End of Life Issues & Advanced Directives TEXT 8-5-17 · PDF file1 End of Life Issues ... , and...

EndofLifeIssues

&AdvanceDirectives

IncludedisasampleADVANCEDIRECTIVEFORHEALTHCARE

…andLinkstoall50State’sAdvanceDirectiveForms

AbouttheAuthor…

BrettW.Decker,CLU

Followingasuccessful25+yearfinancialplanningandsalescareeratvariouslevelswithinthefinancialservicesandinsuranceindustries,BrettW.Decker,CLU,hasalsoestablishedahighlysuccessful track record as an InsuranceCE subjectmatter expert andaCEprovider resourceoverhismostrecent16+years.BretthasforgedanewpathbyprovidingCEcourses,resources,andservicestoCEprovidersandstudentsallaroundtheUSA.Heisahighlyregarded"contract"instructor for InsuranceCE Classes andWebinars andhas conductedplanning and insurancerelatedliveeventsforover15yearswithhighmarksfromwellover10,000+satisfiedstudentsindozensof subject areas. In that sameperiod,healso createdandauthoredmore than80specializedinsuranceCEcourses,aswellasupdatedandreviseddozensmoreforCEprovidersnationally.With 30+years of experience in insurance sales, training, and client building activities in theinsuranceandfinancialservicesindustries,heisalsoarecognizedbroadbasedsubjectmatterspecialist.Brett's broad-based background, practical experience, "hands on" work in the insurancebusiness, and exposure to the foremostmarketing, sales and training consultants nationallyuniquelyequipshimforthe'partner'rolethatheseesforhimselfintheeducationandsupportof others. His work with experts in the fields of communication, training and businessdevelopment has given him much to draw on for his CE clients’ and students’ benefit. Hisinterviews,conversations,andrelationshipswithcountlessinsurancepeoplenationallyaddtohisinsightinCEcoursecreationforthefinancialplanningandinsuranceindustries.

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Contents

1EndofLifeIssues.........................................................................................................................2ThinkingAbouttheEndofLife...................................................................................................2PreparingFortheEndofLife......................................................................................................2TalkingaboutEnd-of-LifeWishes...............................................................................................3DefiningtheEndofLife...........................................................................................................4PreferencesfortheEndofLife...............................................................................................4WhatIsEnd-of-LifeCare?.......................................................................................................4HospiceCare........................................................................................................................5PalliativeCare......................................................................................................................5

QuestionsToAskAstheEndofLifeApproaches....................................................................5PlanningfortheFuture...............................................................................................................5ConsiderTheseSituations.......................................................................................................5PlanfortheFuture..................................................................................................................6WhatExactlyIsan“ImportantPaper”?..................................................................................6PersonalRecords.....................................................................................................................6StepsforGettingAffairsinOrder...........................................................................................7LegalDocuments.....................................................................................................................8Resources................................................................................................................................8GettingYourAffairsinOrder..................................................................................................9Whoshouldyouchoosetobeyourhealthcareproxy?......................................................9HowdoyouhelpsomeonewithAlzheimer’sordementiagettheiraffairsinorder?........9

AdvanceCarePlanning.............................................................................................................10WhatIsAdvanceCarePlanning?..........................................................................................10MedicalResearchandAdvanceCarePlanning.....................................................................10DecisionsThatCouldComeUpNearDeath..........................................................................11CPR....................................................................................................................................11VentilatorUse....................................................................................................................11ArtificialNutritionorArtificialHydration..........................................................................11ComfortCare.....................................................................................................................12

MoreAboutHospiceCareandPalliativeCare......................................................................12GettingStarted..................................................................................................................12

DoYouoraFamilyMemberhaveAlzheimer'sDisease?......................................................13MakingYourWishesKnown.................................................................................................13LivingWill..........................................................................................................................13DurablePowerofAttorneyforHealthCare......................................................................14OtherAdvanceCarePlanningDocuments........................................................................14WhatAboutPacemakersandICDs?..................................................................................15SelectingYourHealthcareProxy.......................................................................................15MakingItOfficial...............................................................................................................15

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FutureDirections..................................................................................................................16AfterYouSetUpYourAdvanceDirective..........................................................................16StillNotSure?....................................................................................................................16LookingTowardtheFuture...............................................................................................17AdvanceDirectiveWalletCard..........................................................................................17Printablewalletcardspecifyingadvancedirectiveinformation.......................................17

2SpotlightonEnd-of-LifeDecisions.............................................................................................19Whitney'sDaughter:Family'sHeartbreakingLifeSupportDecision........................................19JoanRivers................................................................................................................................21KeyLegalCases.........................................................................................................................22WhatHappensWhenThereareNODirectives.....................................................................22KarenAnnQuinlan................................................................................................................22NancyBethCruzan................................................................................................................23MichaelMartin......................................................................................................................23Theresa("Terri")MariaSchindlerSchiavo............................................................................25

3TheBasics...................................................................................................................................29AdvanceMedicalDirectiveFacts..............................................................................................29IntroductiontoAdvanceMedicalDirectives............................................................................30AdvanceDirectives................................................................................................................30Health-careProxy..................................................................................................................30DurablePowerofAttorney(DPOA)......................................................................................30ImportanceofanAdvanceDirective.....................................................................................31HistoryofAdvanceDirectives...............................................................................................31TheFirstLivingWills..........................................................................................................31TheStates..........................................................................................................................32

TheCurrentSituation...............................................................................................................33TypesofHealthCareDocuments.............................................................................................33LivingWills............................................................................................................................34PowersofAttorneyforHealthCare......................................................................................34Whatisanadvancedirectiveforhealthcare?......................................................................34IsanyparticularformofADHCrequired?.............................................................................35WhomayexecuteanADHC?................................................................................................35Whatisahealthcareagent?................................................................................................35Whatismeantbyhealthcare?.............................................................................................35Whatpowersdoesmyhealthcareagenthave?...................................................................35Doesmyhealthcareagenthaveaccesstomedicalrecords?...............................................36Howdoesmyhealthcareagentmakedecisions?................................................................36AmIrequiredtoappointahealthcareagentinmyADHC?.................................................36HowdoIexpressmytreatmentpreferencesforaterminalconditionorstateofpermanentunconsciousnessinmyADHC?.............................................................................................36Whatisaterminalcondition?...............................................................................................36Whatisastateofpermanentunconsciousness?..................................................................37Whatarelife-sustainingprocedures?...................................................................................37

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What are my options for treatment preferences for a terminal condition or state ofpermanentunconsciousness?...............................................................................................37Canmyhealthcareagentmakedecisionsregardingmytreatmentinaterminalconditionorstateofpermanentunconsciousness?.............................................................................37Am I required to expressmy treatment preferences for a terminal condition or state ofpermanentunconsciousnessinmyADHC?...........................................................................38IsmyhealthcareproviderrequiredtohonormyADHC?.....................................................38WhateffectdoesmymarriageordivorcehaveonmyADHC?.............................................38WhatisthedifferencebetweenanADHCandadurablepowerofattorneyforhealthcare?..............................................................................................................................................38WhatisthedifferencebetweenanADHCandalivingwill?.................................................38Whatisaguardian?..............................................................................................................39

4PowersofAttorneyandAdvanceDirectives.............................................................................40FinancialPowerofAttorney.....................................................................................................40Whatisafinancialpowerofattorney?.................................................................................40WhatarethetypicalpowersgrantedunderaDurablePowerofAttorney?........................41WhatRulesshouldmyagentfollowwhenactingonmybehalf?.........................................41Whatifthereismorethanoneattorney-in-fact?................................................................41Whendoesthepowerofattorneytakeeffect?....................................................................42Doesthepowerofattorneytakeawayaprincipal’srights?.................................................42Cantheprincipalchangehisorhermind?...........................................................................42Cananattorney-in-factbeheldliableforhisorheractions?...............................................42Cananattorney-in-factbecompensatedforhisorherwork?.............................................42Cantheattorney-in-factbefired?........................................................................................42Whatkindofrecordsshouldtheattorney-in-factkeep?......................................................42AdvanceDirectiveforHealthcare/HealthcarePowerofAttorney:......................................43InGeneral..........................................................................................................................43

Is the Advance Directive for Healthcare the same as a Durable Power of Attorney forHealthcareormyLivingWill?...............................................................................................43Whattypeofmedicalproceduresandtreatmentsareyoutalkingabout?..........................44WhydoIneedtocompleteanAdvanceDirectiveforHealthcare?......................................44Whatisa“DoNotResuscitate”(DNR)order?......................................................................44WhendoesaphysicianwriteaDNRorder?..........................................................................44HowwillmedicalpersonalknowthataDNRorderisinplace?............................................45DoesaDNRorderstopmedicalpersonalfromtreatingapatientcompletely?...................45CanaDNRorderberevoked?...............................................................................................45Whatisa“code”?.................................................................................................................45Whatisa“nocode”?............................................................................................................45IsthereaformoftheAdvanceDirectiveforHealthcare?....................................................45

5WhattoKnowandDo...............................................................................................................47ThingsYouShouldDo...........................................................................................................47ThingsYouShouldKnow.......................................................................................................47

6AdvanceDirectiveforHealthCare............................................................................................51Purpose:....................................................................................................................................51

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Instructions...............................................................................................................................52Definitions................................................................................................................................52Certificationofaterminalconditionorstateofpermanentunconsciousness........................54ThedifferencebetweenthisadvancedirectiveformandtheLivingWillandDurablePowerofAttorneyforHealthCare..........................................................................................................54Nolimitationontheuseofotheradvancedirectivesforms....................................................54ThreePartsoftheAdvanceDirectiveforHealthCare..............................................................54Requirementsforthepersonmakinganadvancedirectiveforhealthcare........................55Executingtheadvancedirectiveforhealthcare...................................................................55Restrictionsonthehealthcareagent...................................................................................55Dutyofthehealthcareagenttoact.....................................................................................55Authorizedresponsibilities/dutiesofthehealthcareagentrelatedtothenecessarycareofthedeclarant.........................................................................................................................56Prohibitedactionsbythehealthcareagent.........................................................................56When the attending physician, health care provider and/or health care facility refuse tohonortheadvancedirectiveforhealthcare........................................................................56Revokingthisadvancedirectiveforhealthcare...................................................................57Whattodowiththecompletedform...................................................................................57

7AdvanceDirectiveforHealthCare–“Forms”...........................................................................58AdvanceDirectiveForm–“Sample”.........................................................................................59

8WhattoDoNow.........................................................................................................................65Suggestions...............................................................................................................................65ImportantPointstoRememberAboutAdvanceDirectives:.................................................66

RResources..................................................................................................................................67

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EndofLifeIssues&AdvanceDirectives

ObjectivesandOverview

Thinkingabout theendofa life isnevereasy,whether it isyourownor the lifeof someoneclose toyou.But,planningaheadandhavingabetterunderstandingofwhat ishappening inthelastdaysandhoursmightmeanacomfortabledeathandcouldmakeaverydifficulttimejustalittleeasier.Thiscoursewillhelp.Thanks to theNational Institute on Aging at NIH, the information in this course is based onscientific researchanddevelopedwithexperts in end-of-life issues. It’s full of information tohelpusbetterunderstandadvance careplanning. Therearealso suggestions forbeginningaconversationaboutend-of-lifecareandprovidingcomfortcarefriends,clients,andotherswithsomeoneneartheendoflife.To underscore the realities of life and responsibility for consequences of our actions, wespotlightfamousendoflifecasesandpersonalities.Inaddition,ifyou'relikemostpeople,youandyourclientsaren'teagertospendtimethinkingabout what would happen if you or they became unable to direct their own medical carebecauseofillness,anaccident,oradvancedage.Thiscoursewillhelptotacklethismoreoftenandmoreconfidently.However,ifyouandyourclientsdonotdoatleastalittlebitofplanning-writingdownyourand theirwishesabout thekindsof treatmentyouand theydoordon'twant to receiveandnamingsomeoneyouandtheytrusttooverseeyourandtheircare-theseimportantmatterscouldwindupinthehandsofestrangedfamilymembers,doctors,orsometimesevenjudges,whomayknowverylittleaboutwhatyouandtheywouldprefer.So,wetakearealcloselookattheWho,What,Where,Why,andHowasitrelatedtoAdvancedDirectives.Weevenprovideyouwithaccesstoasampleandalinkinstructionforeverystatesoyoucanmakesureyouhaveoneforyourselfandspouse,ifany,andcertainlyforyourclients.

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Lesson1ObjectivesUponcompletionofthissection,youwill:

§ Gainincreasedawarenessofendoflifeissues.§ Knowhowtopreparefortheendoflife.§ Bepreparedtothinkabout,talkabout,anddefineendoflifewishes.§ Bepreparedtobeginplanningforthefuture.§ Knowhowtogetendoflifeaffairsinorder.§ Beabletobetterassistothersinadvancedcareplanning. § Beabletobetterassistothersinmakingtheirwishesknown.

1EndofLifeIssuesThinkingAbouttheEndofLifeThinkingabout theendofa life isnevereasy,whether it isyourownor the lifeof someoneclose toyou.But,planningaheadandhavingabetterunderstandingofwhat ishappening inthelastdaysandhoursmightmeanacomfortabledeathandcouldmakeaverydifficulttimejustalittleeasier.Hereissomeinformationtohelp.Derived largely from theNational InstituteonAgingatNIH, the following information in thischapterisbasedonscientificresearchanddevelopedwithexpertsinend-of-lifeissues.It’sfullof information tohelpyouunderstandadvancecareplanning.Therearealso suggestions forbeginningaconversationaboutend-of-lifecareandprovidingcomfortcarefriends,clients,andotherswithsomeoneneartheendoflife.

PreparingfortheEndofLifeFewofusarecomfortabletalkingaboutdeath,whetherourownoralovedone’s.Itisascary,eventaboo,subjectformany.Theendofa life,nomatterhowlongandwell lived,canbringwithitasenseoflossandsadness.Itcanalsobeareminderofourownmortality,sowemayavoideventhinkingaboutdeath.

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Thisisnormal--butdeathisnormal,too.Allofuswillfaceitatsomepoint.Becauseofadvancesinmedicine,eachofus,aswellasourfamiliesandfriends,mayfacemanydecisionsaboutthedyingprocess.Ashardas itmightbetofacetheideaofyourowndeath,youmighttaketimetoconsiderhowyourindividualvaluesrelatetoyourwishesforend-of-lifecare.By decidingwhat end-of-life care best suits your needswhen you are healthy, you can helpthoseclosetoyoutomaketherightchoiceswhenthetimecomes.Thisnotonlyrespectsyourvalues,butalsomaygiveyourlovedone’scomfort.Thereareseveralwaystomakesureothersknowthekindofcareyouwantwhendying.

TalkingaboutEnd-of-LifeWishesThesimplest,butnotalwaystheeasiest,wayistotalkaboutend-of-lifecarebeforeanillness.Discussingyourthoughts,values,anddesiresaboutend-of-lifecarebeforeyoubecomesickwillhelppeoplewhoareclosetoyoutoknowwhatcareyouwant.Youcoulddiscusshowyoufeelaboutusinglife-prolongingmeasures(forexample,CPRoraventilator)orwhereyouwouldliketo be cared for (for example, home or nursing home). Doctors should be told about thesewishesaswell.Forsomepeople,itmakessensetobringthisupatasmallfamilygathering.Somemayfindthattellingtheirfamilytheyhavemadeawill(orupdatedanexistingone)providesanopportunitytobringupthissubjectwithotherfamilymembers.Ashardas itmightbetotalkaboutyourend-of-lifewishes,knowingyourpreferencesaheadof timecanmakedecision-makingeasierforyour family.Youmayalsohavesomecomfortknowing thatyour family canchoosewhatyouwant.Ontheotherhand, ifyourparents(oranothercloserelativeorfriend)areagingandyouareunsure aboutwhat theywant, youmight introduce the subject. You can try to explain thathavingthisconversationwillhelpyoucareforthemanddowhattheywant.Youmightstartbytalkingaboutwhatyouthinktheirvaluesare,insteadoftalkingaboutspecifictreatments.Trysayingsomething like,“WhenUncle Isaiahhadastroke, I thoughtyouseemedupsetthathiskidswantedtoputhimonarespirator.”Or,“I’vealwayswonderedwhyGrandpadidn’tdieathome.Doyouknow?”Encourageyourparentstosharethetypeofcaretheywouldchoosetohaveattheendoflife,ratherthanwhattheydon’twant.Thereisnorightorwrongplan,onlywhattheywouldlike.Iftheyarereluctanttohavethisconversation,don’tforceit,buttrytobringitupagainatalatertime.

