Advance Directives: Do You Have a Plan?
If you ever become too sick to communicate clearly, who will make decisions about your healthcare? Advance directives are legal documents you create before that happens, to guide your loved ones and your healthcare team in making those decisions.
There are two main advantages to having these documents. First, if life-sustaining measures become necessary in the future, the situation will be less stressful for everyone involved if they know you put your wishes in writing ahead of time. Second, the forms are recognized in all healthcare settings, and all healthcare professionals must follow them.
In New York State, there are three types of advance directives:
- A Do Not Resuscitate order (DNR)
- A living will
- A health care proxy
This article will discuss DNRs, living wills, health care proxies and the MOLST (Medical Orders for Life-Sustaining Treatment) form.
DNR (Do Not Resuscitate)
A DNR (“Do Not Resuscitate”) is a medical order that you ask your doctor to write. It tells the medical staff that if you experience an emergency situation in which you stop breathing and/or your heart stops beating, you do not want them to begin CPR (cardiopulmonary resuscitation). CPR can include chest compressions, an electric shock or drugs to get the heart to start beating again, or the insertion of a breathing tube. If you want a DNR, discuss it with your doctor now, before an emergency occurs.
A living will allows you to specify in writing the kinds of treatments you do or do not want, especially about end-of-life care, should you become unable to make decisions or communicate your wishes. Before it goes into effect, two doctors must state that you have a terminal illness — or that you will never regain consciousness — and that you can no longer make your own decisions.
A living will is not a specific form; many examples are available online. Your living will should include your name and state that you are the one who is creating the document. It should include:
- The date
- A statement that lists the medical treatments you do or do not want to prolong your life or provide end-of-life care
- Your signature
- The signatures of two witnesses, with the date
- Statements from the witnesses that you signed the document willingly and were not under pressure or being forced to sign it
It is also recommended that you have the document notarized (signed by a notary public), although that isn’t required by New York State law. You can usually find a notary public at a bank or city hall; some charge a fee for this service.
Health Care Proxy
A health care proxy lets you appoint a trusted adult (called a healthcare agent) to make medical decisions about your care in the event that you are unable to make them yourself. (If that happens, two doctors must first declare that you are not capable of making your own decisions.) It’s very important to document this arrangement in writing with a health care proxy form. Otherwise your doctors may choose not to follow the instructions given by your healthcare agent, even if you provided the agent with those specific instructions.
- You can give your healthcare agent the authority to make decisions for you in all medical situations. This would include such treatments as CPR (cardiopulmonary resuscitation), the use of feeding tubes, being put on a ventilator (a machine that breathes for you) and pain relief.
- You can put an expiration date on the form if you want to limit the time period during which your agent can make those decisions.
- If you don’t provide your healthcare agent with specific instructions, that person will be authorized to make decisions based on what they think you would want or based on what they consider the best option.
If you are unable to make treatment decisions for yourself and you have not appointed a health care proxy, a surrogate proxy will be appointed from the surrogate list below. New York State starts with the person described in #1. If you do not have a spouse or domestic partner, then your child who is 18 or older will be next in line.
- Your spouse (if you are not legally separated) or your domestic partner
- Your son or daughter, age 18 or older
- Your parent
- Your brother or sister, age 18 or older
- Your close friend
What’s the difference between a proxy and a surrogate? A proxy is someone you choose who can make any decision you specified on your health care proxy form. A surrogate is chosen by the state and is authorized to make any decision based on your religious or moral beliefs. If you don’t have specific religious or moral beliefs — or if your surrogate doesn’t know what they are — the surrogate will make decisions based on what they believe to be in your best interest.
Fast Facts: Advance Directives
- Advance directives are a helpful planning tool for everyone, regardless of current health.
- The forms are free.
- You have the right to create both a living will and a health care proxy in order to leave specific medical instructions in writing and appoint a health care agent to carry them out.
- You decide exactly what types of medical care and treatments to allow or not.
- You can cancel your living will at any time by simply destroying the document. You are not required to notify anyone before canceling.
- You must use a health care proxy form (not a living will) to name a healthcare agent.
- Your agent can make decisions related to artificial nutrition and hydration in keeping with your instructions on your health care proxy form.
- In the event that your heart stops, your agent will have the authority to decide whether or not you will receive CPR, unless you specify in your health care proxy form that your agent may not make this decision for you.
- Once your agent’s authority begins, he or she has the right to access your medical information and records to help make informed decisions.
- Your agent’s decision is final unless a family member or institution objects and obtains a court order overriding the decision or disqualifying the agent.
- Your agent is not financially responsible for the cost of your care.
- You can cancel the appointment of the agent on your health care proxy at any time and then fill out a new form naming a different agent.
- You can cancel your health care proxy by notifying your health care agent, doctor or anyone else who has a copy — either orally or in writing.
Medical Orders for Life-Sustaining Treatment (MOLST)
The MOLST form is a medical order approved by the New York State Department of Health. It details your wishes for life-sustaining treatment, but it is filled out and signed by your doctor. (The doctor needs to have a valid license to practice in New York.) The MOLST form is on bright pink paper, so it can be easily identified in an emergency.
The LegalCare team at Roswell Park can assist you in creating advance directives.
If you need more information about advance directives or would like to review the forms, here are a few sources:
- Advance Directives: Making Your Wishes Known and Honored (NY State Office of the Attorney General) Health Care Bureau Helpline: 800-428-9071
- CancerCare: The Role of a Health Care Proxy
- New York State Health Care Proxy form (available in English, Chinese, Haitian Creole, Italian, Korean, Russian, and Spanish)
- Advance directive forms by state (from AARP)
- Frequently Asked Questions about DNR (New York State Dept. of Health) — includes information about “Out of Hospital” DNRs and DNR bracelets
- Deciding About Health Care: A Guide for Patients and Families (New York State Dept. of Health) — available in English and Spanish
- At Roswell Park: Social Work: 716-845-8022; Resource Center for Patients & Families: 716-845-8659