An introduction to advance directives"Well it will be a new experience anyway." Imagine
These are examples of difficult health care situations faced by patients, families, and physicians every day. If such decisions had to be made for you, who would make them? And, how would they decide? In Arizona and in all other states and the District of Columbia, it is your legal right to prepare for a time when you might not be able to make your own decisions. You can choose who should make decisions about your health care and provide instructions on how such decisions are to be made. Until recently, physicians could rarely do much to control whether a seriously ill or injured patient lived or died. Advances in medical technology have substantially changed that. Today the way we die and the timing of death is often a matter of choice. More than half of us will die following a decision to stop or not start a life-sustaining treatment. While advance directives can only imperfectly guide the process making such decisions, it is helpful to begin with an understanding what these documents are and what the laws that enable their use allow them to do. Understanding their limitations can come later in the advance care planning process. You can legally prepare for future decisions about your health care in more than one way. For example, you can discuss your wishes with your physician and have her or him document your discussions in your medical record. This is a perfectly legal way for you to authorize your physician to forego life-sustaining medical treatment under the circumstances that you and your physician agree to. However, these days, health care providers tend to expect patients to provide them with legal documents known as "advance directives." In Arizona, advance directives include the Living Will and the Health Care Power of Attorney. The law in all states and the District of Columbia authorizes at least one of these documents. Many states authorize both. The Prehospital Medical Care Directive is another directive authorized in Arizona and in a growing number of other states. (When referring to Arizona advance directives, names have initial capital letter. References to generic document types are in lower case.) The living willIn a written living will you provide instructions for any person legally authorized to make health care decisions for you at any time you are unable to make your own decisions. In all states that have some form of living will (it may have a different name in your state), the document is in effect only when you are unable to make your own decisions. The name "living will" is unfortunate because some people confuse it with a will used to dispose of your property after your death. These two documents have almost nothing in common. In most states, but not Arizona, you must be determined by at least one physician, sometimes two, to have a "terminal condition" for a living will to be in effect. Arizona eliminated reference to terminal conditions from its statute (though, unfortunately, not from its sample form). There is no medical standard for clearly distinguishing patients who are terminally ill. Prognosis of time of death even for people with incurable, life-threatening conditions is notoriously unreliable. A diagnosis of an incurable, life-threatening condition, itself, is not the sole reason people decide to forgo life-sustaining treatment. Dorothy Garske Center suggests that living will documents should not rely on ambiguous expressions like "terminal conditions" and "no heroic measures." The last thing we want when we are at life’s end is for people to be arguing over the meaning of ambiguous instructions in an advance directive. Ambiguity can never be completely eliminated from your documents, but it should be minimized. Reliance on a determination of terminal illness is likely to mean subjecting patients to a much longer course of aggressive medical treatment than they would expect when they complete a living will. Your living will should clearly state your underlying values and your reasons for preparing a living will, such as avoiding a quality of life that is unacceptable to you. It should describe circumstances in which you do not want life-sustaining treatments, such as artificial feeding, CPR, ventilators, and surgeries, used to prevent your death. It can also give your directions about using pain medication. The forms at this site provide reasonably clear directions about these and other important topics. The health care power of attorneyIn a health care power of attorney you give someone you trust legal authority to make health care decisions for you if you become unable to make such decisions. The person you appoint is known as your "agent." (Health care agents are called "proxies" in a few states.) Your agent has the same authority to make decisions about your health care that you have while you are competent, unless your restrict that authority in your health care power of attorney document. In addition to naming a primary agent, you may name alternate or successor agents to act on your behalf if your primary agent is not available. In Arizona and most other states, your agent is required by law to follow your living
will. If you have no Living Will or the one you have does not give adequate guidance, your
agent must still honor your known values and wishes and otherwise act in your best
interest in Arizona. Documents appointing health care agents or proxies are known as "durable" powers of attorney. A power of attorney is "durable" if it states that it is in effect when the person who completed it (the principal) cannot make his or her own decisions (some state statutes provide specific wording to be used). A durable power of attorney for health care must specifically state that it authorizes health care decision-making. Durable powers of attorney are very different from ordinary powers of attorney. An ordinary power of attorney loses its legal validity when the person who prepared it becomes incapacitated. An ordinary power of attorney cannot be used to delegate authority to make health care decisions. (An important, but very different, kind of durable power of attorney, is the general durable power of attorney. It is used for granting a trustworthy person authority to make financial decisions on your behalf should you become incapacitated.) A combined living will and health care power of attorneyIn Arizona and many other states you may prepare a directive that is both a living will and a health care power of attorney. A combined directive is easier to complete and distribute. It provides all potential decisionmakers with your statement of treatment wishes and values. It is less likely to present health care providers with conflicting instructions than separate documents. Prehospital Medical Care DirectiveThe orange Prehospital Medical Care Directive should be used in Arizona only if you do not want to receive CPR at any time, under any circumstances. If breathing or heartbeat stop and emergency medical service ("911") is called, emergency personnel will almost certainly attempt cardiopulmonary resuscitation (CPR), unless they are promptly presented with a valid Prehospital Medical Care Directive. Neither a Living Will nor Health Care Power of Attorney can be relied upon to prevent emergency personnel from administering CPR. Many states provide for this type of "do not resuscitate" form. Unlike living wills and health care powers of attorneys, the documents authorized for one state or jurisdiction are probably never acceptable in other states or jurisdictions. Do not use the Prehospital Medical Care Directive available through this site in any other state than Arizona. Every adult and mature minor is advised to complete a living will and a health care power of attorney. All three of the advance directives described above are available on this site. Return to Overview of Advance Care Planning
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