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DefiningtheEndofLifeTheendoflifeandhowpeoplediehaschangedagreatdealinthepastcentury.Thanksinlargepart to advances in public health,medicine, and health care,most Americans no longer diesuddenlyfrominjuryorinfection.Instead,welivelongerand,moreoftenthannot,dieafteraperiodofchronicillness.Asaresult,itishardtoknowwhenthedyingprocessbegins.Somepeoplepassquickly,whileothersrecoverfromsevereillnessseveraltimesbeforedeath.Evenpeoplewhoarethesameageandsex,withthesamediseaseandstateofhealth,areunlikelytoreachtheendoflifeatthesametime.Weoftenrelyonhealthcareproviderstotelluswhentheendoflifeisnear.Buteventhemostexperiencedhealthcareprovidermayfindithardtopredictwhensomeonewilldie.Anexpertmaysaytheend iswithinweeksormonths,butthedyingpersonslipsawaymuchsoonerorsurvivesforayearormore.

PreferencesfortheEndofLifeBecausetheendof life ishardtopredict, it isbesttoplanahead.Youmightwanttostartbyaskingyourselforalovedone,“Whatisthebestwaytoplanfortheendoflife?”Theanswerwilldiffer fromperson toperson.Somepeoplewant to spend their finaldaysathome,surroundedbyfamilyandfriends.Othersmayprefertobealone,ortobeinahospitalreceivingtreatmentsforanillnessuntiltheveryend.Theanswermayalsochangeovertime--thepersonwhowantedeverythingpossibledonetoprolong life may decide to change focus to comfort. Someone else who originally declinedtreatmentmay agree to an experimental therapy thatmay benefit future patients with thesamecondition.Nomatterhowapersonchooses toapproach theendof their life, thereare somecommonhopes--nearlyeveryonesaystheydonotwanttodieinpainortolosetheirdignity.Planningfor end-of-life care, also known as advance care planning, can help ensure such hopes arefulfilled.Wewilllearnmoreaboutadvancecareplanningintheupcomingsection“PlanningforCare”.

WhatIsEnd-of-LifeCare?End-of-life care is the broad term used to describe the special support and attention givenduringtheperiodleadinguptodeath,whenthegoalsofcarefocusoncomfortandqualityoflife.

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HospiceCareOne of the ways end-of-life care is provided is through hospice. Hospice, as defined by theCenterforMedicareandMedicaidServices,isaprogramofcareandsupportforadyingpersonwhosedoctorandahospicemedicaldirectorcertifyhaslessthansixmonthstolive.The focus of hospice is on comfort, not cure. Currently, patientsmust bewilling to give upcurativetreatmentstoreceiveMedicarecoverageforhospicecare.(Medicarecontinuestopayforanycoveredhealthproblemsthatareunrelatedtothedyingperson’sterminalillness.)

PalliativeCareUnlike hospice care, you do not have to be dying or give up curative treatments to receivepalliative care. The term “palliative care” is sometimesmistakenly used tomean end-of-lifecare,butpalliativecareisatreatmentavailabletoanyoneofanyagewhoissufferingfromthediscomforts,symptoms,andstressofaseriousillness.Palliative care is used effectively to provide relief from many chronic conditions and theirtreatments,too.Olderpersonswhoare livingwithoneormorechronic illnessesmaybenefitfrom palliative care long before they need end-of-life or hospice care. Unlike hospice care,palliativecaremaybeusedforaslongasnecessary.

QuestionsToAskAstheEndofLifeApproachesRegardless of a person’s choices for treatment and care at the endof life, it is important tomaintainthequalityofadyingperson’slife.Tobetterunderstandthecareoptionsavailableforsomeone who is approaching death, you may wish to ask the dying person’s health careproviderthefollowingquestions.

• Sincetheillnessisworsening,whatwillhappennext?• Whyareyousuggestingthistestortreatment?• Willthetreatmentbringphysicalcomfort?• Willthetreatmentspeeduporslowdownthedyingprocess?• Whatcanweexpecttohappeninthecomingdaysorweeks?• IfIormylovedonetakethistreatmentorparticipateinthisclinicaltrial,will it

benefitothersinthefuture?

PlanningfortheFuture

ConsiderTheseSituationsBen has been married for 47 years. He always managed the family’s money. But since hisstroke,Ben isnot able towalkor talk.Hiswife, Shirley, feelsoverwhelmed.Of course, she’s

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worriedaboutBen’shealth.But,ontopof that, shehasno ideawhatbills shouldbepaidorwhentheyaredue.Acrosstown,80-year-oldLouiselivesalone.Onenight,shefellinthekitchenandbrokeherhip.Shespentaweekinthehospitaland2monthsinarehabilitationnursinghome.Eventhoughhersonlivesacrossthecountry,hewasabletopayherbillsandhandleherMedicarequestionsrightaway.That’sbecause,severalyearsago,LouiseandhersonmadeaplanaboutwhatheshoulddoincaseLouisehadamedicalemergency.

PlanfortheFutureNooneeverplans tobe sickordisabled.Yet, it’s this kindofplanning that canmakeall thedifferenceinanemergency.Longbeforeshefell,Louiseputallherimportantpapersinoneplaceandtoldhersonwheretofindthem.Shegavehimthenameofherlawyer,aswellasalistofpeoplehecouldcontactather bank, doctor’s office, insurance company, and investment firm. She made sure he hadcopies of herMedicare and other health insurance cards. She added her son’s name to hercheckingaccountandsafedepositboxatthebank.LouisemadesureMedicareandherdoctorhadwrittenpermissiontotalkwithhersonaboutherhealthandinsuranceclaims.Ontheotherhand,Benalwaystookcareoffamilymoneymatters,andhenevertalkedaboutthedetailswithShirley.NoonebutBenknewthathislifeinsurancepolicywasinaboxinthecloset or that the car title and deed to the housewere filed in his desk drawer. Ben neverexpectedthathiswifewouldhavetotakeover.HislackofplanninghasmadeatoughjobeventougherforShirley.

WhatExactlyIsan“ImportantPaper”?The answer to this questionmay be different for every family. Remember, this is a startingplace.Youmayhaveotherinformationtoadd.Forexample,ifyouhaveapet,youwillwanttoincludethenameandaddressofyourveterinarian.Includecompleteinformationabout:

PersonalRecords

• Fulllegalname• SocialSecuritynumber• Legalresidence• Dateandplaceofbirth• Namesandaddressesofspouseandchildren• Locationofbirthanddeathcertificatesandcertificatesofmarriage,divorce,citizenship,

andadoption• Employersanddatesofemployment

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• Educationandmilitaryrecords• Namesandphonenumbersofreligiouscontacts• Membershipsingroupsandawardsreceived• Names and phone numbers of close friends, relatives, doctors, lawyers, and financial

advisors• Medicationstakenregularly(besuretoupdatethisregularly)• Locationoflivingwillandotherlegaldocuments• FinancialRecords• Sourcesofincomeandassets(pensionfromyouremployer,IRAs,401(k)s,interest,etc.)• SocialSecurityandMedicare/Medicaidinformation• Insuranceinformation(life,health,long-termcare,home,car)withpolicynumbersand

agents’namesandphonenumbers• Namesofyourbanksandaccountnumbers(checking,savings,creditunion)• Investment income (stocks, bonds, property) and stockbrokers’ names and phone

numbers• Copyofmostrecentincometaxreturn• Locationofmostup-to-datewillwithanoriginalsignature• Liabilities,includingpropertytax—whatisowed,towhom,andwhenpaymentsaredue• Mortgagesanddebts—howandwhentheyarepaid• Locationoforiginaldeedoftrustforhome• Cartitleandregistration• Creditanddebitcardnamesandnumbers• Locationofsafedepositboxandkey

StepsforGettingAffairsinOrderPutyourimportantpapersandcopiesoflegaldocumentsinoneplace.Youcansetupafile,puteverything in a desk or dresser drawer, or list the information and location of papers in anotebook. Ifyourpapersare inabanksafedepositbox,keepcopies ina fileathome.Checkeachyeartoseeifthere’sanythingnewtoadd.Tellatrustedfamilymemberorfriendwhereyouputallyourimportantpapers.Youdon’tneedto tell this friend or familymember about your personal affairs, but someone should knowwhereyoukeepyourpapersincaseofanemergency.Ifyoudon’thavearelativeorfriendyoutrust,askalawyertohelp.Givepermission in advance for your doctor or lawyer to talkwith your caregiver as needed.There may be questions about your care, a bill, or a health insurance claim. Without yourconsent,yourcaregivermaynotbeabletogetneededinformation.YoucangiveyourokayinadvancetoMedicare,acreditcardcompany,yourbank,oryourdoctor.Youmayneedtosignandreturnaform.

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LegalDocumentsTherearemanydifferenttypesoflegaldocumentsthatcanhelpyouplanhowyouraffairswillbehandledinthefuture.Manyofthesedocumentshavenamesthatsoundalike,somakesureyou are getting the documents youwant. Also, State laws vary, so find out about the rules,requirements,andformsusedinyourState.Willsandtrustsletyounamethepersonyouwantyourmoneyandpropertytogotoafteryoudie.Advancedirectivesletyoumakearrangementsforyourcareifyoubecomesick.Therearetwowaystodothis:A livingwill gives youa say in yourhealth care if youbecome too sick tomakeyourwishesknown.Inalivingwill,youcanstatewhatkindofcareyoudoordon’twant.Thiscanmakeiteasierforfamilymemberstomaketoughhealthcaredecisionsforyou.A durable power of attorney for health care lets you name the person you want to makemedicaldecisionsforyouifyoucan’tmakethemyourself.Makesurethepersonyounameiswillingtomakethosedecisionsforyou.Forlegalmatters,therearetwowaystogivesomeoneyoutrustthepowertoactinyourplace:

• Ageneralpowerofattorneyletsyougivesomeoneelsetheauthoritytoactonyour behalf, but this power will end if you are unable to make your owndecisions.

• Adurablepowerofattorneyallowsyoutonamesomeonetoactonyourbehalf

foranylegaltask,butitstaysinplaceifyoubecomeunabletomakeyourowndecisions.

ResourcesYoumay want to talk with a lawyer about setting up a general power of attorney, durablepowerofattorney,jointaccount,trust,oradvancedirective.Besuretoaskaboutthelawyer’sfeesbeforeyoumakeanappointment.Youshouldbeabletofindadirectoryoflocallawyersatyourlibrary,oryoucancontactyourlocalbarassociationforlawyersinyourarea.YourlocalbarassociationcanalsohelpyoufindwhatfreelegalaidoptionsyourStatehastooffer.Aninformedfamilymembermaybeabletohelpyoumanagesomeoftheseissues.

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GettingYourAffairsinOrder

Whoshouldyouchoosetobeyourhealthcareproxy?Ifyoudecidetochooseaproxy,thinkaboutpeopleyouknowwhoshareyourviewsandvaluesaboutlifeandmedicaldecisions.Yourproxymightbeafamilymember,afriend,yourlawyer,orsomeonewithwhomyouworship.Ifyouragingparentscannolongermaketheirownhealthcaredecisions,howdoyoudecidewhattypeofcareisrightforthem?It can be overwhelming to be asked to make health care decisions for someone who is nolonger able to make his or her own decisions. Get a better understanding of how to makehealthcaredecisionsforalovedone,includingapproachesyoucantake,issuesyoumightface,andquestionsyoucanasktohelpyouprepare.

HowdoyouhelpsomeonewithAlzheimer’sordementiagettheiraffairsinorder?AcomplicationofdiseasessuchasAlzheimer’sisthatthepersonmaylackorgraduallylosetheability to think clearly. This change affects his or her ability to participate meaningfully indecision making and makes early planning even more important. Find legal and financialplanningtipsforpeoplewithAlzheimer’sdisease,includinginformationonadvancedirectives,resources,andadditionaladvanceplanningadvice.Interestedinorgandonationandtransplantation?FindresourcesIamconsideringbecominganorgandonor.Istheprocessdifferentforolderadults?There are many resources for older organ donors and recipients available from the U.S.government. Find information for potential donors and transplant recipients over age 50,includinghowtoregistertobeadonor.IwanttomakesuremyaffairsareinorderbeforeIdie,butI’mnotsurewheretobegin.TheNational Institute onAging has a resource about Endof Life:HelpingWith Comfort andCare.This guide can help you and your loved ones discuss key issues at the end of life, includingfinding hospice care, what happens at the time of death, managing grief, and preparingadvancedirectivesalongwithresourcesformoreinformation.Formoreinformationaboutgettingyouraffairsinorder,pleaseseetheResourcesectionattheendofyourcourse.

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AdvanceCarePlanning

WhatIsAdvanceCarePlanning?Advance care planning is not just about old age. At any age, a medical crisis could leavesomeone too ill tomake his or her own healthcare decisions. Even if you are not sick now,makinghealthcareplans for the future is an important step towardmaking sure youget themedical care you would want, even when doctors and family members are making thedecisionsforyou.Morethanoneoutof fourolderAmericansfacequestionsaboutmedicaltreatmentneartheend of life but are not capable of making those decisions. This tip sheet will discuss somequestionsyoucanthinkaboutnowanddescribewaystoshareyourwisheswithothers.Writethemdownoratleasttalkaboutthemwithsomeonewhowouldmakethedecisionsforyou.Knowinghowyouwoulddecidemighttakesomeoftheburdenofffamilyandfriends.Advance care planning involves learning about the types of decisions thatmight need to bemade, considering those decisions ahead of time, and then letting others know about yourpreferences,oftenbyputtingthemintoanadvancedirective.Anadvancedirectiveisalegaldocumentthatgoesintoeffectonlyifyouareincapacitatedandunable to speak for yourself. This couldbe the result of diseaseor severe injury—nomatterhowoldyouare.Ithelpsothersknowwhattypeofmedicalcareyouwant.Italsoallowsyoutoexpress your values and desires related to end-of-life care. You might think of an advancedirectiveasa livingdocument—onethatyoucanadjustasyoursituationchangesbecauseofnewinformationorachangeinyourhealth.

MedicalResearchandAdvanceCarePlanningMedical research plays an important role in the health of Americans of all ages. Because ofadvancesinmedicineandinpublichealth,Americansarelivinglongerandstayinghealthierastheygrowolder.TheNational InstituteonAging(NIA)supportsmuchoftheresearcharoundthecountrythatlooksathowpeopleageandhowtoimprovetheirhealthintheirlateryears.NIAispartoftheNationalInstitutesofHealth(NIH),thenation’smedicalresearchagency.Some NIA-supported research focuses on advance care planning, including examining whypeoplemightcompleteadvancedirectivesandtheeffectofthesedirectivesonend-of-lifecare.Inonestudy,forexample,scientistsfundedbyNIAfoundthatadvancedirectivescanmakeadifferenceandthatpeoplewhodocumenttheirpreferencesinthiswayaremorelikelytogetthecaretheypreferattheendoflifethanpeoplewhodonot.

