What is an advance directive?
An advance directive, sometimes called a "living will," is a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself. This information is important if you become unconscious or otherwise too sick to make your wishes known.
State and federal laws give you the right to make many health care decisions in advance so that your wishes can be honored in the event you can’t express them. It is your right, as a competent adult (a person over the age of 18), to decide whether to accept, reject or discontinue medical treatment for yourself. This includes decisions about life-sustaining treatments, such as breathing machines and feeding tubes.
Documents such as the advance directive can help ensure that your loved ones and your health care team honor your wishes. Even though these situations can be uncomfortable to think about, planning in advance offers you and your family members peace of mind and helps eliminate confusion in a difficult time.
What is included in an advance directive?
An advance directive has several sections, which allow specific health care directions to be given or to appoint others to make decisions if needed. These include:
A living will is a written document that specifies what medical treatment you would or would not want in the event you are in a terminal condition or a persistent vegetative state. A living will directs health care providers to cease or refrain from certain medical/surgical treatments.
A terminal condition is an incurable, irreversible medical condition in an advanced state caused by injury, disease or physical illness, which will, in the opinion of the attending physician, to a reasonable degree of medical certainty, result in death regardless of the continued application of life-sustaining treatment.
Power of Attorney
A durable power of attorney for health care decisions is a document by which you can designate, in writing, another person (an agent) who will be able to make health care decisions on your behalf if you are unable to do so yourself. You may specify whether the appointment of an agent takes effect immediately or at the time you are unable to make your own decisions.
The appointed health care agent has broader power to execute your wishes than can be provided under a living will, so you will want to select your agent carefully to make sure your agent knows and will follow your wishes. Unlike with a living will, you don’t have to be in a terminal condition for the power of attorney to take effect.
Health Care Instructions
Health care instructions are another form of written advance directive that can be used alone or together with the appointment of a health care agent. Health care instructions allow you to specify what treatment you want or do not want in the event you are in a terminal condition, persistent vegetative state or end-stage condition, and to express other health care decisions, such as a do not resuscitate (DNR) orders, organ and tissue donation and special instructions for dialysis, and blood transfusions.
How do I make an advance directive?
Talk with your physician and your family or others close to you about your feelings regarding medical treatment and health care. If you are in a hospital, you can ask your nurse about having a trained hospital representative, such as a chaplain or a social worker, speak with you about advance directives and provide the necessary forms.
You don’t have to have a lawyer to get an advance directive, but if you have legal concerns or questions, you should consult one. Please note that laws about advance directives are different in each state.
There are sample forms available online from various organizations you can use to get started with your advance directive (Johns Hopkins is not responsible for the contents of these forms):
- Maryland Attorney General
- District of Columbia Hospital Association
- National Hospice and Palliative Care Organization
- Oficina del Fiscal General del Estado de Maryland
Frequently Asked Questions
No, you do not. However, an advance directive is a good way to make your wishes regarding your medical treatment known, to reduce confusion among your family and your caregivers and to have your wishes honored.
There are two types of advance directives: those that are written in a document and those that are spoken in the presence of a witness.
You may make an oral statement to your physician in the presence of a witness, providing instructions or appointing a health care agent. This statement regarding your wishes must be recorded in your medical record by your physician and signed and dated by the physician and witness.
Different states may have different restrictions on who you can name as your health care agent. Generally, your agent may be any competent adult other than an employee, owner or operator of the health care facility where you are being treated, although there may be exceptions if this person is related to you.
Legally, you can designate multiple health care agents, but it is recommended that only one agent receives the durable power of attorney. You can also name an alternate agent who would take on the responsibilities of your primary agent if he or she resigns or is otherwise unable to fulfill their duties.
In most cases, there will be no problem in carrying out your wishes. However, there may be some special circumstances, such as:
- If a disagreement arises between equal ranking decision-makers regarding your medical treatment, your physician may consult the hospital's Patient Care Advisory Council.
- If your physician believes that an instruction to withhold or withdraw life-sustaining procedures from you is inconsistent with generally accepted standards of patient care, the physician may consult the hospital's Patient Care Advisory Committee or file a petition in court.
- A physician doesn’t have to provide treatment he or she believes to be medically ineffective or ethically inappropriate. In cases when such treatment is requested by a patient or those making decisions on the patient’s behalf, the physician must offer them an option to request a transfer to another physician and, if desired, assist with the transfer. Pending the transfer, the physician must comply with the request for treatment if failure to comply would result in the death of a patient.
Once you've completed an advance directive, tell your health care provider and close family or friends about your decisions and give them a copy.