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Advanced Health Care Directive [USA]

An Advance Health Care Directive (AHCD) is a document that instructs others about your care should you be unable to make decisions on your own. It only becomes effective under the circumstances delineated in the document. An Advance Health Care Directive allows you to do either or both of the following:

  • Appoint a Health Care Agent The AHCD allows you to appoint a health care agent (also known as “Durable Power of Attorney for Health Care” or “attorney-in-fact”), who will have the legal authority to make health care decisions for you if you are no longer able to speak for yourself. This is typically a spouse, but can be another family member, close friend, or anyone else you feel will see that your wishes and expectations are met. The individual named will have authority to make decisions regarding artificial nutrition and hydration and any other measures that prolong life—or not.
  • Prepare Instructions for Health Care
    The AHCD allows you to make specific written instructions for your future health care in the event of any situation in which you can no longer speak for yourself.
    The Advance Health Care Directive provides a clear statement of wishes about your choice to prolong your life or to withhold or withdraw treatment. You can also choose to request relief from pain even if doing so hastens death. A standard advance directive form provides room to state additional wishes and directions and allows you to leave instructions about organ donations.

Speak with Your Physician

It is important that you discuss your health care desires with your physician. He or she is likely to be the one caring for you when your instructions become relevant and is much more likely to honor requests that have been communicated directly. Furthermore, your physician can help you phrase your requests in a way that makes sense to physicians and can answer any questions you may have. Finally, your physician can point out any illogical or inconsistent features of your requests. Sometimes refusing one kind of treatment makes it illogical to expect to receive another kind of treatment. Your physician can smooth out some of these “rough edges” and help make a consistent and coherent directive. He or she will also tell you if there are aspects of your requests that he or she cannot honor because of personal, moral, or professional constraints.

Speak with Your Family

Despite your best efforts to plan for all eventualities in a health care declaration, actual events may not “fit” your directives. It is therefore important that you discuss your desires with family and friends. They can then often help clarify your directives on the basis of recollections of specific discussions under specific circumstances. In addition, if you have discussed your wishes with a number of people, it is more likely that those wishes will be honored.

Another benefit of discussion with family members is the avoidance of unpleasant scenes and confrontations when you are incapacitated. While family members may have little legal authority to make decisions for incapacitated patients, they often feel they have moral authority. They may be confused by statements not previously shared with them, and may even try to contest your wishes legally if they feel your choices are not in your “best interest.”

From The Living Will: A Guide To Health Care Decision Making []

Frequently Asked Questions

  • Are AHCD forms complicated?

AHCD forms are quite easy to fill out, but the content can be complex and should be thought through very carefully. Discussions with family members, legal, health or other appropriate professionals are highly encouraged before signing such a document. It is particularly important to talk with everyone who might be involved about your wishes because in times of stress, others may confuse their own wishes with your wishes. Individuals responsible for seeing directives followed may encounter resistance from care providers, friends or other family members. The way to avoid potential conflict—and even court action—is to tell your physician, close family and others who may be in your decision-making circle about your directives.

Advance directive forms and living wills are not complicated. They can be short, simple statements about what you want done or not done if you can’t speak for yourself. Remember, anything you write by yourself or with a computer software package should follow your state laws. So, it’s essential for you to know what the laws are in your state. While you are not required to seek legal advice to prepare an advance directive, it may be a good idea to do so to ensure that the actual instructions for your wishes are stated accurately. It has to be absolutely clear to be enforceable. 

  • Where do I find AHCD forms?

AHCD forms are available via State Healthcare Association websites, Community and Senior Services Organizations, attorneys handling wills, estates, probate and Elderlaw matters, Geriatric care managers, and Hospitals or hospice programs.

The Eldercare Locator (800) 677-1116 can also direct you to organizations and sites that can provide a copy of the advance directive form used by your state.

Not only is it important to develop our practice on impermanence, but also a pragmatic approach is necessary to ensure that life, aging, dying and death considerations are in place.  Certain documents are integral in our care when we are not in a capacity to make decisions or also are important for those who must make decisions on our behalf.

  • What do I do with my completed AHCD forms?

Once you have completed your advance directive, it may be necessary to have it notarized depending on who witnesses your signature—follow the instructions on the document. Providing many trusted individuals with copies of your advance directive will insure that your health care wishes are met in the event that you cannot express your wishes for yourself.

Copies should be given to family member(s); your primary care physician, hospital or health care institution, and/or anyone named in the directive.

A copy can also be sent to your attorney or kept in a safety deposit box or anywhere else you may keep copies of a will or other important papers. Be sure that you have discussed the directive with the person you designate as your health care agent and that he or she understands your wishes and the responsibilities involved.

  • What happens if I change my mind?

Directives can be revoked or replaced at any time as long as you are capable of making your own decisions. It is recommended that your documents be reviewed every two years or so (or if your health status changes) and revised to ensure that it continues to accurately reflect your situation and wishes.

As evidenced by the Schiavo case, choices about end of life are important for all adults—not just for the older population. Not only does an Advance Directive let your voice be heard about what you want, but it also relieves others of making these decisions for you and can prevent the type of situation we are seeing on the news today.

Thinking About Your Preferences

When completing the AHCD form it is important to think about your medical care preferences so you can talk with others.

In general it is not helpful to list a lot of specific treatments that you do not want – for example, “l don’t want tubes,” “l don’t want a respirator,”  etc. It is more helpful to think in terms of the goals and priorities you would use in making such decisions. Most of us tend to accept or reject specific treatment because it promises to do something that we value. So, we often submit even to painful and invasive procedures when they promise benefits that are very important to us. We reject even minor pain and inconvenience if we expect no benefit to come of it.

Some issues to think about because they tend to be universally important in making treatment decisions – but where individuals differ in their priorities (this is not exhaustive): relief of pain; ability to experience relationships; ability to engage in favorite activities; ability to think; ability to communicate; financial cost; suffering and anxiety to others; reconciliation and tying up loose ends; control of bodily functions; ability to move about; privacy;and religious needs.

Here are some statements that have been helpful for others. You may find it helpful to adopt or adapt one or more of them to express your own priorities:

    • In cases of doubt, err on the side of life.
    • I want those treatments that offer reasonable hope to restore me to a condition that my loved ones think l would find acceptable.
    • I do not want treatment that might postpone death but probably would not restore me to a quality of life that I find acceptable.
    • I do/do not want a treatment if there is some small, remote chance that it might help me.
    • I want treatment decisions made with a view to my overall condition and the treatment’s ability to improve this.
    • I want sufficient pain medication to keep me free of pain even if the dosage necessary might shorten my life.
    • I want the cost of treatment and its financial impact on my family/community to be considered in making decisions.
    • If I lose consciousness with no reasonable hope of ever regaining it l want all treatment stopped (including food and fluids).
    • I want my loved one/professionals  to make decisions about my care the way they think I would make them, were I able.

Information gathered by Center for Healthcare Ethics Orange, California 92669

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