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DecisionsThatCouldComeUpNearDeathSometimeswhendoctorsbelieveacureisnolongerpossibleandyouaredying,decisionsmustbemadeabout theuseof emergency treatments to keep youalive.Doctors canuse severalartificialormechanicalwaystotrytodothis.Decisionsthatmightcomeupatthistimerelateto:

• CPR(cardiopulmonaryresuscitation)• ventilatoruse• artificialnutrition(tubefeeding)orartificialhydration(intravenousfluids)• comfortcare

CPRCPR(cardiopulmonaryresuscitation)mightrestoreyourheartbeatifyourheartstopsorisinalife-threatening abnormal rhythm. The heart of a young, otherwise healthy person mightresumebeatingnormallyafterCPR.Anotherwisehealthyolderperson,whoseheartisbeatingerraticallyornotbeatingatall,mightalsobehelpedbyCPR.CPR is less likelytoworkforanolderpersonwhois ill,can’tbesuccessfullytreated,and isalreadyclosetodeath. It involvesrepeatedlypushingonthechestwithforce,whileputtingairintothelungs.Thisforcehastobequite strong, and sometimes ribs are broken or a lung collapses. Electric shocks known asdefibrillationandmedicinesmightalsobeusedaspartoftheprocess.

VentilatorUseVentilators are machines that help you breathe. A tube connected to the ventilator is putthrough the throat into the trachea (windpipe) so themachine can force air into the lungs.Putting the tube down the throat is called intubation. Because the tube is uncomfortable,medicines are used to keep you sedated (unconscious) while on a ventilator. If you can’tbreatheonyourownafterafewdays,adoctormayperformatracheotomyor“trach”(rhymeswith“make”).Duringthisbedsidesurgery,thetubeisinserteddirectlyintothetracheathroughaholeintheneck.Forlong-termhelpwithbreathing,atrachismorecomfortable,andsedationis not needed. People using such a breathing tube aren’t able to speakwithout special helpbecauseexhaledairgoesoutofthetrachratherthanpasttheirvocalcords.

ArtificialNutritionorArtificialHydrationAfeedingtubeand/orintravenous(IV)liquidsaresometimesusedtoprovidenutritionwhenapersonisnotabletoeatordrink.Thesemeasurescanbehelpfulifyouarerecoveringfromanillness.However,ifyouareneardeath,thesecouldactuallymakeyoumoreuncomfortable.Forexample, IV liquids,which are given through a plastic tube put into a vein, can increase theburdenon failingkidneys.Or if thebody is shuttingdownneardeath, it isnotable todigestfood properly, even when provided through a feeding tube. At first, the feeding tube isthreaded through thenosedown to the stomach. In time, if tube feeding is stillneeded, thetubeissurgicallyinsertedintothestomach.

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ComfortCareComfortcareisanythingthatcanbedonetosootheyouandrelievesufferingwhilestayinginlinewithyourwishes.Comfortcare includesmanagingshortnessofbreath;offering icechipsfordrymouth;limitingmedicaltesting;providingspiritualandemotionalcounseling;andgivingmedicationforpain,anxiety,nausea,orconstipation.Oftenthisisdonethroughhospice,whichmaybeoffered in thehome, inahospice facility, inaskillednursing facility,or inahospital.With hospice, a team of healthcare providers works together to provide the best possiblequality of life in a patient’s final days, weeks, or months. After death, the hospice teamcontinuestooffersupporttothefamily.Learnmoreaboutprovidingcomfortattheendoflife.

MoreAboutHospiceCareandPalliativeCareAsmentionedpreviously, hospice care is intended to provide comfort to a patient and theirfamily during a life-threatening illness, rather than provide treatments to cure the illness.Palliative care is similar to comfort care in hospice, but it is offered alongwith anymedicaltreatments you might be receiving for a life-threatening illness, such as chemotherapy forcancerordialysisforkidneyfailure.Themaingoalofbothhospiceandpalliativecareistokeepyoucomfortable.Inaddition,youcanalwayschoosetomovefromhospicetopalliativecareifyouwanttopursuetreatmentstocureyourillness.

GettingStartedStartbythinkingaboutwhatkindoftreatmentyoudoordonotwantinamedicalemergency.Itmighthelptotalkwithyourdoctorabouthowyourpresenthealthconditionsmightinfluenceyourhealth in the future. Forexample,whatdecisionswouldyouor your family face if yourhighbloodpressureleadstoastroke?If you don’t have any medical issues now, your family medical history might be a clue tothinking about the future. Talk to your doctor about decisions that might come up if youdevelophealthproblemssimilartothoseofotherfamilymembers.Inconsidering treatmentdecisions,yourpersonalvaluesarekey. Isyourmaindesire tohavethe most days of life, or to have the most life in your days? What if an illness leaves youparalyzedorinapermanentcomaandyouneedtobeonaventilator?Wouldyouwantthat?Whatmakeslifemeaningfultoyou?YoumightwantdoctorstotryCPRifyourheartstopsortotryusingaventilatorforashorttimeifyou’vehadtroublebreathing,ifthatmeansthat,inthefuture,youcouldbewellenoughtospendtimewithyourfamily.Eveniftheemergencyleavesyou simply able to spend your days listening to books on tape or gazing out the windowwatching thebirdsand squirrels compete for seeds in thebird feeder, youmightbecontentwiththat.

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But,therearemanyotherscenarios.Hereareafew.Whatwouldyoudecide?

• Ifastrokeleavesyouparalyzedandthenyourheartstops,wouldyouwantCPR?What if you were also mentally impaired by a stroke—does your decisionchange?

• Whatifyoudevelopdementia,don’trecognizefamilyandfriends,and,intime,cannotfeedyourself?Wouldyouwantafeedingtubeusedtogiveyounutrition?

• Whatifyouarepermanentlyunconsciousandthendeveloppneumonia?Wouldyouwantantibioticsandaventilatorused?

• For some people, staying alive as long as medically possible is the mostimportantthing.Anadvancedirectivecanhelpmakesurethathappens.

Yourdecisionsabouthowtohandleanyofthesesituationscouldbedifferentatage40thanatage 85. Or they could be different if you have an incurable condition as opposed to beinggenerally healthy. An advance directive allows you to provide instructions for these types ofsituationsandthentochangetheinstructionsasyougetolderorifyourviewpointchanges.

DoYouoraFamilyMemberhaveAlzheimer'sDisease?Many people are unprepared to dealwith the legal and financial consequences of a seriousillness such as Alzheimer's disease. Advance planning can help people with Alzheimer's andtheir families clarify their wishes and make well-informed decisions about health care andfinancialarrangements.

MakingYourWishesKnownWe will discuss this further in your course, but there are two elements in an advancedirective—a livingwill andadurablepowerofattorney forhealth care. Therearealsootherdocumentsthatcansupplementyouradvancedirectiveorstandalone.Youcanchoosewhichdocuments to create, depending on how youwant decisions to bemade. These documentsinclude:

• livingwill• durablepowerofattorneyforhealthcare• other documents discussingDNR (do not resuscitate) orders, organ and tissue

donation,dialysis,andbloodtransfusions,etc

LivingWillAlivingwillisawrittendocumentthathelpsyoutelldoctorshowyouwanttobetreatedifyouaredyingorpermanentlyunconsciousandcannotmakedecisionsaboutemergencytreatment.Ina livingwill, youcansaywhichof theproceduresdescribedaboveyouwouldwant,whichonesyouwouldn’twant,andunderwhichconditionseachofyourchoicesapplies.

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DurablePowerofAttorneyforHealthCareAdurablepowerof attorney for health care is a legal documentnaming ahealthcareproxy,someonetomakemedicaldecisionsforyouattimeswhenyoumightnotbeabletodoso.Yourproxy,alsoknownasasurrogateoragent,shouldbefamiliarwithyourvaluesandwishes.Thismeansthatheorshewillbeabletodecideasyouwouldwhentreatmentdecisionsneedtobemade.Aproxycanbechoseninadditiontoorinsteadofalivingwill.Havingahealthcareproxyhelpsyouplanforsituationsthatcannotbeforeseen,likeaseriousautoaccident.Adurablepowerofattorneyforhealthcareenablesyoutobemorespecificaboutyourmedicaltreatmentthanalivingwill.Some people are reluctant to put specific health decisions in writing. For them, naming ahealthcare agent might be a good approach, especially if there is someone they feelcomfortabletalkingwithabouttheirvaluesandpreferences.

OtherAdvanceCarePlanningDocumentsYoumight also want to prepare separate documents to express your wishes about a singlemedicalissueorsomethingnotalreadycoveredinyouradvancedirective.Alivingwillusuallycovers only the specific life-sustaining treatments discussed earlier. Youmight want to giveyour healthcare proxy specific instructions about other issues, such as blood transfusion orkidney dialysis. This is especially important if your doctor suggests that, given your healthcondition,suchtreatmentsmightbeneededinthefuture.Twomedical issues thatmight arise at the end of life are DNR orders and organ and tissuedonation.ADNR(donotresuscitate)ordertellsmedicalstaffinahospitalornursingfacilitythatyoudonotwantthemtotrytoreturnyourhearttoanormalrhythmifitstopsorisbeatingunevenly.EventhoughalivingwillmightsayCPRisnotwanted,itishelpfultohaveaDNRorderaspartof your medical file if you go to a hospital. Posting a DNR next to your bed might avoidconfusioninanemergencysituation.WithoutaDNRorder,medicalstaffwillmakeeveryefforttorestorethenormalrhythmofyourheart.Anon-hospitalDNRwillalertemergencymedicalpersonnel toyourwishesregardingCPRandothermeasures torestoreyourheartbeat ifyouarenotinthehospital.AsimilardocumentthatislessfamiliariscalledaDNI(donotintubate)order.ADNItellsmedicalstaffinahospitalornursingfacilitythatyoudonotwanttobeputonabreathingmachine.Organandtissuedonationallowsorgansorbodyparts fromagenerallyhealthypersonwhohasdiedtobetransplantedintopeoplewhoneedthem.Commonly,theheart,lungs,pancreas,kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissuedonation. You can carry a donation card in your wallet. Some states allow you to add thisdecisiontoyourdriver’slicense.Somepeoplealsoincludeorgandonationintheiradvancecare

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planningdocuments.Atthetimeofdeath,familymaybeaskedaboutorgandonation.Ifthoseclosetoyou,especiallyyourproxy,knowhowyoufeelaboutorgandonation,theywillbereadytorespond.

WhatAboutPacemakersandICDs?Somepeoplehavepacemakerstohelptheirheartsbeatregularly.Ifyouhaveoneandareneardeath, it may not necessarily keep you alive. But, you might have an ICD (implantablecardioverter-defibrillator)placedunderyourskintoshockyourheartbackintoregularbeatingsif the rhythmbecomes irregular. If other life-sustainingmeasures arenot used, the ICDmayalso be turned off. You need to state in your advance directive what you want done if thedoctorsuggestsitistimetoturnitoff.

SelectingYourHealthcareProxyIfyoudecidetochooseaproxy,thinkaboutpeopleyouknowwhoshareyourviewsandvaluesaboutlifeandmedicaldecisions.Yourproxymightbeafamilymember,afriend,yourlawyer,or someonewithwhom youworship. It’s a good idea to also name an alternate proxy. It isespeciallyimportanttohaveadetailedlivingwillifyouchoosenottonameaproxy.Youcandecidehowmuchauthorityyourproxyhasoveryourmedicalcare—whetherheorsheis entitled tomake awide range of decisions or only a few specific ones. Try not to includeguidelines thatmake it impossible for the proxy to fulfill his or her duties. For example, it’sprobably not unusual for someone to say in conversation, “I don’t want to go to a nursinghome,” but think carefully about whether you want a restriction like that in your advancedirective.Sometimes,forfinancialormedicalreasons,thatmaybethebestchoiceforyou.Of course, check with those you choose as your healthcare proxy and alternate before younamethemofficially.Makesuretheyarecomfortablewiththisresponsibility.

MakingItOfficialOnceyouhavetalkedwithyourdoctorandhavean ideaof thetypesofdecisionsthatcouldcomeupinthefutureandwhomyouwouldlikeasaproxy,ifyouwantoneatall,thenextstepistofilloutthelegalformsdetailingyourwishes.Alawyercanhelpbutisnotrequired.Ifyoudecidetousealawyer,don’tdependonhimorhertohelpyouunderstanddifferentmedicaltreatments.That’swhyyoushouldstarttheplanningprocessbytalkingwithyourdoctor.Manystateshavetheirownadvancedirectiveforms.YourlocalAreaAgencyonAgingcanhelpyou locate the right forms. You can find your area agency phone number by calling theEldercareLocatortoll-freeat1-800-677-1116orgoingonlineatwww.eldercare.gov.Somestateswantyouradvancedirectivetobewitnessed;somewantyoursignaturenotarized.Anotaryisapersonlicensedbythestatetowitnesssignatures.Youmightfindanotaryatyourbank,postoffice,orlocallibrary,orcallyourinsuranceagent.Somenotarieschargeafee.

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Somepeople spend a lot of time inmore thanone state—for example, visiting children andgrandchildren. Ifthat’syoursituationalso,youmightconsiderpreparinganadvancedirectiveusingformsforeachstate—andkeepacopyineachplace,too.

FutureDirectionsAnumberofstatesaredevelopingorstartingtouseanadvancecareplanningformknownasPOLST (Physician Orders for Life-Sustaining Treatment) or MOLST (Medical Orders for Life-SustainingTreatment).These formsserve inadditiontoyouradvancedirective.Theymake itpossibleforyoutoprovidemoredetailedguidanceaboutyourmedicalcarepreferences.Yourdoctorwilltalkwithyouand/oryourfamilyforguidance,buttheformisfilledoutbythedoctoror, sometimes, anursepractitionerorphysician’s assistant.Once signedby yourdoctor, thisform has the force of any other medical order. These forms are often printed on brightlycolored paper so they are easily found in a medical or hospital file. Check with your statedepartmentofhealthtofindoutifthisformisavailablewhereyoulive.

AfterYouSetUpYourAdvanceDirectiveTherearekeypeoplewhoshouldbe told thatyouhaveanadvancedirective.Givecopies toyourhealthcareproxyandalternateproxy.Giveyourdoctoracopyforyourmedicalrecords.Tellkeyfamilymembersandfriendswhereyoukeepacopy.Ifyouhavetogotothehospital,give staff there a copy to include in your records. Because youmight change your advancedirectiveinthefuture,it’sagoodideatokeeptrackofwhoreceivesacopy.Reviewyouradvancecareplanningdecisionsfromtimetotime—forexample,every10years,ifnotmoreoften.Youmightwant to reviseyourpreferences for care if your situationoryourhealthchanges.Or,youmightwanttomakeadjustmentsifyoureceiveaseriousdiagnosis; ifyougetmarried,separated,ordivorced; ifyourspousedies;or ifsomethinghappenstoyourproxyoralternate.Ifyourpreferenceschange,youwillwanttomakesureyourdoctor,proxy,andfamilyknowaboutthem.

StillNotSure?Whathappensifyouhavenoadvancedirectiveorhavemadenoplansandyoubecomeunableto speak for yourself? In such cases, the state where you live will assign someone tomakemedicaldecisionsonyourbehalf. Thiswillprobablybeyour spouse, yourparents if theyareavailable, or your children if they are adults. If you have no familymembers, the state willchoosesomeonetorepresentyourbestinterests.Always remember, an advance directive is only used if you are in danger of dying and needcertain emergency or special measures to keep you alive but are not able to make thosedecisionsonyourown.Anadvancedirectiveallowsyoutocontinuetomakeyourwishesaboutmedicaltreatmentknown.

