Advance care planning (ACP) is an ongoing process that supports individuals at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. ACP can provide specific instructions as to what an individual may want or not want to happen when a serious illness, worsening condition, health crisis, or life-limiting event affects their decision-making capability.

By planning ahead for difficult decisions regarding care, individuals can prepare for uncertainties that lie ahead. Advance care planning has been shown to improve outcomes for individuals as serious illness progresses. Planning for difficult health decisions can help ease the concerns of family members, prevent confusion about decision-making, and help manage future care in a conscientious way.

Well written and documented advance directives (AD) can help family members, friends, or caregivers avoid conflict among each other or with healthcare providers when care decisions need to be made under difficult circumstances.  An AD is a written statement of an individual's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them on their own.

Types of Advance Medical Directives

Advance directives are used by individuals with many different health conditions. Even healthy individuals with no known health problems can prepare advance directives in order to plan for unexpected health crises and future medical care decisions. There are two main types of advance directives: a living will and a Healthcare Proxy or Medical Power of Attorney (MPOA).

Living Will

The idea of a living will was first proposed in 1969 by Luis Kutner, a human-rights lawyer who was nominated numerous times for the Nobel Peace Prize. Kutner was concerned that end-of-life medical decisions were influenced too much by technology that could keep someone alive, regardless of a person's own wishes or quality of life.

Living wills were designed to allow individuals to make conscientious decisions about their future care, taking into account personal values such as dignity, control, and comfort. When creating a living will, individuals also often consider their living situations and their concerns about becoming a burden to others. These are complex issues that should be discussed in depth with doctors, loved ones and caregivers. 

A living will spells out in writing the type of care an individual does or does not want, should they be unable to make their own decisions. Living wills are legally enforceable documents that state if, when, or for how long they would want specific treatments, such as:

• CPR:  Administered manually or with a device to restart the heart if it stops beating; some individuals choose a do-not-resuscitate (or DNR) order in the late stages of disease or life
• Feeding tube: Administers nutrition intravenously (through a tube) that is surgically inserted into the stomach
• Mechanical ventilator: Assists a person’s breathing with a tube inserted down the throat or through a tracheotomy incision in the neck
• Palliative care: An approach for managing pain and providing comfort without using treatments to prolong life

Other considerations include where an individual would like to receive treatment and wishes concerning aging in place and nursing home care facilities. 

Healthcare Proxy 

Sometimes called a medical power of attorney or a healthcare agent, a healthcare proxy is an individual appointed to make medical decisions when an individual is unable to do so for themselves. Legally, an individual can only have one health care proxy, but can have an alternate proxy designated in case that the primary healthcare proxy becomes unavailable.

A healthcare proxy can be a spouse, an adult child, or a friend. Some individuals may choose not to have a health care proxy if they are confident their caregivers are closely aligned with their health care choices. The health care proxy should also have a copy of the living will and be familiar with the decisions individuals have made about future care.

Challenges in Creating an Advance Directive

Creating the legal documents for an advance medical directive can become complicated and confusing with the legalase. Some states require specific types of witnesses to sign a living will. Some states require the document to be notarized by a notary public. Some require both.

An advance directive can be changed at any time, and it is important to review the directive periodically to be sure it still accurately reflects an individual's wishes for future care. For instance, they might change their mind about medical treatments in the living will. Or might want to change the healthcare proxy for any number of reasons, particularly if the proxy is having health problems of their own or is no longer available.

Advance directives raise difficult questions. It can be hard to consider health care decisions. Sometimes it takes several conversations to discuss these sensitive topics with healthcare providers, family members, and spiritual or legal advisers.

Working with an ACP Expert 

Iris takes ownership of the entire ACP process and champions the benefits of ACP to your patients. We take the burden of having these conversations off of the providers and remove the barrier to having these discussions. Our team manages the entire ACP process including member identification, outreach, expert led ACP facilitations and work with these patients and their families to deeply explore care goals on an ongoing basis. We document these care goals in full compliance with state and federal regulations, leveraging our own proprietary documentation in this process to ensure members’ unique care goals are described in full. We then distribute these documents to the points of use, ensuring physicians and family members are empowered with the information they need to carry out their wishes.