Advanced care directives are specific instructions, prepared in advance, that are intended to direct a person's medical care if he or she becomes unable to do so in the future.

PURPOSE
Advanced care directives allow patients to make their own decisions regarding the care they would prefer to receive if they develop a terminal illness or contract a life-threatening injury. Advanced care directives are also used to designate someone the patient trusts to make decisions about medical care, if the patient becomes unable to make (or communicate) these decisions.

Federal law (1990 Patient Self-Determination Act) requires hospitals, nursing homes, and other institutions that receive Medicare or Medicaid funds to provide written information regarding advanced care directives to all patients and residents upon admission.

Potential advantages for individuals who develop advanced care directives include the following:

• Decreased personal worry
• Enhanced health care provider knowledge regarding patient's wishes
• Decreased application of "defensive medicine" by provider
• Decreased implementation of futile, costly, specialized interventions
• Decreased overall health care costs
• Decreased feelings of helplessness and guilt for family
• Decreased legal concerns for everyone involved

The primary limitation of advanced care directives is the inability to predict what situations may arise in the future or what new modes of care may be available for situations considered nearly hopeless today.

EXAMPLES OF ADVANCE DIRECTIVES
Verbal instructions. These are any decisions regarding care that are communicated verbally by an individual to his or her health care provider(s) and family members.

Organ donation. This may be accomplished by completing an organ donation card and carrying it in your wallet. A second card may be placed with important papers (such as a living will, insurance papers, and so on.) Most hospitals or other major health care centers have organ donor information available.

Many states offer people who are applying for new or renewed drivers' licenses the opportunity to make a decision regarding organ donation and have it recorded on the driver's license. More information may be obtained by calling 1-800-24-DONOR.

Living will. This is a written, legal document that conveys the wishes of an individual in the event he/she becomes terminally ill and incapable of communicating. A living will may indicate specific care or treatment the person does or does not wish to have implemented in the event of a terminal illness. This may include specific procedures, care, or treatments such as the following:

• CPR, if cardiac or respiratory arrest occurs
• Artificial nutrition, through intravenous or tube feedings
• Prolonged maintenance on a respirator, if unable to breathe adequately alone
• Blood cultures, spinal fluid evaluations, and other diagnostic tests
• Blood transfusions

State laws vary regarding living wills. Information specific to individual states usually may be obtained from the State Bar Association, State Medical Association, State Nursing Association, and most hospitals or medical centers.

NOTE: A living will is not to be confused with a last will and testament that distributes assets after a person's death.

Special medical power of attorney. A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make and/or communicate such decisions personally.

NOTE: This document provides for power to make medically related decisions only and does not imply appointed power to make legal or financial decisions.

DNR (do not resuscitate) order. This states that CPR (cardio pulmonary resuscitation) is not to be initiated if breathing stops or the heart stops beating. The order may be written by the person's doctor after discussing the issue beforehand with the person (if possible) or his or her proxy or family.

RECOMMENDATIONS

• In the event you choose to write up a living will or special medical power of attorney, make sure you obtain information regarding specific state(s) laws that may apply and write the document(s) to be consistent with the law(s).
• If you have a living will or special medical power of attorney, provide copies for your family members, health care provider(s), and carry a copy with you (in a wallet, glove compartment of car, or similar location). If you have a planned admission to a hospital, take copies for the hospital to include in your medical chart and inform all medical personnel involved with your case of the existence of such documents.
• Consider the possibilities of the future, and plan ahead. Studies have shown that although the majority of people believe having some form of advance directives is a good idea, only 7% to 8% of the population has actually developed any type of advance directives for themselves. Many people state that they want their families to make health care decisions; however, less than half of these people have ever discussed the issue and their specific desires with family members. Remember, these decisions can be changed at any time. If a living will is changed, however, everyone involved including family or proxies and all healthcare providers must be informed and new copies of instructions made and distributed.

SUMMARY
The process of establishing advanced care directives may be difficult. It requires one to think about individual priorities regarding quality of life and the potential for death. Treatment options, as well as their possible influence on quality of life measures, need to be fully understood and considered. The potential implications of choosing or refusing specific forms of care need to be evaluated. Discussions regarding advanced care directives should be initiated, and later reviewed for clarification, with personal health care providers, family members, and friends (as applicable).