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LookingTowardtheFutureNobodycanpredictthefuture.Youmayneverfaceamedicalsituationwhereyouareunabletospeakforyourselfandmakeyourwishesknown.Buthavinganadvancedirectivemaygiveyouandthoseclosetoyousomepeaceofmind.

AdvanceDirectiveWalletCardYoumightwant tomake a card to carry in yourwallet indicating that you have an advancedirectiveandwhere it iskept.Here isaslightlyrevisedexampleofthewalletcardofferedbytheOfficeoftheAttorneyGeneralinMaryland.Itusesthephrase“healthcareagent”insteadof“healthcareproxy.”Youmightwanttoprintthisonetofilloutandcarrywithyou.Itcanalsobefoundonlineatwww.oag.state.md.us/Healthpol/adDir_cards.pdf(PDF,178K).

PrintablewalletcardspecifyingadvancedirectiveinformationAnAdvanceHealthCareDirective,whichincludesaLivingWill,isonlyusefulifitcanbefoundand read when you are unable tomakemedical decisions for yourself. Typically, if you areunable tomakemedical decisions for yourself, you are not able to tell your doctor or yourfamilywhereyourAdvanceDirectiveis located.That iswhytheAttorneyGeneral’sOfficehasdeveloped a small card that you can keep in your wallet to document the location of yourAdvanceHealthCareDirective.Twocardsareprovidedforsoeachspousehasone.Theyeachshouldcutoutacard,fill it in,foldit,andputitintheirwalletorbillfold.Thesecardsarenot the sameasaDoNotResuscitateorDNRorder. If youwantemergencymedical services personnel to refrain from resuscitating you, you need aMedical Orders forLife-SustainingTreatment(MOLST)form.Thatformhastobefilledoutbyaphysicianoranursepractitioner.Copiesareavailable fromyourState’sEmergencyMedicalServicesSystems.YoucanGoogle“MOLSTForm”andclickonthelink.For more information about Advance Health Care Directives, you can visit the AttorneyGeneral’swebsiteforyourstate.

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§ Learnaboutorberemindedaboutspecificfamouscasesandendoflifedecisions.§ Learnaboutandgainfurtherinsightbylookingat:

o WhitneyHouston'sdaughterandthefamily'slifesupportdecisiono JoanRiversCaseo KeyLegalCases

§ Becomebetterawareofwhathappenswhentherearenodirectiveso KarenAnnQuinlano NancyBethCruzano MichaelMartino Theresa("Terri")MariaSchindlerSchiavo

2SpotlightonEnd-of-LifeDecisions

Whitney'sDaughter:Family'sHeartbreakingLifeSupportDecisionInAprilof2015asBobbiKristinaBrownenteredherthirdmonthinacoma,herfamilyfacesanexcruciating choice: Keep the 24-year-old alive onmachineswith little hope for recovery, orwithdrawlifesupportandletnaturetakeitscourse.Theagonizingdecisionisonefacedbymanyfamilies,andeachsituationisunique,atopexperttellsNewsmaxHealth.But one thing is common to all end-of-life situations: They are easier if the patient has leftinstructionsabouthowtheywanttobetreated.Brown,thedaughterofthelatesingerWhitneyHouston,wasfoundface-downinherbathtubonJan.31andnowisbeingkeptaliveinacriticalcarefacility.Likemostpeople,especiallypatientssoyoung,BobbiKristinaapparentlydidnothaveanend-of-lifedirectivethatwouldinstructherfamilyofherwishes,accordingtoreports.

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“Whetherthey’reyoung,old,orin-between–peopleneedtomaketheirwishesknown,”MarcLeavey,M.D.,toldNewsmaxHealth.“Yearsago,wedidn’thave themeans tokeeppeoplealive thisway. If somethinghappened,youweregoingtodie.Butnow,wecanusemachinerytotakecareofaperson’slifefunctions.“Wecankeepthembreathing,theirheartbeating,andtheirkidneysfunctioning.Theonlythingwereallycan’tfixistheirbrain.Butifthebodyisotherwiseintact,wecankeepsomeonegoingindefinitely,andthat’sactuallyarealproblem,”saidDr.Leavey,aninternistatMercyMedicalCenterinBaltimore.Partoftheproblemisthatweasasocietyhavebecomemoredistancedfromdeath,andmoreconvincedthat it isthe jobofdoctorsandhospitalstokeepusalivenomatterwhat,saidDr.Leavey.“Beforemoderntechnologycamealong,whenmomanddadgotoldandsick,they’dbekeptinthebackbedroomandthefamilywouldtakecareofthemandthekidswouldseethatdeathwasapartoflife.“Nowmomordadishookeduptoamachineinahospitalandtheirchildrenarenotifiedbyaphone call that they’ve died.We’ve distanced it, and as a result, people don’t want to talkaboutitanymore,”Dr.Leaveysaid.“Weneedtostarttalkingaboutit.”Therearemythsaboutend-of-lifedirectivesthatkeeppeoplefromexecutingthem,Dr.Leaveysaid.“Peoplethinkit’sanordertodie,butitcanbetheopposite.Youcansay,‘Idon’twanttoliveundercertaincircumstances,oryoucansay,‘Doeverythingyoucantokeepmealive,’”hesaid.Such directives can be changed in the event that people decide differently later, he noted.“Peopledothatallthetime,”headded.Andageshouldnotbeafactor.“Weaskteenagerswhentheygettheirfirstdriver’s licenseiftheywanttobecomeorgandonors.Thatmayseemoddifyouthinkaboutit,butthisisnotthatdifferent,”saidDr.Leavey.“BobbiKristinamayhavenotwantedtobekeptalive,hookeduptoamachineandtubes,orshemight havewanted to be kept alive nomatterwhat. Butwe’ll never knowbecause shedidn’tsay.Andnowit’stoolate,”hesaid.End-of-life instructionsareusuallyput intoa legaldocumentknownasanadvancedirective.Statesvaryintheirrequirements,butsuchdirectivescaninclude:

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§ A living will: This tells your doctor how you want to be treated if you are dying orunconsciousandcannotmakedecisionsaboutemergencytreatment.Youcanstipulatewhichproceduresyouwouldwant,whichonesyoudon’t,andunderwhichconditionseachofyourchoicesapplies.

§ Adurablepowerofattorney forhealthcare:This legaldocumentnamesahealthcareproxy,whichissomeonesuchasafamilymembertowhomyougiveauthoritytomakemedicaldecisionsforyouwhenyouarenotabletodoso.

§ ADNRor“donotresuscitate”order:Thisdocumenttellsthemedicalstaffinahospital

ornursing facility that youdonotwant them to try to returnyourheart toanormalrhythm if it stopsor isbeatingunevenly. You canalsoexecuteanon-hospitalDNR tokeepambulancepersonnelfromresuscitatingyou.TherearesimilarformsforCPRandalsoaDNI(onnotintubate)orderifyoudonotwanttobeputonabreathingmachine.

You can download forms for an advance directive in your state by going here.http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289

JoanRiversAccordingtoCharlotteLibovofNewsmax.com,JoanRiverswasthemostenergetic81-year-oldyou could imagine. Herwork schedulewould haveworn out people half her age. Suddenly,whileseemingtobethepictureofhealth,shesufferedcardiacarrestwhileundersedationforaminormedicalprocedure.ShewasputonlifesupportandeventuallydiedonSept.4.The comic legend’s without-warning death should motivate people to put their end-of-lifeinstructionsinwritingbeforeitistoolate,atopdoctortoldNewsmaxHealth.“What happened to Joan Rivers should be a wake up call for the baby boomer generationwhichtoooftenthinks,‘I’mfine,I’mdoingwonderfullywell.Idon’thavetoworryaboutsuchthings,”’saysMarcLeavey,M.D.“Thisisarealproblemforagenerationthatlikestothinkyoung.Theyhavetoberealisticandconsiderthequestion:‘WhatifsomethinghappenstomeandIdon’tcomeoutofit?’”addedDr.Leavey,aninternistatMercyMedicalCenterinBaltimore.Shortly before her death, the machines keeping Rivers alive were disconnected so that shecould die peacefully surrounded by family, according to reports. Her daughter Melissa isthought tohavemadeanydecisions inaccordance toRivers’wishes.ThepairwasverycloseandMelissawasRivers’onlychild.Writtenend-of-life instructionsmake itmucheasier fora familytocopewhena lovedone isdying,Dr.Leaveysaid.

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Instead ofmaking a heartbreaking decision that could leave regrets, loved ones are able tofollowthepatient’sspecificinstructionswithaclearmind,knowingit’swhattheywant,saidDr.Leavey.And contrary to popular belief, end-of-life instructions don’t always specify that a patientdoesn’twanttobekeptonlifesupport.Often,theystipulate“Doeverythingyoucanforme,”Dr.Leaveysaid.Anunderstandingofmajorcourtcasescanhelpyoubetterunderstandthepitfallsthatcausedotherindividualsandfamiliesproblems.Thereareliterallyhundredsofcourtcasesofrelatedtoadvancedirectivesand treatmentdecision-making,butonly a fewof themorenotable casesarepresentedhere.

KeyLegalCases

WhatHappensWhenThereareNODirectives

KarenAnnQuinlanAccording to LifecareDirectives, LLC, in their article “Key Legal Cases-What Happens WhenThereareNODirectives”,KarenAnnQuinlanwasa22-year-oldwomanwhofellintoacomaonApril15,1975followinganapparentoverdoseofdrugsandalcohol.Shesufferedseverebraindamage from oxygen deprivation as she wasunable tobreathe properly following theoverdose. Upon arrival at a hospital, itwas found that she could notmaintain an adequatebreathing rate, and so she was attached to a breathing machine (i.e., a "respirator" or"ventilator").The coma did not improve, nor did her breathing, and Karen remained in an "persistentvegetative" state having never regained consciousness. After many months, her physiciansagreedthattherewasnohopefor improvementandherfamilyrequestedthatthebreathingmachineberemoved.Karen's physicians, however, were concerned about the legality of stopping a breathingmachine in so young a patient, particularly when she was not otherwise in an immediatelyterminalcondition.Sothecourtswerepetitionedtoauthorizetheremovaloftherespirator.Thiswasthefirsttimethatanyhighercourthadeverbeenrequiredtoaddresswhetherornotlife-sustainingmedical treatment could be stopped in a persistently vegetative (i.e.,permanently unconscious) patient. In 1976 the New Jersey court ruled that artificial lifesupportcouldbediscontinuedinthiscase--butonlybecauseMs.Quinlanhadpreviouslyandspecificallymadeknownherwishnot tohaveher lifemaintained indefinitelybytheuseofabreathingmachine.Key Learning: The courts allowed the removalof thebreathingmachine specifically andonly

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becausetherewasappropriateevidenceofKaren'spriorwishes.Ofnote,however,therewasnosuchevidenceaboutherwishesregardingtheuseoffeedingtubes.Thereforeherfatherdidnotagreetohavethetubefeedingsstopped,eventhoughthecourtorderalsoallowedforthis.AftermorethanayearofassistedbreathingKaren'sbreathingreflexeshadstabilizedenoughtosustainher lung functionevenafter thebreathingmachinewas removed.Consequently, shelivedanadditional10yearsinherpersistentvegetativecondition,sustainedbyfeedingtubes.NancyBethCruzanAlsoaccordingtoLifecareDirectives,LLC,intheirarticle“KeyLegalCases-WhatHappensWhenThereareNODirectives”,NancyBethCruzanwasa33-yearoldwomanwhosustainedseverebraindamagefollowinganautomobileaccidentinJanuary,1983.Intheaccident,shenotonlysufferedoverwhelminghead injuries,butshealso landedfacedown inwaterat theroadsidecausingfurtherbraindamagefromoxygendeprivation.Nancyneverregainedconsciousnessandherlifewassustainedbythecontinuoususeoftubefeeding.Overtimeherphysiciansconcludedthatshewouldneverrecoverconsciousness.Fouryearslater,herfamilyrequestedthatthetubefeedingsbestopped.Afterthehospitalrefused,Nancy'sparentspetitionedthecourtsforthenecessaryauthorization.During the hearings, however, the state argued persuasively against the family's request. InparticularitwasnotedthatMs.Cruzanhad"neverspecificallytoldherfriendsorfamilythatshewouldnotwanttobefedthroughsuchatube."The family appealed to the United States Supreme Court. There it was ruled that a"constitutional right to refusemedical care, including feeding tubes" did exist. However, theCourtalsoruledthat"astatecouldrequire'clearandconvincingevidence'thatremovalofthetubeiswhatthepatientwouldhavewanted."It took the family until June of 1990 (almost seven years) to gather enough evidence fromrelatives, friendsandothersbefore theCourts finally ruled thatsufficientevidencedidexist.Ms.Cruzan's feeding tubewas then removedonDecember15th,andshediedonDecember27th.KeyLearning:Clearandconvincingevidenceofoneswishesmaywellberequired.Therefore,youmustspeakplainlyaboutwhatyoudoordonotwantdoneifyouwishtoensurethatyourdesireswillbehonored.

MichaelMartinFurther according to LifecareDirectives, LLC, in their article “Key Legal Cases-What HappensWhenThere areNODirectives”, on January 16, 1987, 35-year oldMichaelMartinwas badlyinjuredinacar-trainaccident,includingmajorinjuriestohisbrain.Theinjurieslefthimseverelymentallyimpaired,unabletowalkortalk,aswellasdependentontheuseoffeedingtubesto

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sustain his life. Hewas not, however, left in a "vegetative" condition. He recovered to thepointofbeingabletorespondtosomesimplerequests,andappearedabletorecognizefaces.Hiswife,Mary,wasappointedashislegalguardian.Fiveyearspassed,andMichael'sconditiondidnot improve.MarynotedthatMichaelhadmadenumerousstatements inthepastaboutnotwantinghis lifeartificiallysustained inahighlydebilitatedcondition.Thus,onMarch19,1992,MaryfiledapetitioninthecourtsrequestingauthorizationtoremoveMichael'sfeedingtubes.However,Michael'smother,LeetaMartin,andhissister,PatriciaMajor,opposedtherequestand filed a petition of their own, asking that Mary be removed as Michael's guardian.Allegationsweremade thatMary onlywanted the life-sustaining treatments discontinued inordertoobtainsettlementfundsfromalawsuitagainsttherailroad.Marycounteredthatthemoney was not a factor, noting that the funds substantially increased over time and thusextendingMichael'slifewouldbethegoalifthatwerethecase.During the court proceedings, Mary testified that Michael was "a private but active personbefore the accident." She further explained that had always found it difficult to be aroundpeople"whoweredisabledordependentonothers"andhadfrequentlystatedthat"hewouldrather die than be dependent on people and machines." His wife testified of several"discussionsbetweenMikeandmeregarding...ourwishes...ifeitherofuswaseverinvolvedinaseriousaccident,hadadisablingorterminalillnessorwasdyingofoldage."Shenotedthatthediscussions"beganapproximatelyeightyearsago,"andthattheyspokeofthese things "on many different occasions." Specifically, "several were triggered by movieswhichwesawtogether.Mike'spositionwasalwaysthesame:hedidnotwanttobekeptaliveon machines and he made me promise that I would never permit it."Two co-workers also testified that "he had remarked to them that "he would not want tocontinuelivinginavegetativestate."However,Mr.Martinwasnotinavegetativecondition,andthussuchtestimonywasdeemedinsufficient.His sisteralsoacknowledged that "Michaelonce toldher thathewouldnotwant tobekeptalive by a respirator if he were in a coma." But, again, he was not now in a coma.OnOctober 30, 1992, the trial court ruled on the basis ofMary's testimony that "clear andconvincingevidencehadbeenpresented,"andthecourtappearedsatisfiedthatMichaelwouldnotwanthislifeartificiallyprolongedinthissituation.However,thecourtfurtherruledthatMichael'spastwishes"couldnotbeconsideredbecausethey were not expressed in writing." In addition, although the court specifically found thatwithdrawing the feeding tubesappeared tobe"inMichael'sbest interests,"hiswishescouldnot be honored because he was not "terminally ill." Therefore, the petition was denied.Thecasewasappealed to theMichiganCourtofAppeals (which ruled in favorofMary),andfrom there to theMichigan State Supreme Court. The state supreme court concluded thatMichael'spriorstatementswereinsufficienttoprovehiswishes

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.Specifically,hispaststatementswereruled"general,vagueandcasual..."Regardingcommentsmade to hiswife after seeing debilitated people,movies, etc, itwas noted that "...Michael'spurported remarks...were 'no different than those that many of us might make..'" in suchsituations,buttheycouldnotbedeemedconclusivestatementsastohisfuturewishes.Thus,thecourtorderedthatthetubefeedingsmustbecontinued.Key Learning: Casual statementsmade to lovedonesmaywell notbe sufficient evidenceforyourwishestobehonored.Eventheappearanceofsecondarymotives(financialgain,etc)cangreatly complicate the process, potentially causing other genuine concern. It is essential,therefore,thatyouclearlydocumentyourwishesinawrittenadvancedirective,bothtoensurethatyourdesiresareunequivocallyknownandwillbehonoredandtoprotectthoseyoulovefromunnecessarilypainfulnegativeallegationsanddistress.

