Taking care of yourself and your family means making decisions about medical care while your health allows you to do so.

Although death comes to everyone, many of us tend to fear its approach and may avoid confronting the issues surrounding the end of life. Nevertheless, it is important for each person to document his or her wishes in writing prior to serious illness or physical or mental disability. Otherwise, those wishes may not be known and cannot be honored, thus creating an unnecessary burden for loved ones.

What are advance directives?

Advance directives are written instructions in the form of a living will and/or durable power of attorney for health care. Advance directives do not go into effect until the signer loses decision-making capacity.

A living will (health care treatment directive) is a legal document that communicates a person's desires about withholding and/or withdrawing medical treatment in the event that he or she suffers from an incurable and terminal condition. Living wills outline in advance the treatment choices and instructions to be followed by caregivers if the signer cannot take part in making health care decisions. It is called a 'living will' because it must be signed with the same type of formality as a regular will but its provisions take effect before death.

A living will:

• may spell out specific measures that the person wishes, or does not wish, to have taken to extend life when he or she is clearly dying

• may specify the use or non-use of breathing machines, feeding tubes, oxygen, intravenous fluids, or other medications

• may list specific illnesses or conditions (persistent vegetative state, coma, terminal illness with no hope of recovery or cure, end-stage dementia) under which the provisions of the living will are to go into effect.

A living will must be witnessed to be legal, and a person must be competent when he or she signs it. Requirements vary from state to state, but usually the witnesses must be unrelated to the patient, cannot be creditors or heirs to the patient's estate, and cannot be the patient's doctor. It is wise to prepare a living will at a time when you are healthy, not when you have been seriously ill or are in the hospital.

Most states have laws that recognize advance directives. Not all states do, however, and living wills may not always be binding. Some states do not recognize living wills that have been drafted in other states. You need to be familiar with the laws in your state.

A durable power of attorney for health care (DPAHC) designates a family member or friend to follow the person's wishes and to make medical decisions on his or her behalf should the signer lose decision-making capacity. It is more flexible and comprehensive than the living will, and is regarded by some as preferable to it.

For this document to be legal, the person must be competent at the time he or she signs it. Anyone with a progressive brain disorder such as Parkinson's disease or Alzheimer's disease may wish to draw up the DPAHC papers early in the illness. The duty of an agent in the durable power of attorney for health care is to follow the signer's wishes. In states that recognize such documents, families and physicians can not override a living will or the agent of a DPAHC.

Once signed, such documents should be kept in a safe place, but not in a safe deposit box where they may not be accessible when they are needed. It is a good idea to discuss your wishes with your friends, family members, and your physician. Giving these people copies of your living will or DPAHC also is advisable. That way, should you become incapacitated, others will have access to the documents that express your wishes.

Sample forms for writing your living will, a durable power of attorney, and a Health Care Treatment Directive are available with this handout. If you want copies of those sample forms and they were not provided with this handout, ask for them. They are only samples, however, and may not conform to the laws in your state.

The Midwest Bioethics Center (816-756-1735) provides information about advanced directives nationwide. Choice in Dying will provide a copy of state-specific advance directives free to anyone who writes the organization (Choice in Dying, 200 Varick Street, New York, NY 10014) or calls (1-800-989-WILL). Your state health department, local hospitals, or state bar also may be able to provide you with state-specific advance directives. You may wish to consult your lawyer about advance directives and drawing up a durable power of attorney for health care or a living will and a regular will that conform to the laws in your state.

What happens if the person is already incompetent or physically unable to manage his or her own financial and medical affairs?

Some older people are unable to manage their own affairs due to medical illness or a mental impairment. The central issue is whether that person can understand and make decisions involving medical and financial choices. A person can be confused about time and place, but nonetheless may be able to understand his or her choices if they are carefully explained. It is also possible for an older person to be capable of making decisions about his or her health but not about finances. Physicians are often asked to evaluate the competency of a patient, but a doctor can only make a medical determination about someone's decision-making ability. A court must make any legal determination about competency.

All states allow the courts to establish limited guardianships (also called conservatorships) and unlimited guardianships.

A limited guardianship allows the appointed guardian to make decisions for someone in areas where the court has determined that the person lacks the ability to function. This type of arrangement is often made for managing finances. Someone judged incompetent for financial purposes is still able to make decisions regarding his or her health.

An unlimited guardianship removes all rights of the individual to vote, to decide where to live, and to manage his or her money and health. That person is said to be incompetent for all purposes and receives the protections generally given to a child.

What is the meaning of 'resuscitate' and 'do not resuscitate (DNR)?'

If you are in a clinic, hospital, or nursing home, you may be asked to sign a code status sheet. This will indicate to the staff what measures, if any, you want taken should you be found not breathing and without a heartbeat. Code status may be changed at any time.

Cardiopulmonary resuscitation (CPR) was developed in the 1960s as a way to prevent sudden and unexpected death. When administered quickly, it is generally effective for heart attacks, drownings, drug overdoses, and similar acute situations. However, CPR is not generally as effective for people with chronic and severe illnesses or where death is expected to occur soon.

A full code means that you want everything possible to be done to revive you. This includes administering chest compressions, electrical shocks, and medication (to start your heart) and putting you on a ventilator (a machine to keep you breathing). This type of CPR has the most success but is still less successful for people with chronic medical conditions. Some people request a limited code, which usually excludes being put on a ventilator and is much less often successful.

When CPR is medically futile, your doctor should explain why. In those cases, a no code order (DNR, for Do Not Resuscitate) may be written. It is important to recognize that a DNR order only pertains to not having CPR and does not limit other types of treatment. A person should receive all indicated medical and nursing care, even when CPR would be of no benefit. A discussion with your doctor about CPR is an excellent opportunity to review your overall medical condition and treatment plan.

For samples of advance directives, see

Durable Power of Attorney for Health Care Decisions

Health Care Treatment Directive

Living Will Declaration