Advance Directive for Healthcare

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Introduction to the Advance Directive Form

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The form provided here will help guide the decisions that need to be made about your health care should you lose the ability to communicate your wishes more directly.

To fill out this form you need not consult with anyone—including family, physician or attorney—but you would be wise to do so.  It can be very helpful to think through your goals for health care, along with the convictions and values on which they are based, with a close friend or family member.  Similarly (and perhaps even first), consulting with your physician can give you invaluable understanding about the kinds of end-of-life situations that the form is intended to address.  Consulting with an attorney can also be useful, particularly if your state has unique legal requirements related to advance directives.

To find out if your state has any special requirements, you can contact Legal Counsel for the Elderly, American Association of Retired Persons, P.O. Box 96474, Washington, DC 20090-6474 (phone: 202-434-2197).  A few states, for example, require one witness to be a Notary Public, forbid certain people from being your agent, or require the use of a state form if the document is to have legal (and not just advisory) status.  In most cases a form for health care decisions is required even if you already have a power of attorney document for other decisions.

This cover sheet and the attached form do not constitute legal advice.  Nevertheless, they are designed to give you a way to communicate your health care wishes effectively—which can prove helpful should you become unable to do so more directly.  Moreover, the form attempts to incorporate virtually all of the provisions required in most states at the time of publication.

The ethical justifications of the guidelines included in this advance directive form, plus other ethical issues involved in end-of-life treatment decisions, are discussed in the easy-to-read 80-page End of Life Decisions* question-and-answer book produced by The Center for Bioethics & Human Dignity.  You are strongly encouraged to read through this book and to think through the issues it raises, in conjunction with completing the advance directive form.

You—as the person whose health care is the focus of this advance directive form—are called the “Principal.”  The form includes two documents in one.  It includes a durable power of attorney for health care, in that it specifies the person (your “agent”) who is to make decisions on your behalf should you lose the capacity to do so.  It also includes living will guidelines, in that it contains written guidance—not for your physician as in traditional living wills—but for your agent (and your alternate agents if your agent becomes unwilling or unable to act as your agent).

The form specifies that the guidance can be disregarded only when your agent deems that following it would result in an action contrary to your wishes—for example, in unanticipated exceptional situations.  This provision avoids the problem with most advance directives, which fail to indicate whether the living will instructions or the judgment of the agent take priority when the two appear to conflict.  But you still need to select an agent who knows your values and wishes, can make difficult decisions, and is usually available.

You are welcome to make copies of the form and this cover sheet, but only for the personal use of you or your loved ones and not for any commercial purpose.

Please note the following:

1) Although only one decision-maker (“agent”) needs to be identified in the document, there is space for two additional back-up decision-makers ("alternate agents") to be identified.  Identifying at least one alternate agent is a particularly wise idea.

2) The signatures of the agent and alternate agents at the end of the document are not required in most states.  However, obtaining them assures that all identified decision-makers get the opportunity to read the advance directive—and hopefully to discuss it with you as well—so that they are in a good position to honor your wishes should the need arise. 

3) Keep a copy of your completed advance directive in an easily-accessible place in your home and advise people particularly close to you where that location is.  The agent and alternate agents named in the form should also receive signed originals of the form, as should your physician, and your attorney if you have one.  Keep a list of who has these originals, so that you know whom to contact if you re-do your form.  The form specifies that photocopies are not authoritative, so that if you update and replace the original forms you can be sure that out-of-date photocopies will not create confusion later regarding your latest wishes.

4) Any words can be deleted from the guidelines regarding your care on page 1 of the form simply by crossing them off.  Wherever words are deleted, the person producing the advance directive (the “Principal”) needs to sign his or her initials beside the material deleted.  As indicated at the beginning of the Guidelines section, you can delete all guidelines and simply appoint an agent.

5) Anything can be added to the guidelines on page 1 as well.  To add material, record your additional instructions or other comments on pages separate from the form, attach those pages to the form, and write the number of pages being added in the designated space near the beginning of the Guidelines section.  If there are no additional pages, write “0” in that box.

6) The form allows ending treatment if certain medical criteria are clearly met according to one or more physicians who have personally examined you.  Advise your agent that while a physician well known and trusted by you or the agent may be sufficient to make any medical determinations involved, the agent should obtain further medical opinion if there is any question about the physician’s competence or objectivity.

7) There are two boxes near the bottom of page 1 that allow you to specify your wishes regarding artificial nutrition and hydration (forms of food and water administered through tubes or IV lines for those unable to swallow well).  Some feel that they are mandatory even when other life-sustaining technological interventions are withheld or withdrawn.  However, others consider the justification of artificial food and water—like that of artificial air (provided through a ventilator) and other life-sustaining interventions—to depend on whether they can truly enable life to continue or they essentially add a burden to an imminent and unavoidable dying process.  See the BioBasics End of Life Decisions* book, question #22.

You are encouraged to add, on additional pages, anything you like concerning your faith convictions, your personal values, and/or your health care goals in order to give your agent as complete a picture of your priorities as possible.  Your views concerning other issues covered in the End of Life Decisions* book can also be included here—such as the care you want if you become disabled, demented, permanently unconscious, or in severe pain.  Of course, some or all of that information can be conveyed orally instead if you prefer.

 

*Gary Stewart, et al. Basic Questions on End of Life Decisions: How Do We Know What's Right? (Kregel, 1998).

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last updated 1/7/04