Theresa("Terri")MariaSchindlerSchiavoFinally, according to Lifecare Directives, LLC, in their article “Key Legal Cases-What HappensWhen There are NO Directives”, the case of Theresa ("Terri") Maria Schindler Schiavo isunquestionably the best known of all legal end-of-life cases. The case was pursued in thecourts over the course of 12 years and was followed through the media by a world-wideaudience.InFebruaryof1990attheageof26,Terrireportedlycollapsedathome.Becauseshewasbeingtreated forbulimia (aneatingdisorder), itwassuggested thata relatedpotassium imbalancemayhavecausedherhearttostop.Regardless,Terri sufferedseverebraindamagefroma lackofoxygen,andwas leftunabletoeat,walk,ortalk,andrequiredtubefeedingtosurvive.In 1991 her husband, Michael Schiavo, flew Terri to California for experimental therapy.However,thetherapyproducednomeasurablesuccess.Healsomovedherattimesfromonenursinghometoanotherinsearchofbetterrehabilitationandcare.Forthefirstthreeyears,allaccountsindicatethatMichaelremainedveryinvolvedinhiswife'scareandthatheandherparents,theSchindlers,enjoyedanamicablerelationship.However, theamicability apparently ended in1993, shortly afterMichaelwona$1.3millionmalpractice settlement over the treatment of Terri’s potassium imbalance. $750,000 wasawarded in Terri's name and for her care. The rest was awarded toMichael for his loss of"spousalconsortium."Michaelclaimsthat inFebruary1993Terri's fathercametohimandrequested"hisshare"oftheaward.Michaelallegedlydeclined,statingthatthefundsweretobeusedforTerri'scare.

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Terri's father disputes this account, stating he had only requested access to Terri’s funds tosecurefurtherrehabilitation,whichheclaimedMichaelwasnolongerpursuing.Later, inJuly1993,Terri'sparentstriedtohaveMichaelremovedasguardianandthemselvesappointed inhisstead.TheyallegedpoorcarebyMichael,andalsovoicedsuspicionsthathemayhaveoriginallytriedtostrangleher.Theyspeculatedthatthis,ratherthanthepotassiumimbalancemayhavebeenthecauseofherdebilitatinginjury.TheyfurtherallegedthatMichaelwas the source of Terri’s bulimia, noting that Terri had been ‘heavy’ in high school andwasextremely self-conscious about herweight. They claimed thatMichael had pressured her tostaythinwithstatementssuchas,“Ifyouevergetthatfatagain,I'lldivorceyou.”Michaeldeniedtheallegationsofassaultandclaimedhenevermadedisparagingstatementsorthreats.Thecasewasultimatelydismissed.In 1998 Michael became engaged to a woman who was eventually to become his secondspouse. Together they had two children. At this juncture, the Schindlers again sued forguardianship.Theybasedthesuitupongroundsofadulteryanduponrenewedallegationsofneglectandabuse.Theireffortsagainfailed.Bymanyaccounts,MichaelremaineddevotedtoTerri and toher care. Indeed, itwasnotedby some that hewas foundmore frequently herbedsidethanTerri’sotherfamilymembers.Yet, there was no discounting the considerable concern and effort of the Schindlers. Inparticular they were devoted to Terri’s continuing rehabilitation. This aroused considerablecontroversy. Some professionals felt that the kinds of "stimulus-based" therapies they werepursuingcouldcauseTerriunnecessarydistressanddisruption,andpotentiallydomoreharmthan good. EventuallyMichael sought toprevent Terri’s parents from further involvement inthisregard.Theirresponsewastosecurecovert“telephone‘toughlove’rehabilitation”whentheyweredeniedotheroptions.As the years passedMichael became increasingly convinced that Terri’s conditionwould notimprove.DrawinguponstatementsheclaimedTerrihadmadetohim,hepetitionedthecourtsforremovalofherfeedingtube.Inparticular,hetestifiedaboutapastconversationthey'dhadaboutadisableduncle.DuringthediscussionTerrihadtoldhimnevertoprolongherlife inaseverely disabled condition. A girlfriend of Terri’s provided additional supporting testimony.Thus, on February 11, 2000, 10 years after Terri’s original collapse, a circuit court judgeapprovedtherequest.Theparents sued foran injunction.TheyalsocitedpriorconversationswithTerri,alongwithher religious affiliation and beliefs. They added their own conviction that she was not trulycomatose, and thus could yet improve, as injunctive grounds. They also produced testimonyfrom awomanwho had datedMichael between 1992 and 1993who claimed to have onceaskedhimwhatheknewaboutTerri’swishes.Shestatedthathehadresponded,“Weneverspokeaboutthis.MyGod,Iwasonly25yearsold....Wewereyoung.Weneverspokeofthis.”

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Finally,theyallegedthatMichaelonlywantedthefeedingtuberemovedbecausehewantedtoretaintheremainderofthemalpracticeaward.Over the next five years, a total of six court battles and multiple investigations ensued.Ultimately,33expertsweresoughtoutbytheSchindlerstosupporttheirclaimthatTerriwasstillaware,abletocommunicate,andmightyetbenefitfromrehabilitation.Asimilarnumberofcounter-opinionswereobtained fromotherexperts, in rebuttal.Ultimately,bysomereports,overhalfofthetotalfundsawardedforTerri'scarewereeventuallyspentonlegalfees.A legal defense organization temporarily covered the Schindler's considerable legal costs forsometwoyears,followedbyadditionalfundsandrepresentationfromareligiously-basedlegalgroup. One businessman offeredMichael Schiavo $1million towalk away from Terri, and a“pledgefund”wassetupforasimilarpurposewhichclaimed$6millionindonations.Michaelconsistentlydeclinedanysuchoffers.Equally devoted right-to-die groups took up Michael's cause and condemned all legal andgovernment intrusions. The television media picked up the case along with the family'sdisputes. This resulted in endless news reports and finally culminated in appearances byMichaelSchiavoonthetelevisionshow"LarryKingLive,"andbyTerri'ssisteronthe"Oprah"televisionshow.Over theyearsTerri's feeding tubewas repeatedly removedand reinserted,dependinguponcurrent court orders. During one period of removal, the Florida governor’s office receivedupwardsof 165,000e-mails throughapetitiondrive requesting that the governor intervene.Callsalsocamefromdisabledrightsactivist JoniTada, fromactorMelGibson, fromFocusontheFamilyfounderDr.JamesDobson,andfromtheVatican.The resultwas "Terri's Law," passed inOctober 2003,which allowedGov. Jeb Bush and theFloridaAttorneyGeneraltostepin.TheACLUenjoined these efforts, and the Florida SupremeCourt eventually struckdown thelaw.IntheSpringof2005,stateandfederalcongressionalhearingswereheldandvariousbillsproposedandpassed.During the month of March of 2005 the 11th Circuit Court of Appeals, the Florida StateSupreme Court, and the United States Supreme Court either denied appeals or refused tofurtherintervene.EventuallyTerri’shusbandprevailedandherfeedingtubewasremoved.OnMarch31,2005,shediedwithMichaelatherbedside.AfterTerri'sdeath,amuchanticipatedautopsywasperformed.Theresults:profoundlysevere"atrophy"(witheringaway)ofthebrain,reducedtohalfitsnormalsize;cortical(braindamageinduced)blindness;and,findingsconsistentwithadiagnosisof"persistentvegetativestate."Itwasconcludedthatnoamountoftherapycouldcorrectthedamage.Finally,itwasalsonotedthattherewasnoevidenceofstrangulationorotherneckinjury.

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Even so, the Schindlers issued a statement regarding the autopsy, noting that it had alsoconfirmed that "Terri was not terminal, that Terri had no livingwill, that Terri had a strongheart, and that Terri was brutally dehydrated to death." An attorney (who was not also aphysician) specializing in "medical ethics cases" alsopointedoutherbelief that, "The frontaltemporal and temporal poles and insular-cortex demonstrated relative preservation," andconcludingbysaying,"Whatthistellsusisthathercortexretainedfunctionandthatherbrainwasmorenormal intheareathatcontrolshigher-level thinking"-- inshort,underscoringtheparents'beliefthatTerrihadretainedthecapacityforsubstantialcognitiveawareness.Clearlythecourtrulingsandtheautopsydidnotendthecontroversy.Afterallwassaidanddone,perhapsthemostenduringfinalwordscamefromMichaelSchiavohimself.OnTerri’sgravestonehehadthefollowingwordsengraved,"Ikeptmypromise."KeyLearning:Thereismuchtolearnfromthiscase.Failingtomakeyourwishesopenlyknown,particularlyinwriting,canpullyourfamilyapartandcancostyouandyourlovedones’untoldburdens in suffering, financial expense, public airing of private lives, and emotional burdensbeyondmeasure.Itremainspossiblethatbothpartiestothelitigationwere"right"inthattheybelievedinwhattheyweredoing.Money,remarriage,emotionalattachment,divergentreligiousviews,anddisagreementsoverrecollections of statements can lead to very different perspectives.When this occurs, greatsorrowandevenoutrightinjusticecanbecarriedoutbyotherwisewell-meaningparticipants.Regardlessofwhowasright,threeindisputablefactsremain:1)Terri livedforadecadeandahalf in aprofoundlydebilitated state; 2) Terri diedafter the removalof amedical treatment(feedings by tube) that could have been continued (if she had wished this);and, 3) of the$750,000.00 awarded for Terri's care, $456,816.00 was eventually expended on legal fees.Eventhatwasnotthetotalcostinvolved,asmanyorganizations,legalfoundations,andprivatedonorscontributedmanythousandsmore.Only by properly documenting your desires can such profound burdens and contentions beavoided.

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§ Learnthebasicsfactsaboutadvancedmedicaldirectives.§ Bebetterversedontheimportanceofanadvancedirective.§ Becomeawareofthehistoryofadvancedirectives.§ Gainknowledgeofthetypesofhealthcaredocuments.§ Learnaboutwhatisanadvancedirectiveforhealthcare.§ Be able to express treatment preferences for a terminal condition or state of

permanentunconsciousnessinaADHC.§ Beable todetermineoptions for treatmentpreferences for a terminal conditionor

stateofpermanentunconsciousness.§ BeabletotellthedifferencebetweenanADHCandalivingwill.

3TheBasicsIfyou'relikemostpeople,youandyourclientsaren'teagertospendtimethinkingaboutwhatwouldhappenifyouortheybecameunabletodirectyourownmedicalcarebecauseofillness,anaccident,oradvancedage.However,ifyoudon'tdoatleastalittlebitofplanning-writingdownyourwishesabout thekindsof treatmentyoudoordon'twant to receiveandnamingsomeoneyoutrusttooverseeyourcare-theseimportantmatterscouldwindupinthehandsof estranged familymembers, doctors, or sometimes even judges,whomay knowvery littleaboutwhatyouwouldprefer.

AdvanceMedicalDirectiveFactsAdvance directives are designed to outline a person's wishes and preferences in regard tomedical treatments and interventions. When a patient is incapable of making his/her ownmedical decisions, a health-care proxy can act on the patient's behalf to make decisionsconsistentwithandbasedonthepatient'sstatedwill.Advancedirectivepoliciesmaydifferentfromone state to another. Drafting a proper advance directive formmay require assistancefrom your personal physician and an attorney. Advance directives are important documentsthatshouldbeincludedwitheachindividual'spersonalmedicalrecords.

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IntroductiontoAdvanceMedicalDirectives

AdvanceDirectivesThe term "advance directives" refers to treatment preferences and the designation of asurrogatedecision-maker in theevent thataperson shouldbecomeunable tomakemedicaldecisionsonherorhisownbehalf.Advance directives generally fall into three categories: living will, power of attorney, andhealth-careproxy.Living will: This is a written document that specifies what types of medical treatment aredesiredshouldtheindividualbecomeincapacitated.Alivingwillcanbegeneralorveryspecific.Themostcommonstatementinalivingwillistotheeffectthat:

§ ifIsufferanincurable,irreversibleillness,disease,orconditionandmyattendingphysician determines that my condition is terminal, I direct that life-sustainingmeasuresthatwouldserveonlytoprolongmydyingbewithheldordiscontinued.

More specific living wills may include information regarding an individual's desire for suchservicessuchas:

§ Analgesia(painrelief),§ Antibiotics,§ Artificial(intravenousorIV)hydration,§ Artificialfeeding(feedingtube),§ CPR(cardiopulmonaryresuscitation),§ Life-supportequipmentincludingventilators(breathingmachines),§ Donotresuscitate(DNR).

Health-careProxyThisisalegaldocumentinwhichanindividualdesignatesanotherpersontomakehealth-caredecisions if he or she is rendered incapable of making their wishes known. The health-careproxyhas,inessence,thesamerightstorequestorrefusetreatmentthattheindividualwouldhaveifcapableofmakingandcommunicatingdecisions.

DurablePowerofAttorney(DPOA)Throughthistypeofadvancedirective,anindividualexecuteslegaldocumentsthatprovidethepower of attorney to others in the case of an incapacitatingmedical condition. The durablepowerofattorneyallowsan individualtomakebanktransactions,signsocialsecuritychecks,

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applyfordisability,orsimplywritecheckstopaytheutilitybillwhileanindividualismedicallyincapacitated.DPOAcanalsospecificallydesignatedifferentindividualstoactonaperson'sbehalfforspecificaffairs.Forexample,onepersoncanbedesignatedtheDPOAofhealth-careormedicalpowerof attorney, similar to thehealth-careproxy,while another individual canbemade the legalDPOA

ImportanceofanAdvanceDirectiveAdvance directives were developed as a result of widespread concerns over patientsundergoingunwantedmedicaltreatmentsandproceduresinefforttopreservelifeatanycost.As outlined in the following section (history of advance directives), remarkable efforts weremade to institute advancemedical directives as a component ofmedical care in the UnitedStatesoverthelastfewdecades.Fromapracticalstandpoint,medicaldirectivesandlivingwillsfacilitateaperson'smedicalcareand decision making in situations when they are temporarily or permanently unable makedecisions or verbalize their decisions. By having previously documented personalwishes andpreferences,thefamily'sandphysicians'immensedecision-makingburdenislightened.Atthesame time, patient autonomy and dignity are preserved by tailoring medical care based onone'sownchoicesregardlessofmentalorphysicalcapacity.Instructive directives (advance directives, living wills, and health-care proxy designation) arecompleted by a person with decision-making capacity. They only become effective when aperson loses his/her decision-making capacity (mentally incapacitated). While a personmaintains ability to make decisions, he/she is the ultimate decision-maker rather than thehealth-careproxyorsurrogatedecision-maker.

