Advance Directives and End-of-life Decision Making

Types of Advance Directives

There are two primary types of advance directives. Instructional advance directives, also known as living wills, contain instructions about the type of life-sustaining treatment an individual would like to receive should he or she become incapacitated. Such instructions can range from legal documents prepared with the help of an attorney to verbal statements made to a family member or a physician. They can be general and express values and goals that the individual feels should guide medical care (e.g., emphasize quality over quantity of life) or relevant religious values. Or they can be specific and carefully delineate particular medical treatments to be used or withheld in particular medical conditions. Most often, instructional directives express a desire to withhold aggressive life-sustaining treatments, but they can also be used to request such treatments. In addition, they can specify preferences regarding pain management, organ donation, or dying at home as opposed to in a hospital.

Proxy advance directives designate another person as a surrogate decision maker, or a proxy, for the patient should he or she become incapacitated. Proxy directives are also known as durable powers of attorney for healthcare and surrogate appointments. The surrogate decision maker is usually a spouse or another close family member. Proxy directives convey the legal right to make treatment decisions but do not necessarily contain explicit guidance regarding what those treatments should be.

Advance directives can be created without using any preprepared forms, but the majority of U.S. states provide standard forms that follow specific state statutes. Verbal statements are also [Page 10]considered legal advance directives, especially if recorded by a medical professional in a patient's chart.

Another common kind of instructional advance directive is a Do Not Resuscitate (DNR) order, which is recorded in a medical chart and indicates a desire to not receive cardiopulmonary resuscitation (CPR). Because resuscitating treatments often fail, such orders are also sometimes called Do Not Attempt Resuscitation (DNAR) orders. Also, because decisions besides those involving resuscitation must often be made, a more comprehensive type of medical order form called Physician Orders for Life-Sustaining Treatment (POLST) has recently been developed and adopted for use in several states. POLST forms record a patient's wishes for a number of different life-sustaining treatments and require both patients and physicians to sign, indicating that they have discussed these preferences.

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