Advance Care Directives

Advance Care Planning conversations between you, family, friends, and your healthcare provider should center on goals of care. No two people are alike and the decisions are solely yours to make, but below are some goals commonly expressed by others near the end of life.

• Saying goodbye to my family and friends
• Being free from pain
• Staying off machines
• Situations you wish to avoid
• Maintaining my dignity
• Not being short of breath
• Not dying alone
• Having someone to listen to me
• Not being a burden to my family
• Having a doctor and nurse who know me
• Being at peace spiritually
• Dying at home
• Having my financial affairs in order

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The next step of Advance Care Planning is documentation. Advance Care Planning documents, but not limited to, are:

1. Advance Care Directives
2. Durable Power of Attorney for Healthcare Decisions

The focus of this website is an Advance Care Directive.

Advance Care Directive allows a person to document the medical treatments and interventions they wish to receive at their end-of-life, such as:

• Mechanical Ventilation
• Cardiopulmonary resuscitation (CPR)
• Artificially administered nutrition and hydration
• Dialysis

An Advance Care Directive allows caregivers, family, and loved-ones to know your wishes. They will not be left to struggle with making decisions on your behalf during an extremely stressful time. Moreover, without advanced care planning patients are more likely to receive non-beneficial, painful and expensive treatments prior to death.

1. Person filling it out must be eighteen years or older
2. Person must sign and date form
3. Requires two witnesses to sign and date
   • Witnesses cannot be related or stand to inherit from patient’s death
   • Witnesses cannot be either of your listed proxies
   • Select two people to be your health care proxies. Choose loved ones who know your end-of-life wishes.
   • An Advance Care Directive does not need to be notarized
   • A Durable Power of Attorney for healthcare powers document does need to be notarized

An Advance Care Directive is only activated under the following conditions:

• Patient lacks Decision-Making Capacity (unable to make his or her own healthcare decisions)
• Two Physicians have assessed and documented patient as having one or more of the following:
  • Terminal Condition
  • End-Stage Condition
  • Persistently Unconscious 

When an Advance Care Directive is completed, the following steps are recommended:

• Make copies to provide to family members and especially your healthcare proxy. It is important to provide copies to your designated proxies as well.
• Keep in a location that is easily accessible
• Bring a copy to your primary healthcare provider
  • Review your Advance Care Directive with the provider
  • Have your providers scan the Advance Care Directive into your medical record.
• If admitted to the hospital, bring a copy of Advance Care Directive

• Download this presentation outlining the process of completing an advance care directive.

Filling out Advance Care Directives can feel intimidating for some people. Below is a short video outlining how to fill one out. Please talk to your health care provider if you have questions or are uncertain of any part of your Advance Directive documents.

Decade: Every 10 years

Distance: When you or close loved ones move, especially if it's far away

Domestic Changes: when your legal status changes with spouse, partner, parent, or child

Diagnosis: When new health issues are identified

Decline: A significant decline in health status

Death: Of a friend or loved one, especially if they were your DPOA-H or healthcare proxy