HistoryofAdvanceDirectivesAccordingtoMedicine.Net,advancedirectivesbegantobedevelopedintheUnitedStatesinthelate1960s.

TheFirstLivingWillsIn 1967, an attorney named Luis Kutner suggested the first living will. Kutner's goal was tofacilitate"therightsofdyingpeopletocontroldecisionsabouttheirownmedicalcare."In1968,thefirstlivingwilllegislationwaspresentedtoastatelegislature.WalterF.Sackett,adoctorelected to the Florida legislature, introducedabill thatwouldallowpatients tomakedecisionsregardingthefutureuseoflife-sustainingequipment.Thebillfailedtopassin1968.Sackettreintroducedthebillin1973anditwasagaindefeated.

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WhileDr.Sackettwas introducing livingwill legislationinFlorida,BarryKeenewaspresentingsimilarbills in theCalifornia legislature.Keene's interest in livingwillswasbasedonpersonalexperience. In 1972, Keene's mother-in-law was unable to limit medical treatment for aterminal illness even after having signed a power of attorney. Keene was elected to theCaliforniaStatesenatein1974.Thelivingwill legislationhedesignedwasdefeatedthatsameyear.Keenereintroducedthebillin1976andinSeptemberofthatyearCaliforniabecamethefirststateinthenationtolegallysanctionlivingwills.

TheStatesWithinayear,43stateshadconsideredlivingwilllegislationandsevenstateshadpassedbills.Advancedirectivelegislationhassubsequentlyprogressedonastate-by-statebasis.By1992,all50states,aswellas theDistrictofColumbia,hadpassed legislation to legalizesome formofadvancedirective.Thefirstcourtdecisiontovalidateadvancedirectiveswasatthestatelevel.Thedecisionwashandeddownby theNew JerseySupremeCourt in1976. InCase70N.J.10,355A2nd647,ChiefJusticeRobertHughesupheldthefollowingjudicialprinciples:

§ Ifpatientsarementallyunabletomaketreatmentdecisions,someoneelsemayexercisetheirrightforthem.

§ Decisions that can lead to the death of a mentally incompetent patient arebettermadenotbycourtsbutbyfamilies,withtheinputoftheirdoctors.

§ Decisions about end-of-life care should take into consideration both theinvasivenessofthetreatmentinvolvedandthepatient'slikelihoodofrecovery.

§ Patients have the right to refuse treatment even if this refusal might lead todeath.

ThecaseinwhichJudgeHughesruledwastherequestbyJoeQuinlantomakelegallybindinghealth-caredecisions forhisdaughter,KarenAnnQuinlan.Asa resultof thecase,KarenAnnQuinlanwasgraduallyweanedfrommechanicalventilation.The federal government: The U.S. federal government has evidenced its interest in advancedirectivesthroughtwoofitsbodies,theCongressandtheSupremeCourt.TheU.S.HouseofRepresentativesin1991enactedthePatientSelf-DeterminationAct.TheActstipulates that all hospitals receiving Medicaid or Medicare reimbursement must ascertainwhetherpatientshaveorwishtohaveadvancedirectives.ThePatientSelf-DeterminationActdoesnotcreateorlegalizeadvancedirectives;ratheritvalidatestheirexistenceineachofthestates.Itwasnotuntil1990thattheUnitedStatesSupremeCourtagreedtohearacaseonthelegalityof advance directives. The Supreme Court had been reticent to hear cases on advancedirectives,reflectingtosomedegreethebeliefthatadvancedirectivesaredeterminedatthe

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stateratherthanfederallevel.In1990,theCourtheardCruzanvs.Director.Thecase,similartothatofKarenAnnQuinlan, involved thedesire todiscontinue thepercutaneousgastrostomyfeedingsofNancyCruzan.TheUnitedStatesSupremeCourtdecidedinfavoroftheindividualrighttorefusetreatment,even life-sustainingtreatment.TheSupremeCourtrefusedtohanddown a specific decision on medical treatment in the case. Following the opinion of theSupreme Court, the case was referred back to the Missouri Supreme Court. The MissouriSupremeCourtheardtestimonyofaverbaladvancedirectivethatwasdeemedtobesufficientevidencetosupporttherefusalofmedicaltreatment.The landmarkQuinlanandCruzan casesemergedoutof similar situationsand similarneeds.Both cases dealt with the medical care of young, physically strong people in a persistentvegetativestate.Whilesimilar intheseregards,thetwojudicialdecisionsdealtwithdifferenttypes of advance directives. The case of Karen Ann Quinlan dealt with the ability of theindividual toappointahealth-careproxy. The caseofNancyCruzanaddressed the rightof ahealthyindividualtoestablishabindinglivingwill.

TheCurrentSituationIn theUnitedStates, fouroutofevery fiveadultshavenoadvancedirective,a situation thatsomehavelikenedtotakingyourcartothemechanicandsaying,"Ithinkitneedsatune-up,but if you find something reallywrongwith it, just go ahead and fix it, even if it won't runafterward?Andbytheway,pleasechargemefortheworkandifIcan'tpayforit,I'msuremyestatewill!"Whenaskedwhatwouldprovideagooddeath,themajorityofAmericansanswer,inessence;"Quick,painless,athome,andsurroundedbyfamily."In1950,abouthalfofAmericanswhodieddidsoathome.Now,about85%ofAmericansdieinahealth-caresetting:ahospital,anursinghome,orarehabilitationcenter.Atleast12%dieinanintensive-careunit.Over thepast threedecades, theUnitedStates - all 50 statesand theDistrictofColumbia --have passed laws to legalize the use of living wills, health-care proxies, and/or the durablepowerofattorney.TheU.S.federalgovernmenthasvalidatedstatelawsonadvancedirectivesthrough the 1991 Patient Self- Determination Act. And the U.S. Supreme Court has handeddownanopinionacknowledgingthecongruenceoftheConstitutionoftheUnitedStateswithstatelawsontherighttodesignatefuturemedicaltreatment.

TypesofHealthCareDocumentsTherearetwobasicdocumentsthatallowyoutosetoutyourwishesformedicalcare:alivingwillandadurablepowerofattorneyforhealthcare.It'swisetoprepareboth.Insomestates,the livingwill and the power of attorney are combined into a single form -- often called anadvancedirective.(Infact,bothofthesedocumentsaretypesofhealthcaredirectives--thatis,

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documents that let you specify your wishes for health care in the event that you becomeunabletospeakforyourself.)

LivingWillsFirst,youneedawrittenstatementthatdetailsthetypeofcareyouwant(ordon'twant)ifyoubecomeincapacitated.Thisdocument ismostoftencalleda livingwill, thoughitmaygobyadifferent name in your state. A livingwill bears no relation to the conventionalwill or livingtrust used to leave property at death; it's strictly a place to spell out your health carepreferences.Youcanuseyourlivingwilltosayasmuchoraslittleasyouwishaboutthekindofhealthcareyouwanttoreceive.

PowersofAttorneyforHealthCareYou'll also want what's usually called a durable power of attorney for health care. In thisdocument,youappointsomeoneyoutrusttobeyourhealthcareagent(sometimescalledanattorney-in-factforhealthcare,healthcareproxy,orsurrogate)tomakeanynecessaryhealthcaredecisionsforyouandtoseethatdoctorsandotherhealthcareprovidersgiveyouthetypeofcareyouwishtoreceive.According to the Fiduciary Law Section of the State Bar of your state, you have the right tocontrol all aspects of your personal care andmedical treatment, including the right to insistuponmedical treatment or direct that medical treatment be withheld or withdrawn. If youcannot(ordonotwantto)communicateyourhealthcaredecisionsforyourself,youhavetherighttochoosesomeonetomakehealthcaredecisionsforyou.Youalsohavetherighttostateyour treatment preferences if you have a terminal condition or are in a state of permanentunconsciousness.The Advance Directive for Health Care Act gives you an opportunity to choose someone tomakehealth care decisions on your behalf and tomake a clear expressionof your decisionsregardinghealthcareifyouareinaterminalconditionorstateofpermanentunconsciousnessbyexecutinganadvancedirectiveforhealthcare.

Whatisanadvancedirectiveforhealthcare?Anadvancedirectiveforhealthcare(ADHC)isalegaldocumentinwhichyou:

(1) appointyourhealthcareagent,and/or

(2) direct the withholding or withdrawal of life-sustaining procedures and/or theprovision of nourishment or hydration if you are in a terminal condition or astate of permanent unconsciousness. (Since 2007, the ADHC has replaced the

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legaldocumentscalleddurablepowerofattorneyforhealthcareandlivingwillinyourstate.)

IsanyparticularformofADHCrequired?YoumayuseanyformofADHCthatcomplieswithyourstatelaw.However,thelawprovidesastandard form of ADHC that will be treated as complying with state law if it is properlyexecuted.AnattorneycanprovideyouaformofADHCandhelpyouunderstandit,completeitandproperlyexecuteit.AnADHCmustbeinwriting,signedbyyou,andattestedandsignedbytwoadultwitnesses.YoumayrevokeoramendyourADHCatanytime.

WhomayexecuteanADHC?AnyadultwhoisofsoundmindmayexecuteanADHC.

Whatisahealthcareagent?Ahealthcareagent isapersonappointedbyyou inanADHC toactonyourbehalf tomakedecisionsrelatedtotheconsentto,refusaloforwithdrawalofanytypeofhealthcare.Ahealthcareagentmayalsobegiven theauthority tomakedecisions related toautopsy,anatomicalgiftsandthefinaldispositionofyourbodyafteryourdeath.Aphysicianorhealthcareproviderwhoisdirectlyinvolvedinyourcaremaynotbeyourhealthcareagent.

Whatismeantbyhealthcare?Health caremeans any care, treatment, serviceor procedure tomaintain, diagnose, treat orprovideforyourphysicalormentalhealthorpersonalcare.

Whatpowersdoesmyhealthcareagenthave?Yourhealth care agentwillmakehealth caredecisions for youonlywhenyouareunable tocommunicate your health care decisions or you choose to have your health care agentcommunicateyourhealthcaredecisions.Yourhealthcareagentwillhavethesameauthoritytomakeanyhealthcaredecisionthatyoucouldmake.Thehealthcareagent'sauthorityincludesthepowertoadmityoutoordischargeyoufromanyhospital,skillednursingfacility,hospiceorotherhealthcarefacilityorservice;thepowertorequest,consentto,withholdorwithdrawanykindofhealthcare;andthepowertocontractforanyhealthcarefacilityorserviceforyouandto obligate you to make arrangements for these services. Your health care agent mayaccompanyyouinanambulanceandmayvisitorconsultwithyouinpersonwhileyouareinahospital,skillednursingfacility,hospiceorotherhealthcarefacility.Ifyouchoose,yourhealthcare agentwill also have the power to authorize an autopsy of your body after your death,

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make a disposition of all or any part of your body formedical purposes andmake decisionsaboutthefinaldispositionofyourbody.

Doesmyhealthcareagenthaveaccesstomedicalrecords?Yourhealthcareagentwillbeyourpersonalrepresentativeforallpurposesoffederalorstatelaws relating to privacy of medical records and will have the same access to your medicalrecordsthatyouhaveandcandisclosethecontentsofyourmedicalrecordstoothersforyourongoinghealthcare.

Howdoesmyhealthcareagentmakedecisions?Whenmakinghealth caredecisions for you, yourhealth careagent should thinkaboutwhatactionwouldbeconsistentwithpastconversationsthetwoofyouhavehad,your treatmentpreferencesasexpressed in yourADHC, your religiousandotherbeliefs andvaluesandhowyouhavehandledmedicalandotherimportantissuesinthepast.Ifwhatyouwoulddecideisstill unclear, then your health care agent should make decisions for you that your agentbelievesare inyourbest interest,considering thebenefits,burdensandrisksofyourcurrentcircumstancesandtreatmentoptions.

AmIrequiredtoappointahealthcareagentinmyADHC?Youarenotrequiredtoappointahealthcareagent inanADHC. Ifyouwish,youmayuseanADHConlytoexpressyourtreatmentpreferencesifyouhaveaterminalconditionorareinastateofpermanentunconsciousness.

HowdoIexpressmytreatmentpreferencesforaterminalconditionorstateofpermanentunconsciousnessinmyADHC?InanADHCyoumayexpressyourtreatmentpreferencesforeitherorbothoftwoconditions:ifyou are in a terminal condition or if you are in a state of permanent unconsciousness. Yourconditionwillbedeterminedinwritingbyyourattendingphysicianandasecondphysician inaccordance with currently accepted medical standards. Your treatment preferences in yourADHCwillbefollowedonlyifyoucannolongercommunicateyourtreatmentpreferencesafterappropriate efforts have been made to communicate with you about your treatmentpreferences.Treatmentpreferencesareyourdecisionsastothewithholdingorwithdrawaloflife-sustaining procedures and/or the provision of nourishment and hydration (nutrition andfluids).

Whatisaterminalcondition?Aterminalconditionisanincurableorirreversibleconditionwhichwouldresultinyourdeathinarelativelyshortperiodoftime.

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Whatisastateofpermanentunconsciousness?Astateofpermanentunconsciousnessisanincurableorirreversibleconditioninwhichyouarenotawareofyourselforyourenvironmentandinwhichyoushownobehavioralresponsetoyourenvironment.

Whatarelife-sustainingprocedures?Life-sustainingproceduresaremedications,machinesorothermedicalprocedureswhich,whenapplied to you in a terminal condition or state of permanent unconsciousness, could inreasonablemedicaljudgmentkeepyoualivebutcannotcureyouandwhere,inthejudgmentof the attending physician and a second physician, your death will occur without suchprocedures or interventions. Life-sustaining procedures do not include administration ofmedicationtoalleviatepainortheperformanceofanymedicalproceduresdeemednecessarytoalleviatepain.Life-sustainingproceduresalsodonotincludetheprovisionofnourishmentorhydration (nutrition and fluids), but you may direct the withholding or withdrawal ofnourishmentorhydrationinanADHC.

What aremy options for treatment preferences for a terminal condition orstateofpermanentunconsciousness?TheformofADHCprovidedbythelawallowsyoutoexpressanyoneofthreepreferencesfortreatmentifyouareinaterminalconditionorstateofpermanentunconsciousness:(1)Trytoextendyourlifeasmuchaspossible,usingalllife-sustainingprocedures,andifyouareunabletoreceivenourishmentorhydration(nutritionandfluids)bymouth,thenyouwanttoreceiveartificial nourishment or hydration (by tube or othermedicalmeans); (2) Allow your naturaldeath to occur; you do not want any life-sustaining procedures or artificial nourishment orhydration;(3)Youdonotwantanylife-sustainingproceduresexceptasyouspecificallyindicateintheform,andyoucanchoosetoreceiveartificialnourishmentand/orhydration,aventilatorand/orCPR.Nomatterwhichofthethreeoptionsyouchoose,youmayalsoprovideadditionaltreatmentpreferencesontheform.

Can my health care agent make decisions regarding my treatment in aterminalconditionorstateofpermanentunconsciousness?UnlessyouprovideotherwiseinyourADHC,thetreatmentpreferencesexpressedinyourADHCare ineffective so long as youhave a health care agentwho is available andwilling tomakedecisionsonyourbehalfregardingthewithholdingorwithdrawaloflife-sustainingproceduresand/ortheprovisionofnourishmentorhydration.However,yourhealthcareagentisrequiredtotakeanytreatmentpreferencesexpressedinyourADHCintoaccountwhenmakingdecisionsaboutyourhealthcare.

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AmIrequired toexpressmytreatmentpreferences fora terminalconditionorstateofpermanentunconsciousnessinmyADHC?You are not required to express treatment preferences for a terminal condition or state ofpermanentunconsciousnessinanADHC.Ifyouwish,youmayuseanADHConlytoappointahealthcareagent.

IsmyhealthcareproviderrequiredtohonormyADHC?IfyourhealthcareproviderreceivesyourADHC,yourhealthcareproviderhastheresponsibilitytoentertheADHCinyourmedicalrecords,tograntyourhealthcareagentadequateaccesstoyou,toconsultwithyourhealthcareagent, tocomplywiththedecisionsofyourhealthcareagent and to give your health care agent the same right to examine and copy yourmedicalrecordsthatyouwouldhave.Ahealthcareproviderwhofailsorrefusestocomplywithyourtreatment preferences regarding thewithholding orwithdrawal of life-sustaining proceduresand/or theprovisionofnourishmentorhydrationmustadviseyourhealthcareagent (if youhave one) or your next of kin or guardian and, if directed to do so, must allow you to betransferredtoanotherphysicianwhowillcomplywithyourtreatmentpreferences.

WhateffectdoesmymarriageordivorcehaveonmyADHC?Unlessyouprovideotherwise inyourADHC, if yougetmarriedafterexecutinganADHC, themarriagerevokesthedesignationofanyoneotherthanyourspouseasyourhealthcareagent.AndunlessyouprovideotherwiseinyourADHC,ifyougetdivorcedafterexecutinganADHC,thedivorcerevokesthedesignationofyourformerspouseasyourhealthcareagent.

WhatisthedifferencebetweenanADHCandadurablepowerofattorneyforhealthcare?State’slawusedtoprovidefortheappointmentofahealthcareagentinadocumentcalledadurablepowerofattorneyforhealthcare.InthelastseveralyearstheADHChasreplacedthedurablepowerofattorneyforhealthcareinmanystates.Yourdurablepowerofattorneyforhealthcareexecutedundertheoldlawremainseffective,butitwouldbeagoodideaforyoutoreplaceitwithanADHC.

WhatisthedifferencebetweenanADHCandalivingwill?Statelawsusedtoprovideforthedeclarationoftreatmentpreferencesforaterminalconditionand state of permanent unconsciousness in a document called a living will. The ADHC hasreplaced the living will in many states. Your living will executed under the old law remainseffective,butitwouldbeagoodideaforyoutoreplaceitwithanADHC.

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Whatisaguardian?A court will appoint a guardian for you if the court finds that you are not able to makesignificantresponsibledecisionsforyourselfregardingyourpersonalsupport,safetyorwelfare.Acourtwillappointthepersonnominatedbyyouifthecourtfindsthattheappointmentwillserveyourbestinterestandwelfare.InanADHC,youmaynominateapersontoserveasyourguardian intheeventacourtdecidesthataguardianshouldbeappointed.Youmay(butarenot required to) nominate your health care agent to be your guardian. A guardian does nothavethepowertomanageyourpropertyorfinancialaffairs.This isnot intended tobea comprehensive statementof law. Itspurpose is to inform,not toadvise on any specific legal problem. If you have specific questions regarding any mattercontainedinthispamphlet,youareencouragedtoconsultanattorney.

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§ Gainbetterunderstandingofpowersofattorneyandadvancedirectives.§ Knowabouttherulesaclient’sagentshouldfollowwhenactingontheirbehalf.§ Beabletoanswerthemostcommonquestionsaskedaboutpowersofattorneyand

advanceddirectives.

4PowersofAttorneyandAdvanceDirectivesAccording to an article by Hurley Elder Care Law which provides solutions for families andindividuals as they address the complex process of growing older, in general, a power ofattorneyisalegaldocumentthatauthorizesapersontoactonyourbehalfasyour“agent”or“attorney-in-fact.” These actions given to your agent or attorney-in-fact can be over yourfinancialaffairsand/oroverhealthcarematters.Youhavetheabilitytogivetheagentaverybroadsweepingorgeneralpoweroryoucanlimitthepowersgrantedtotheagent.Thepowersgiventoyouragentwillenduponyourdeath.Apower of attorney is an instrument that everyone should have in place because unexpectedevents can suddenly changeyour circumstancesdrastically. Life rarely givesus fairwarning.With powers of attorney in place, your agent/attorney-in-fact can immediately handle yourtransactionsormakedecisionsonyourbehalf.

FinancialPowerofAttorney

Whatisafinancialpowerofattorney?A financial power of attorney is the grant of legal rights, powers and authority by a personknownasthe“principal”toanotherpersonwhoisknownasthe“agent”or“attorney-in-fact.”Theagentorattorney-in-fact ineffectstandsintheshoesoftheprincipalandactsforhimorheronfinancialandbusinessmatters.Theattorney-in-factcandowhatevertheprincipalmaydo—withdrawfundsfrombankaccounts,tradestock,paybills,cashchecks—exceptaslimitedin the power of attorney. This does not mean that the attorney-in-fact can just take theprincipal’s money and run. The attorney-in-fact must use the principal’s finances as theprincipal would for his or her benefit, and it does not remove the principal’s authority to

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continuetoactonhisorherownbehalf.Theagent/attorney-in-factonlyhastheauthoritytoactatthesametimeinaccordancewiththepowersgrantedinthepowerofattorney.Itisveryimportant that the financial power of attorney be “durable.” Durable means that it is acontinuingpowerthatsurvivestheprincipal’sfuture legal incapacity.So, inthefuture, ifyouarenolongerabletohandleyourownaffairsthenyouragent/attorney-in-factcanstep-inandhandlethemforyou.

WhatarethetypicalpowersgrantedunderaDurablePowerofAttorney?Truthfully, there are no standard powers granted to an agent/attorney-in-fact but there aresomecommonpowersneededtoadequatelyrepresentapersonwiththeirfinancialmatters.Anagent/attorney-in-factneedstohavetheauthoritytodealwithbankingandotherfinancialinstitutionmatters,whichincludecheckingaccounts,savingsaccounts,moneymarketaccountsandcertificateofdepositaccounts.Also,theabilitytosalethehomeplaceorotherrealestatemaybeneeded so theagent/attorney-in-factneeds tohave theauthority tohandleany realpropertytransactions.Also,authorityneedstobegrantedtodealwithpersonalproperty(cars,boats,andhouseholdfurnishings),retirementplantransactions(IRA’s),lifeinsuranceproducts(life insurancepoliciesandannuities), stocksandbondtransactions,andtaxmatters (incomeandgifttaxes).Werecommendthatapowerofattorneyalsogranttheagent/attorney-in-facttheauthoritytomakegiftsinanyamount,notlimitedtotheannualgifttaxexclusionof$13,000.00perperson,incasetheassetsneededtobeshiftedinagreateramounttoqualifyforpublicbenefits.Thepoweralsoneedstoincludetheabilityfortheagent/attorney-in-facttocreateandadministertrustsifagainneededtoqualifyforpublicbenefits.Andfinally,thepowerofattorneyneedstogranttheabilitytoapplyforandreceivepublicbenefitsonbehalfoftheprincipal.

WhatRulesshouldmyagentfollowwhenactingonmybehalf?Theagentorattorney-in-factmustadheretothefiduciarystandardsinourstate.Theagentorattorney-in-facthasadutyofloyaltytothepersonforwhomheorsheisactingfor(principal).Thedutyofloyaltyrequiresthattheagentorattorney-in-factactssolelyinthebestinterestoftheprincipal,freeofanyself-dealing,conflictsofinterest,orotherabuseoftheprincipalforapersonal advantage. In other words, this personmust have your best interest in mind andcannotintentionallyreceiveapersonalgainatyourdetriment.

Whatifthereismorethanoneattorney-in-fact?Dependingonthewordingofthepowerofattorney,theco-agentsmayormaynothavetoacttogetheronall transactions. Inmostcases,when therearemultipleagents/attorneys-in-fact,thepowerofattorneydocumentspecifiesthattheycaneachactindependentlyofoneanother.Nevertheless,it isimportantforthemtocommunicatewithoneanothertomakecertainthattheiractionsareconsistent.

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Whendoesthepowerofattorneytakeeffect?Unless the power of attorney is “springing,” it takes effect as soon as it is signed by theprincipal.A “springing”powerof attorney takeseffectonlywhen theeventdescribed in theinstrumentitselftakesplace.Typically,thisistheincapacityoftheprincipalascertifiedbyoneormorephysicians.

Doesthepowerofattorneytakeawayaprincipal’srights?No, absolutely not. Only a court can take away a principal’s rights in a conservatorship orguardianshipproceeding.Anagent/attorney-in-factsimplyhasthepowertoactalongwiththeprincipal.

Cantheprincipalchangehisorhermind?Certainly.Aprincipalmayrevokeapowerofattorneyatanytime.Allaprincipalneedstodoissendalettertohisorheragent/attorney-in-facttellingthemthattheirappointmenthasbeenrevoked. From themoment the agent/attorney-in-fact receives the letter, he or she can nolongeractunderthepowerofattorney.

Cananattorney-in-factbeheldliableforhisorheractions?Yes,butonlyifheorsheactswithwillfulmisconductorgrossnegligence

Cananattorney-in-factbecompensatedforhisorherwork?Yes, if theprincipalhasagreed topay theattorney-in-fact. Ingeneral, theagent/attorney-in-fact isentitledto“reasonable”compensationforhisorherservices.However, inmostcases,the agent/attorney-in-fact is a family member and does not expect to be paid. If anagent/attorney-in-fact would like to be paid, it is best that he or she discuss this with theprincipal,agreeonareasonablerateofpayment,andputthatagreementinwriting.Thatistheonlywaytoavoidmisunderstandingsinthefuture.

Cantheattorney-in-factbefired?Certainly.Theprincipalmayrevokethepowerofattorneyatanytime.Allheorsheneedstodoissendtheagent/attorney-in-facta lettertothiseffect.Theappointmentofaconservatororguardiandoesnotimmediatelyrevokethepowerofattorney.Buttheconservatororguardian,liketheprincipal,hasthepowertorevokethepowerofattorney.

Whatkindofrecordsshouldtheattorney-in-factkeep?It is very important that the agent/attorney-in-fact keep good records of his or her actions

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underthepowerofattorney.Thatisthebestwaytobeabletoansweranyquestionsanyonemayraise.Themostimportantruletokeepinmindisnottocomminglethefundstheattorney-in-factismanagingwithhisorherownmoney.Keeptheaccountsseparate.Theeasiestwaytokeeprecordsistorunallfundsthroughacheckingaccount.Thecheckswillactasreceiptsandthecheckbookregisterasarunningaccount.

AdvanceDirectiveforHealthcare/HealthcarePowerofAttorney:

InGeneralMany people have or previously had a Living Will and a Durable Power of Attorney forHealthcare.TheLivingWill isa legaldocumentallowinganindividualtochoosewhetherornotheorshewants to die naturally, without death being artificially prolonged by various medicalprocedures. The LivingWill is an authorization to yourmedical professionals to withhold orwithdrawcertainmedicalprocedures,suchasaventilator,respirator,feedingtube,hydrationsolutions,andpainmedication.The Durable Power of Attorney for Healthcare is a legal document appointing and naminganotherpersontomakehealthrelateddecisionsonone’sbehalfanditgivesthispersoncalledtheagent,someideaofwhatwemayormaynotwantregardingpotentialmedicalproceduresthatmayneedtobeadministeredinthefuture.Inmanystates,thenewAdvanceDirectiveforHealthcarereplacedthelawsontheLivingWillandtheDurablePowerofAttorneyforHealthcare.ThenewestdocumentiscalledtheAdvanceDirectiveforHealthcare.TheintentofthisinstrumentiscoverthesameterritoryastheLivingWillandDurablePowerofAttorneyforHealthcarebutalsoistoavoidtheconfusioncreatedbytheoverlapandcontradictionoftheformerdocuments.TheAdvanceDirective forHealthCare inmanystatesnowprovides that individualshave theright to control all aspects of their medical care – including the right to insist on medicaltreatment,requestittobewithdrawnortorefusetreatment.Thenewlegaldocumentallowsindividuals to appoint anagent tomakemedical treatmentdecisionon theirbehalf, if directcommunication is not possible, and it authorizes an individual’s medical professionals towithhold orwithdraw certain treatments or procedures. In addition, the document containsspecificprivacy-relatedreleaselanguageasrequiredbyHIPAA(HealthInsurancePortabilityandAccountabilityAct).

Is the Advance Directive for Healthcare the same as a Durable Power ofAttorneyforHealthcareormyLivingWill?As stated, theAdvanceDirective forHealthcarecombines these twodocuments intoa single

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legal document andmakes it easier for individual’swishes to be known. Durable Powers ofAttorney and LivingWillsmade previously are still valid and youmay continue to use themeffectively. However, if possible, the new document should be executed because additionalconsiderationscanbeaddressedthatwerenotcoveredinyourcurrentdocuments.

Whattypeofmedicalproceduresandtreatmentsareyoutalkingabout?Treatments and procedures that may extend life for otherwise terminal patients such as aventilator,CPR,artificialnutrition(feedingtubes),hydration(IVfluids)andkidneydialysis.

WhydoIneedtocompleteanAdvanceDirectiveforHealthcare?Thislegaldocumentallowsindividualstoexpresstheirwishesabouttheirownendoflifecareevenwhentheycan’tcommunicate.Itletsthefamilyandthemedicalprofessionalsknowwhattheywantandwhattheydonotwanttohappentowhentheyareneartheendoftheirlives.Ifthisdocumentinnotinplace,individualswhocannotmaketheirowndecisionhavetoabidebytheprioritydesignationsunderthestate’s“next-of-kin”law.Thelawstatesthatthefollowingpersons can make medical decisions for patients who do not have capacity to decide forthemselves,inthefollowingorderofpriority:(a)anadultchildforaparent;(b)aparentforanadultchild;(c)anadultforabrotherorsister;(d)agrandparentforagrandchild;(e)anadultgrandchildforagrandparent;(f)anadultniece,nephew,aunt,oruncleinthefirstdegree;or(g)anadult friend.Also,under this law,anAdvanceDirective forHealthcarehas completepriorityoveranyoftheafore-statedrelationshipssothisiswhyitisneeded.

Whatisa“DoNotResuscitate”(DNR)order?A DNR order is a written order from a physician that informs medical personnel thatresuscitationshouldnotbeattempted ifapersonsufferscardiacorrespiratoryarrest.Thereare DNR orders in the hospital and then there are DNR orders written for out in thecommunity. Community can mean a home, assisted living facility, personal care home andskillednursinghome.JustbecauseapersonhasaDNRorderinthehospitaldoesnotmeanitwill transfer out of the hospital. If a person wants a DNR order once leaving the hospitalanotheroneneedstobefilledoutforuseinthecommunity.

WhendoesaphysicianwriteaDNRorder?AphysiciancanwriteaDNRforapatientafteraverbalconversationwithacompetentadultpatientortheperson’shealthcareagent.Boththeagentandthedoctorshouldtrytoabidebythe person’s wishes, which are listed in the Advance Directive for Healthcare. In someinstances,aphysicianwillwriteaDNRorderwhenresuscitationwillnotaltertheoutcomeofthediseaseor ifresuscitationwillcauseunnecessarysuffering. Twophysicianssignaturesarerequired for a DNR to be followed at the necessary time to act on it. In other words, anattending physician with the concurrence (agreement) of another physicianmust determine

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thatthepersonisa“candidatefornonresuscitation”beforetheDNRordercanbewrittenbyanattendingphysician.

HowwillmedicalpersonalknowthataDNRorderisinplace?Inahospitaloroutinthecommunity,therewillbealargenoticeonthefrontofthechart.Inthecommunity, identificationnecklacesandbraceletsareavailableandcanbeworntomakesureallmedicalpersonnelrecognizeandadheretopatient’swishes.

