Advance directives: Why what you have may not be enough

An advance directive is a general term of any document that contains instructions concerning a person's wishes relating to the medical treatment they receive when that person cannot make those decisions for themselves. Here are some commonly found advance directives:

• Living will
• Health care power of attorney
• Physician orders for life-sustaining treatment
• Do not resuscitate and do not intubate orders

Because an advance directive can refer to so many different things, it's important to know what the major types are so you can make an informed decision on which documents to have and what to include in them.

A living will is a document where you indicate your wishes concerning medical treatment and other aspects of your end-of-life wishes in situations where you are unable to convey those wishes yourself. For example, if you were to pass and wanted your organs donated, that request could be in a living will. A living will would also include instructions on the type of medical treatment you prefer.

You might be thinking this is all obvious: you want the best medical care possible and every effort to save your life. But what if saving your life is possible, but it leaves you permanently unconscious? In this situation, do you still want everything possible to be done to keep you medically alive? For some, the answer is yes. For others, the answer is no. A living will makes it clear to others what your wishes are.

Unlike a living will that sets forth the parameters of your medical and end-of-life care and wishes, a health care power of attorney assigns a specific person to make those decisions for you. Some people will have either a health care power of attorney or a living will, but it's best to have both. No living will can anticipate every single scenario where a medical decision will be necessary. So it's good to have an individual who can make decisions in situations that the living will does not account for.

Often abbreviated as a POLST, some states recognize this document to convey the wishes of a patient concerning their medical care. These instructions are often the same as those found in a living will. However, these instructions stay with the patient, sometimes next to their bed while receiving medical care.

A POLST also presents this information in a uniform format that is familiar to medical professionals and does not replace any other advance directives you may have.

A do not resuscitate (DNR) order is a special instruction where medical professionals are not to take certain steps to save your life if you are to stop breathing or your heart stops beating. In other words, you are not to be resuscitated, whether it's through the use of CPR, chest compressions, cardiac drugs or the use of breathing tubes.

A do not intubate order (DNI) is similar to a DNR, except it allows a bit more medical intervention than a DNR would. Specifically, it allows the use of chest compressions and cardiac drugs, but no breathing tube may be placed inside the patient.

If you are someone who would like to have a DNR or DNI order in place, then your living will should contain these instructions. Likewise, whoever you have assigned to be your health care power of attorney should be aware of your DNR and DNI wishes, assuming you have them. However, there are several reasons why having a living will or health care power of attorney isn't always sufficient if you would also like a DNR or DNI order in place.

First, some states will not enforce a living will or health care power of attorney outside of a hospital or medical facility setting. So if you're at home when you have a heart attack and do not want paramedics to use CPR, it's possible those paramedics will not honor those wishes, even if in a living will.

Second, even if you have a health care power of attorney, it can help settle disagreements about medical treatments. For example, a husband might have appointed his wife to be his health care power of attorney. And while receiving medical treatment, the husband stops breathing. Should the doctors intubate and give the husband a breathing tube? Perhaps the wife knows her husband wouldn't want that sort of medical treatment, but maybe their adult child doesn't know this.

So the wife has the legal authority to make the decision not to intubate. However, nothing can stop someone else, such as the adult child, from disagreeing with that decision or even challenging the validity of the health care power of attorney. But with a DNI, the authority of the health care power of attorney doesn't matter because of the DNI order that's in effect.

Many states will have specific terms to refer to the above-referenced advance directives. Below is a chart that outlines some of the additional names these advance directives may go by.