The Advance Directive: What It Is, Why You Need One, and How to Get It Done

Only 36% of American adults have an advance directive. This means that when a medical crisis occurs, and for most people, it eventually will, the people who love them are left guessing what they would have wanted.

An advance directive is a legal document that tells your healthcare providers and your family what medical treatment you want (and don't want) if you become unable to speak for yourself. It is the single most important document most people never write. If you haven't yet looked at the full picture of estate planning myths that keep people from getting started, that's a useful companion to this guide. And if you're thinking about end-of-life care options more broadly, the hospice explainer and the guide to death with dignity laws cover the medical decisions that an advance directive helps you document.

Here is everything you need to know to actually complete one.

People compare these two terms as if they were separate documents and you had to pick one. You don't. A living will is one kind of advance directive. "Advance directive" is the category: any legal document that records your medical wishes in advance and takes effect only when you cannot communicate them yourself. The living will is one half of a complete advance directive. The healthcare proxy is the other half.

If you complete a living will, you already have an advance directive. An incomplete one. The living will covers the situations you predicted: CPR, a ventilator, a feeding tube. The healthcare proxy covers everything you didn't predict, by naming the person who decides when your written instructions run out. Most state forms put both in a single document, so you complete the two halves at once.

The word "will" causes most of the confusion. A living will has nothing to do with property. A last will and testament distributes what you own after you die. A living will directs your medical care while you are alive but unable to speak for yourself. Different documents, different laws, different signatures. You need both.

The same document goes by different names depending on which state form or website you are reading. Advance directive. Advance healthcare directive. Advance medical directive. Medical directive. Healthcare directive. All of these mean the same thing: the legal document that records your medical treatment wishes for the moment you cannot state them yourself.

The variation comes from state law. California's statutory form creates an "advance health care directive."^[6] Virginia's suggested form is titled "Advance Medical Directive."^[7] Other states split the parts into separately titled forms, one for the living will and one for the healthcare proxy. The title changes at the state line. The function does not.

This matters for one practical reason. When you look up your state's form, expect your state's name for it. A form titled "medical directive" or "health care directive" is not a different document, and you do not need one of each. Complete the form your state publishes, whatever your state calls it.

"Advance directive" is an umbrella term for several related documents: a living will, a healthcare proxy (also called a healthcare power of attorney or durable power of attorney for healthcare), and sometimes a POLST or DNR order. These documents work together to ensure that your healthcare wishes are known and legally documented.

Every state has its own advance directive forms and requirements. The documents are legally valid in the state where they are executed, and most states will honor out-of-state advance directives, though there can be complications. If you spend significant time in multiple states, consider completing advance directives in each.

A living will is a document that specifies what medical treatment you want or don't want in specific situations. It typically addresses: cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration (feeding tubes), dialysis, and comfort care.

The most important questions a living will answers are: If your heart stops, do you want CPR? If you can't breathe on your own, do you want to be placed on a ventilator? If you can't eat or drink, do you want a feeding tube? If you are in a persistent vegetative state with no reasonable chance of recovery, do you want life-sustaining treatment continued?

These are hard questions. They are much harder to answer in a hospital waiting room at 2am than they are at your kitchen table on a Tuesday afternoon. A living will answers them in advance, when you have time to think clearly and consult with your family and your doctor.

A living will only takes effect when you are unable to make decisions for yourself. When you are unconscious, incapacitated, or otherwise unable to communicate. It does not affect your ability to make your own medical decisions as long as you are able to do so.

A healthcare proxy, also called a healthcare power of attorney or durable power of attorney for healthcare, designates a specific person (your "agent" or "proxy") to make medical decisions on your behalf if you cannot make them yourself.

This is more important than a living will, because no document can anticipate every possible medical situation. A healthcare proxy gives someone you trust the authority to make decisions in situations your living will didn't cover.

Choosing your healthcare proxy is one of the most important decisions you will make. The person should be: someone you trust completely, someone who knows your values and wishes, someone who can handle stress and communicate clearly with medical professionals, and someone who will advocate for what you want. Even if it conflicts with what they want for you.

This is not always a spouse or a child. Sometimes the person who loves you most is not the person best equipped to make hard decisions under pressure. Think carefully about who you choose, and have an explicit conversation with them about your wishes.

A DNR (Do Not Resuscitate) order is a medical order, signed by a physician, that instructs healthcare providers not to perform CPR if your heart stops. It is not the same as an advance directive, though it is related.

A DNR is appropriate for people who have decided, in consultation with their physician, that CPR is not consistent with their goals of care. It is not appropriate for everyone, and it is not a decision to be made lightly. CPR is not always effective, survival rates for in-hospital cardiac arrest are approximately 25%, and for out-of-hospital arrest, approximately 10%, and when it is effective, it can result in broken ribs, brain damage, and a prolonged period of intensive care.

A POLST (Physician Orders for Life-Sustaining Treatment), called MOLST, MOST, or other names in different states, is a more comprehensive medical order that covers not just CPR but other life-sustaining treatments. It is typically used for people with serious illness or advanced age who have had a detailed conversation with their physician about their goals of care.

Unlike an advance directive, a POLST is a medical order that travels with the patient and must be followed by emergency responders. It is a more powerful document in emergency situations, but it requires a physician's signature and is not appropriate for everyone.

Completing an advance directive is simpler than most people expect. Here is the process:

Get the form for your state. Each state has its own advance directive form. You can find your state's form at CaringInfo.org (a program of the National Hospice and Palliative Care Organization), which provides free, state-specific advance directive forms.

Fill it out. The form will ask you to designate a healthcare proxy and to specify your wishes regarding life-sustaining treatment. Take your time. Read each question carefully. If you're unsure about a medical term, ask your doctor.

Sign it with the required witnesses. Most states require two witnesses, neither of whom can be your healthcare proxy, a family member, or someone who would inherit from you. Some states require notarization instead of witnesses. Check your state's requirements.

Give copies to the right people. Your healthcare proxy, your primary care physician, any specialists you see regularly, and your hospital if you have a preferred hospital. Keep the original in a place where it can be found. Not in a safe deposit box, which may not be accessible in an emergency.

Review it periodically. Your wishes may change over time. Review your advance directive every few years, or after any significant health event or change in your family situation.

Completing an advance directive is necessary but not sufficient. You also need to have a conversation, with your healthcare proxy, with your family, and ideally with your doctor, about what you want.

The conversation is hard. Most people avoid it for the same reason they avoid writing the document: it requires thinking about your own death, and thinking about your own death is uncomfortable.

But the alternative is worse. The alternative is a family gathered around a hospital bed, making decisions they were never prepared to make, without knowing what you would have wanted, in the worst moments of their lives. And when the immediate crisis passes, there is still a mountain of paperwork nobody warned you about. Accounts to close, institutions to notify, and a bureaucratic process that doesn't pause for grief.

The conversation doesn't have to be a formal sit-down. It can happen over dinner, on a drive, in the middle of a conversation about something else. What matters is that the people who might have to make decisions for you know what you want.

Tell them: what matters most to you in your life. What you would consider a good death. What you are afraid of. What you don't want. What you do want. And then write it down, sign it, and give them a copy.

It is one of the most loving things you can do for the people who love you.