Advance Directives: The Four Types

An advance directive is a legal document that gives guidance about the types of healthcare a patient will accept in the event the patient becomes unable to make their own decisions. It can also appoint another person, known as a proxy, to make these decisions on behalf of the patient.¹

When Does an Advance Directive Apply?
- Legality
Who Should Make an Advance Directive
- What to Include
- When It’s Done
- What Happens If You Don’t Have One
The Four Types
Helpful Forms
Sources

When Does an Advance Directive Apply?

Advance directives are valid in any medical setting where the healthcare provider has a record of them. In emergency situations, both in and out of the emergency room, medical personnel and technicians are required to provide all possible life-saving care unless they have a copy of a patient’s advance directive. When a healthcare provider does have the directive on file, they can only go against its orders:

- When the decision goes against the individual health care provider’s conscience;
- When the decision is against the health care institution’s policy; or
- If the decision violates accepted health care standards.²

It is advisable to discuss wishes with a healthcare provider when creating an advance directive to avoid putting them in this type of situation.

Legality

Laws about advance directives vary by state and some have reciprocity agreements recognizing the directives of other states.² If a person spends a significant amount of time in a state other than the one they reside in, it is wise to have a legally binding advance directive on file in both places.

A lawyer is not needed to complete an advance directive, and the directives never expire. They are only invalidated if the patient completes a new one. They can be changed or revoked at any time.³ ^,4

Who Should Make an Advance Directive?

Advance directives are usually used by patients suffering from terminal conditions or life-limiting illnesses from which they are unlikely to recover such as advanced cancers, massive heart attacks, debilitating strokes, or multiple organ failure.² It is also wise for any person undergoing major surgery to submit an advance directive to the hospital where their surgery will take place.

What to Include

While different types of advance directives address different subjects, it is generally wise to try to include the following details in any advance directive:

Care requests;
Body disposition;
List of people not permitted to make decisions about the patient’s medical needs;
Name and contact information for the patient’s proxy;
Names and signatures of witnesses; witnesses can’t be:
- The healthcare agent or proxy;
- Any of the patient’s care providers;
- Related to the patient by blood, adoption, or marriage; or
- Entitled to any portion of the patient’s estate upon their death; ⁵ and
Signature and seal of a notary public if notarization is required by the state.

When It’s Done

When an advance directive is complete, the patient should provide copies to their doctors, proxy and alternate proxies, and any family members who they think should have one. File the original(s) away in a safe place that can be accessed quickly. Some people carry cards in their wallets indicating the existence of an advance directive and the contact information of the person’s proxy.⁶ It is also wise to carry a copy of an advance directive while traveling. The U.S. Advance Care Plan Registry stores a database of advance directives for healthcare providers to access when needed.

What Happens if You Don’t Have One

If a patient is incapacitated and does not have an advance directive, the healthcare team will normally work with immediate family members. In some instances, courts can also appoint medical proxies. ²

The Four (4) Types

Living Wills

A living will explains a patient’s wishes regarding end-of-life care in the instance they are too ill or injured to make their own healthcare decisions. It is typically used with a patient who is permanently unconscious or terminally ill. Two physicians have to confirm the patient’s incapacitation before the medical team can resort to the living will to make decisions.⁷ This kind of advance directive typically addresses whether the patient permits the use of the following treatments:

Comfort/palliative care;
Dialysis;
IV hydration;
Organ, tissue, brain, and body donations;
Resuscitation (CPR & AED);
Tube feeding;
Ventilation (breathing machines); and
Any other type of life support. ⁴

Medical Power of Attorney (MPOA)

In a medical power of attorney (MPOA), also known as a durable power of attorney for healthcare, a patient names a specific individual to be their medical decision-making proxy. If the patient doesn’t have a separate advance directive outlining their specific medical wishes, the proxy is expected to make their decisions based on what they believe the patient would want.⁴ This is why it is crucial for patients to have conversations with their proxies about these subjects. Many states include MPOAs with their living will documents to help avoid this issue.⁷ Many MPOAs include sections for backup proxies in the instance the primary proxy is incapable of performing the necessary duties. A patient’s physician is responsible for deciding if the patient is incapacitated enough to enact their MPOA. Requirements for a person to be a proxy include:

Meets the state’s requirements for a health care agent;
Is not the patient’s doctor or a part of their medical care team;
Is willing and able to discuss medical care and end-of-life issues;
Can be trusted to make decisions that adhere to the patient’s wishes and values; and
Can be trusted to be the patient’s advocate if there are disagreements about their care. ⁶

Do Not Resuscitate (DNR) and Do Not Intubate (DNI)

A do not resuscitate (DNR) is a form that forbids healthcare providers from using particular life-saving resuscitation techniques on a patient. This usually includes the use of cardiopulmonary resuscitation (CPR) and automated external defibrillators (AED).⁴ Some DNR forms also address organ and tissue donation. In order to be legally binding, DNR has to be signed by the patient and their healthcare provider. Some hospitals require a new DNR each time a patient is admitted.⁴

Similar to a DNR, a do not intubate (DNI) form forbids healthcare providers from putting a patient on a ventilator or any other type of breathing machine to keep them alive.⁸

Physician Orders for Life-Sustaining Treatment (POLST)

A Physician Order for Life-Sustaining Treatment, more commonly known as POLST, is a document that lays out specific medical orders for a seriously ill patient. It addresses their wishes for an emergency situation regarding hospitalization, life support, medication, pain management, and resuscitation.⁶ This type of advance directive is not available in all states. It must be signed by the patient’s doctor to be legally binding, and is normally appropriate for patients who are: