an adult of sound mind. Agents should also have the following traits:

• Trustworthy: Make sure your loved one chooses an agent they can trust. As an agent makes decisions on behalf of your senior, they need to know that the agent will follow their instructions. Not only is this important to ensure your loved one's wishes are respected, but it also gives them peace of mind.
• Assertive: The agent should be capable of advocating for your loved one's wishes to healthcare providers and family members.
• Physically Present: Ideally, the agent should live near the individual or easily travel there for detailed discussions with their doctors and healthcare providers and prompt decision-making.
• Objective: The agent should be able to set aside personal feelings to honor your loved one's wishes.

Once your loved one identifies their desired agent or medical power of attorney, initiate a conversation with this person. While your senior may see them as a perfect fit, they may not be on board to accept such a major responsibility. 

Ensuring your loved one has what they need to create an advanced directive may be challenging and emotional. Multiple discussions might be needed to reach an agreement and ensure the agent fully understands the scope of their role and your loved one's wishes.

Choose only one agent to avoid conflicts. However, your senior may consider naming an alternate or successor for their living will to assume the decision-making ability if the primary agent passes away or is incapacitated.

Having end-of-life conversations about advance directives with loved ones can be challenging. The prospect of declining health or imagining life without them might be tough for all participants. These steps can help you have a productive discussion.

• Leave Plenty of Time: Living wills must be created before your parent or other loved one is incapacitated, so you should have the conversations early. Plan to have the conversations over time. It may also take a few conversations to cover all the relevant topics related to the advance directive.
• Emphasize the Positive: While such conversations may be tough and even contentious, they can simplify future decision-making. Remind everyone that early planning can ease future tension and minimize conflicts once your loved one can no longer make decisions on their own.

• Have Everyone Make an AHCD: Rather than put all the attention on just one member of the family, take the opportunity to draw up an advance directive for everyone. This option may make the conversation easier and also ensures that everyone has a directive ready in a worst-case scenario.
• Hire a Professional: In some cases, a neutral party like an attorney, faith leader, or family counselor can help navigate discussions above living wills, ensuring your senior's wishes are respected. Their presence can be especially important if there is conflict in your family.

If you're having difficulty beginning a discussion with your loved one about advance care planning, consider trying these conversation starters:

• "Can I talk to you about my advance health care directive?" Starting a conversation about your advance care planning can provide an opportunity to ask about your senior's plans.
• "Has your doctor ever talked to you about advance health care directives?" This question can be helpful if you think your loved one might need to be eased into a conversation. If they seem receptive, you can talk with them about their plans. If not, you can suggest they ask their doctor about directives and follow up at a later date.
• "I picked up this pamphlet from the doctor's office today." Doctors, hospitals, and Area Agencies on Aging often have pamphlets or forms that detail how to start advance care planning. This question can introduce the topic to your senior and help start a conversation.
• "Who do you want to make decisions for you in the future?" Some older adults may respond best to a straightforward approach. If this is your loved one, start your discussion with a direct question.

End-of-life decision-making can be challenging for family members and caregivers, but having a living will in place may make it easier. What is a living will or advanced health care directive? Simply put, this document outlines your loved one's wishes for medical care if they cannot voice these wishes themselves. Choosing a medical power of attorney and urging your senior to create an advance directive are two loving ways you can ensure their wishes are met, offering peace of mind to all.

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