What Is an Advance Directive and Why Should Older Adults Have One?

An advance directive is a legal document that states the medical care you would want, or not want, if you become unable to speak for yourself, and it can name a person to make decisions for you. Older adults often benefit because serious illness, a stroke, or memory loss can arrive suddenly or gradually. This article explains the main types, what to put in one, how to make it usable, and when to review it.

What is an advance directive?

An advance directive is written guidance about your future medical care. MedlinePlus, from the National Library of Medicine, describes advance directives as legal documents that spell out your decisions about end-of-life care ahead of time and that let you give someone you trust the authority to make those decisions if you cannot (MedlinePlus: Advance Directives). It only takes effect when you cannot speak for yourself. While you can make your own choices, your word comes first.

The rules about how these documents are written, witnessed or notarized differ from state to state, so check your state's official form or your state health department. A form that is valid in one state may need changes in another, so it helps to use a form designed for the state where you live.

The main parts of an advance directive

Advance directives usually include one or more of the following. Names and details vary by state.

Living will

A living will describes the treatments you would or would not want if you were seriously ill or near the end of life. Common topics include:

• Cardiopulmonary resuscitation (CPR), which uses chest compressions and sometimes electric shocks to restart the heart
• A breathing machine (mechanical ventilation)
• Tube feeding or intravenous nutrition
• Dialysis for kidney failure
• Antibiotics or other treatments given when the main goal is comfort
• Donation of organs or tissues

Health care power of attorney

This document names a health care agent, sometimes called a proxy or surrogate. Your agent speaks for you only when you cannot. A living will cannot anticipate every situation, so an agent who understands your values can fill the gaps.

Why older adults may want an advance directive

Several situations can leave a person unable to take part in decisions: a stroke, a serious infection that requires intensive care, advanced heart or lung disease, or dementia. MedlinePlus covers end-of-life issues as a topic where planning ahead may spare you and your family from guessing (MedlinePlus: End of Life Issues).

Without a directive, clinicians usually turn to family members, and state law may decide who has the authority. Relatives can disagree, or may simply not know what you would choose. A written record can reduce that uncertainty, although it cannot remove every difficult decision.

A directive is not only about stopping treatment. Many people use it to say they want full treatment, to say which outcomes would be acceptable to them, or to describe what matters most, such as being at home, being able to recognize family, or avoiding pain.

Planning ahead when memory problems are possible

People who are living with early memory loss can often still take part in planning, and doing it earlier gives the document a better chance of reflecting their own voice. A prospective intervention study (Project DECIDE) in people with Alzheimer's disease reported more valid advance directives among those offered structured advance care planning (Project DECIDE, part 1). Capacity is assessed for each decision rather than as all-or-nothing, and a clinician applying your state's standards can help judge whether someone can still complete a document.

If you are concerned about changes in thinking, talk to your clinician. One symptom alone does not establish dementia, and many people with mild memory changes do not progress quickly. Our article on mild cognitive impairment covers that question.

Some people also write specific wishes about late-stage dementia care. Published discussions of this area exist, including a recent paper on a proposed advance directive addressing voluntary stopping of eating and drinking (New VSED Advance Directive). Whether instructions about stopping eating and drinking can be honored varies by state, facility and clinician, so this is a topic to raise with an attorney and your care team.

How to choose a health care agent

Think about someone who:

• Is an adult you trust to follow your wishes, even if they would choose differently
• Can stay calm and speak up with medical teams
• Is reachable, ideally living nearby or able to travel
• Is willing to take on the role

Name an alternate agent in case your first choice is unavailable. Many people choose a spouse or an adult child, but the best fit is the person who understands you, whatever their relationship. Be cautious about naming someone who may have a conflict of interest. If you have concerns about how someone treats an older relative, see our article on signs of elder abuse or neglect.

Steps to put one in place

1. Reflect. Consider what a good day looks like for you, which outcomes you would find unacceptable, and how you feel about life-prolonging treatments.
2. Talk with your clinician. They can explain what treatments like CPR or a ventilator involve for someone with your health conditions, so you can decide what fits.
3. Talk with your family and agent. Documents work better when people have already heard your reasons.
4. Complete the forms. Use your state's forms. Witness or notary requirements vary, and an elder law attorney can help if your situation is complicated.
5. Share copies. Give copies to your agent, family, and every clinician or hospital that cares for you, and ask that it be added to your medical record. Keep the original somewhere accessible, not in a safe deposit box that no one can open in an emergency.
6. Review it. Many people revisit their directive after a new diagnosis, a hospital stay, the death of an agent, a move to another state, or a change in their wishes.

Are advance directives legally binding, and do clinicians follow them?

Advance directives are recognized under state law, but they can still go unused if no one knows one exists, if it cannot be found quickly, or if its wording does not match the situation. A paper on how valid advance directives are in acute situations explores some of these challenges (The Validity of Advance Directives in Acute Situations). Clear, specific language and a well-informed agent can help.

Research on completion is mixed and depends on the population studied. For example, one cohort study looked at how completing an advance directive related to hospital care among chronically homeless people (Effect of Advance Directive Completion on Hospital Care). Results from one group cannot be assumed to apply to everyone, so the strongest reason to complete one is to make your own wishes known.

Mental health and other special directives

Some people with a serious mental illness use a psychiatric advance directive to state treatment preferences and name a trusted person during a crisis. A randomized trial of a facilitated version found that support in completing the document was a way to encourage advance treatment planning (Facilitated psychiatric advance directives). Laws on these differ by state. If someone is thinking about harming themselves, call or text 988, the Suicide and Crisis Lifeline; call 911 if there is immediate danger. People with long-term rare or multi-organ conditions may also work with their specialty clinic on a directive, as described in one clinic implementation report (Advance Directive Focus in a Chronic Multi-Organ Rare Disease Clinic).

Advance directive vs. living will, POLST and DNR: what is the difference?

"Advance directive" is the umbrella term. A living will and a health care power of attorney are the two usual parts of it, and both can be completed by any adult at any health level.

A do-not-resuscitate (DNR) order is different. It is a medical order written by a clinician, often for people who are already seriously ill. Some states also use a POLST or a similar form. It is completed with a clinician, usually for people with serious illness or frailty, and it works alongside an advance directive and does not replace it. Whether either one fits your situation is something to discuss with your own care team.

Palliative care and hospice are types of care, not documents. Our article on palliative care and hospice explains how those services differ.

Common misunderstandings

• "It means I will be denied treatment." A directive states your choices. It can ask for full treatment as well as limits on it.
• "I can't change it." You can generally revise or revoke a directive while you have decision-making capacity. Tell your agent, family and clinicians, and replace older copies.
• "My family will just know." Close relatives often guess incorrectly or disagree about what a loved one would want.
• "It is only for people who are very sick." Sudden events can happen to anyone, which is why many clinicians encourage adults to plan.

When you have an emergency

Anyone can call 911 in an emergency. Paramedics generally begin treatment unless they have a valid out-of-hospital order they can see, and a regular advance directive in a drawer may not stop emergency treatment. If you have a DNR or POLST form, ask your clinician how your state handles those orders at home and keep a copy where responders can find it.

When to Seek Medical Care