DoesaDNRorderstopmedicalpersonalfromtreatingapatientcompletely?No, a DNR only refers to resuscitation (CPR) efforts and does not interfere with othertreatments. For example, transfusions, kidney dialysis, use of a ventilator and antibiotictherapy.Treatmentthatkeepsapersonfreeofpainandcomfortableshouldalwaysbegiven.

CanaDNRorderberevoked?Yes,DNRorders shouldbe reviewedperiodicallyby thedoctorand revoked ifappropriate.ApersoncanrevokehisDNRatanytime.

Whatisa“code”?Acodeisawordthathospitalandnursinghomesusetomeanresuscitationeffortsshouldbeinitiated.

Whatisa“nocode”?A“nocode”isaninformalnameforaDNR.

IsthereaformoftheAdvanceDirectiveforHealthcare?Yes.TheAdvanceDirectiveforHealthCareform(seeChapter7)containsfour(4)parts.Thefirstpartprovidesforanindividualtoappointahealthcareagenttomakehealthcaredecisionsonhisorherbehalfuponincapacity.Typically,aspouseand/orchild,orchildren,arenamedasthehealthcareagent(s).Otherscenarios includeatrustedfriendwhoisnamedandwillhaveyourbestinterestinmind.Further,thefirstpartoftheformcangivethehealthcareagenttheability tomakedecisionsafterone’sdeathwith respect toanautopsy,organdonation,bodydonation formedical study,and finaldispositionof thebody. Inmaking thesedecisions, theagent should consider conversations with the patient, which includes medical treatmentpreferences,andreligious,culturalandotherbeliefsof thepatient.Next, thesecondpartoftheformlaysoutspecificscenariosrelatingtomedicalconditionssuchasaterminalillnesswithimminentdeath,andastateofpermanentunconsciousness.Foreachmedicalcondition, the

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specificmedicaltreatmentpreferencesmaybeselectedbythe individual;thus,makinghisorher wishes known to the health care agent and physicianwhomay provide the treatment.Further,thethirdpartoftheformallowsanindividualtonominateaguardianintheeventacourtdecidesthatoneshouldbeneeded.Itisalwayspreferabletohaveanadvancedirectiveinplacethatindicateswhoyouwanttomakesignificantresponsibledecisionsforyouregardingyourpersonalsupport,safety,orwelfare.Andfinally,thefourthpartoftheformprovidesthesignature and witness requirements necessary to evidence that the decisions made in theadvancedirectiveareclear,effectiveandgenuinelyone’sown.

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§ Bemoreawareandmorecapableofknowingaboutthingsyoushoulddo.§ Bemoreawareandmorecapableofknowingaboutthingsyoushouldknow.

5WhattoKnowandDo

ThingsYouShouldDoInordertohavealegaldocumentthatexpressesyourwishesforthehealthcareyouwanttoreceiveat theendofyour life,youshouldcompleteanAdvanceDirective forHealthCare. IncompletingtheAdvanceDirectiveforHealthCare,youwilldotwothings:

§ Legally appoint someone as your Health Care Agent to make health caredecisionsforyouwhenyoucannotordonotwanttospeakforyourself,and

§ Formally state your preferences for themedical treatments you do or do notwanttoreceive.

ThingsYouShouldKnow

§ Youdonotneedtohirea lawyer tocompleteanAdvanceDirective forHealthCare. The document includes instructions on how to complete the form.However, you are encouraged to consult your lawyer, doctor, or otherprofessionalstohelpyoumakeinformeddecisions.

§ Asacompetentadult,youhavetherighttorefuseanyunwantedtreatmentsorprocedures for any reason, even treatments that could keep you alive (unlessyouarepregnantwithaviablefetus).

§ TheAdvanceDirective forHealthCarecoversonlyhealthcaredecisions. Ithasnoeffectoverfinancialaffairsthatareunrelatedtoyourhealthcare.

§ You or your Health Care Agent are responsible for notifying your doctor andotherhealthcareprovidersthatyouhaveanAdvanceDirectiveforHealthCare.

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§ IfyouchoosenottocompleteanAdvanceDirectiveforHealthCare,theremayberestrictionsonthehealthcaredecisionsthatrelativesorfriendscanmakeforyou.

§ If a doctor or other health care provider has direct knowledge of yourpreferences as documented in your Advance Directive for Health Care orexpressed by your Health Care Agent, he is required to abide by yourpreferencesaslongasyourpreferencesarelegal.

§ If thedoctororhealthcareprovider isunwillingtohonoryourpreferences,hemustassistintransferringyourcaretoanotherprovider.

§ State’slawprotectsadoctororhealthcareproviderwho,ingoodfaith,followsyour preferences as documented in the Advance Directive for Health Care ordirectedbyyourHealthCareAgent.

§ It is against many state’s law for any person willfully to hide, cancel or alteranotherperson’shealthcaredirective,itsamendmentsorcancellation.

§ AnotherpersoncancompleteanAdvanceDirectiveforHealthCareforyoubutonly with your expressed consent and in your presence. Once you have beendeterminedtobeincapableofmakingyourowndecisions,youcannotcompleteanAdvanceDirective forHealthCare,nor can someoneelse completeone foryou.

§ A hospital, nursing facility, home health company, or hospice program cannotrefuse toadmit youbecauseyoudonothaveanAdvanceDirective forHealthCare.

§ Completing an Advance Directive for Health Care will have no effect on yourability tobuy,paypremiumson,or collectonany typeof insurance, includinghealth,life,anddisabilityinsurance.YoucannotberequiredtohaveanAdvanceDirectiveforHealthCareinordertoobtainhealthinsurance.

§ The lawsonhonoringhealthcaredirectivesdiffer fromstate tostate.BecausetheAdvanceDirectiveforHealthCareyoucompleteinyourstateexpressesyourpreferencesaboutmedicalcare,itwillinfluencethatcarenomatterwhereyouare treated. However, there is a possibility that your Advance Directive forHealthCaremaynotbehonored inanotherstate. Ifyouspendagreatdealoftimeinanotherstate,youmaywanttocompleteadocumentthatmeetsalltherequirementsofthatstate.

§ If you have an emergency and your Advance Directive for Health Care is notreadily available, life sustaining treatmentsmay be started. Treatment can bestoppedifitisdiscoveredthatitisnotwhatyouwant.

§ The Advance Directive for Health Care is not connected to any governmenthealthcareprogram,suchasMedicareorMedicaid.Anycompetentadultmaycomplete a Advance Directive for Health Care regardless of how they pay fortheirhealthcare.

§ TheAdvanceDirectiveforHealthCareallowsyoutoappointaHealthCareAgent–thisisapersonwhowillhavethelegalpowertomakedecisionsregardingyourhealth care – but ONLY when you are incapable of making those decisionsyourselforchoosenottomakeyourowndecisions.

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§ You may be incapable of making your own decisions because you areunconscious, mentally ill, in a coma, in the advanced stages of Alzheimer’sDiseaseorareotherwiseunabletomakeyourowndecisions.Youdonothavetobe terminally ill or near death for your Health Care Agent to be able tomakedecisions for you, but youmust be incapable ofmaking your own decisions orchoosenottomakeyourowndecisions.

§ State lawsprotects yourHealthCareAgent as longasheor sheacts in “goodfaith”andinaccordancewithyourinstructions.

§ YourHealthCareAgentcannotbeheldresponsibleforthecostofyourmedicalcare.However,ifyouhavenamedyourspouseasyourHealthCareAgent,yourspousemayberesponsibleforthecostofyourmedicalcarebecauseheorsheisyourspouse.

§ AchangeinyourmaritalstatusmayrevoketheappointmentofyourHealthCareAgent.

§ TheAdvanceDirectiveforHealthCarealsowillgiveyoutheoptiontonominatesomeone to serve as your guardian. A court may appoint a guardian if itdetermines that you arenot able tomake significant responsible decisions foryourself.

§ YoumaynominatethesamepersonyoudesignatedasyourHealthCareAgenttoserveasyourguardianHowever, ifyouchosetonominatesomeoneelsetobeyourguardian,youshouldbeawarethatthepersonnamedasyourHealthCareAgent would have priority over your guardian in making your health caredecisions,unlessacourtdeterminesotherwise.

§ ThepersonyounameasyourHealthCareAgentwillhavebroadpowerstomakehealth care decisions for you, including the power to require, consent to, orwithdraw any type of personal care or medical treatment for any physical ormentalcondition.

§ YourHealthCareAgentcanagreetoadmitordischargeyoufromanyhospital,nursinghome,orotherinstitution.

§ Statelaw,whereapplicable,doesnotallowyourHealthCareAgenttoputyouinamental hospital against yourwill or tomake decisions about sterilization orpsychosurgery.

§ ThelawdoesnotrequirethepersonyounameasyourHealthCareAgenttoactfor you. You must ask that person if he or she is willing to accept thisresponsibility.

§ Your Health Care Agent must use due care to act for your benefit and inaccordancewithyourAdvanceDirectiveforHealthCare.

§ AcourtcantakeawaythepowersofyourHealthCareAgentifitfindsthatyourAgent is not acting according to your preferences or that your Agent is notcompetenttomakedecisions.

§ YoumayappointaHealthCareAgentaswellasoneormoreback-upAgents,incaseyourprimaryAgentisnotavailablewhendecisionsneedtobemade.

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§ Youcanchooseanyonewhoisover18yearsofageoroldertobeyourHealthCareAgent.Theonly restriction is thatyoucannotappointyourdoctororanyotherpersonwhodirectlyprovideshealthcaretoyou.

§ Unlessyouexpressly limitthedurationoforrevokeyourAdvanceDirectiveforHealth Care, or a court acting in your behalf terminates it, your Health CareAgent may exercise the powers you have given him or her throughout yourlifetime,evenafteryoubecomedisabled,incapacitated,orincompetent.

§ If youchangeyourmind, yourAdvanceDirective forHealthCarecanbeeasilyamendedorcanceled.

Note: This information is a general summary of the rights of competent adults. It does notcontainallthetechnicaldetailsofthelaw.Also,itdoesnotdealwithdecisionsforminorsorforthosewhoarenowmentallyincapable,nordoesitapplytotreatmentoutsideofyourstate.Itisnottheintentofthisdocumenttoprovidespecificlegalormedicaladvice.Individuals are encouraged to consult professionals such asphysicians, clergy and lawyers tohelpthemmakeinformeddecisions.

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§ LearnmoreabouttheactualAdvanceDirectiveforHealthCare.§ LearnmoreaboutthedefinitionsaboutAdvanceDirectiveforHealthCare.§ Beabletotellthedifferencebetweentheadvancedirectiveformandthe livingwill

anddurablepowerofattorneyforhealthcare.§ Gaininsightintothethreepartsoftheadvancedirectiveforhealthcare§ Learnabouttherequirementsforthepersonmakinganadvancedirectiveforhealth

care.§ Findouthowtorevokeanadvancedirectiveforhealthcare.

6AdvanceDirectiveforHealthCare

Purpose:Inrecognizingtherightof individualsto(1)controlallaspectsofhisorherpersonalcareandmedical treatment, (2) insist upon medical treatment, (3) decline medical treatment, or (4)direct thatmedical treatmentbewithdrawn, theGeneralAssembly inmost stateshas in thepast,providedstatutoryformsforboththelivingwillanddurablepowerofattorneyforhealthcare. To help reduce confusion, inconsistency, out-of-date terminology, and confusing andinconsistentrequirementsforexecution,andtofollowthetrendsetbyotherstatestocombinetheconceptsofthelivingwillandhealthcareagencyintoasinglelegaldocument,theeffortsofa significant number of individuals representing the academic,medical, legislative, and legalcommunities,stateofficials,ethicsscholars,andadvocacygroupsproducedthedevelopmentofaconsolidatedadvancedirectiveforhealthcare.Thisnewlycreatedformusingunderstandableand everyday language is meant to encourage more citizens of many states to voluntarilyexecuteadvancedirectivesforhealthcaretomaketheirwishesmoreclearlyknown.TheGeneral Assembly of applicable states takes note that the clear expression of individualdecisionsregardinghealthcare,whethermadebytheindividualoranagentappointedbytheindividual, is of critical importance not only to citizens but also to the health care and legalcommunities, third parties, and families. In furtherance of these purposes, the GeneralAssemblyenactnewlaws.ThoseChapterssetforthgeneralprinciplesgoverningtheexpressionofdecisionsregardinghealthcareandtheappointmentofahealthcareagent,aswellasaformofadvancedirectiveforhealthcare.

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InstructionsTheeffectoftheAdvanceDirectiveforHealthCareActontheLivingWillsandDurablePowersofAttorneyforHealthCareLaws.State’slawsonadvancedirectiveschangedsignificantlyoverthelastseveralyears.

§ Manystate’sAdvanceDirectivesforHealthCareActwillorhavereplacedtheirLivingWill’sOfficialCodes.

§ TheLivingWillandDurablePowerofAttorneyforHealthCarewillnolongerbeavailableasoptionsforadvancedirectivesinthose.

§ Validly executed Living Wills created between certain dates will remain validuntilrevoked.

§ Validly executedDurablePowersofAttorney forHealthCare createdbetweencertaindateswillremainvaliduntilrevoked.

ToknowifyourcurrentLivingWilland/orDurablePowerofAttorneyforHealthCareisvalid,find a copy of the old code sections to confirm the witnessing requirements or consult anattorneywhocancompareitwiththelawineffectpriortotheirnewlawchanges.If one chooses to complete an Advance Directive for Health Care, it will replace any otheradvancedirectiveforhealthcare,durablepowerofattorneyforhealthcare,healthcareproxy,orlivingwillthatcurrentlyis inplace.Onemaychoosenottocompletethisformandhis/hercurrent Living Will and/or Durable Power of Attorney for Health Care form, if valid now,remainsvalid.

AnAdvanceDirectiveforHealthCareisNeverRequired.

Definitions'Advance directive for health care' means a written document voluntarily executed by adeclarantinaccordancewiththerequirementsofyourstate’sCodeSection.'Attending physician' means the physician who has primary responsibility at the time ofreferenceforthetreatmentandcareofthedeclarant.'Declarant'meansapersonwhohasexecutedanadvancedirectiveforhealthcareauthorizedbythischapter.'Durablepowerofattorneyforhealthcare'meansawrittendocumentvoluntarilyexecutedbyanindividualcreatingahealthcareagencyinaccordancewithyourstate’sCodeChapter.

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'Healthcare'meansanycare,treatment,service,orproceduretomaintain,diagnose,treat,orprovideforadeclarant´sphysicalormentalhealthorpersonalcare.'Healthcareagent'meansapersonappointedbyadeclarant toact forandonbehalfof thedeclarant tomake decisions related to consent, refusal, orwithdrawal of any type of healthcare anddecisions related to autopsy, anatomical gifts, and final disposition of a declarant´sbodywhenadeclarant isunableorchoosesnot tomakehealthcaredecisions forhimselforherself.Theterm'healthcareagent'shallincludeanyback-uporsuccessoragentappointedbythedeclarant.'Health care facility' means a hospital, skilled nursing facility, hospice, institution, home,residential ornursing facility, treatment facility, andanyother facilityor servicewhichhas avalidpermitorprovisionalpermitissuedunderaChapterofyourstatetitleorwhichislicensed,accredited, or approvedunder the lawsof any state, and includeshospitals operatedby theUnitedStatesgovernmentorbyanystateorsubdivisionthereof.'Health care provider' means the attending physician and any other person administeringhealth care to thedeclarant at the timeof referencewho is licensed, certified, orotherwiseauthorizedorpermittedbylawtoadministerhealthcareintheordinarycourseofbusinessorthe practice of a profession, including any person employed by or acting for any suchauthorizedperson.'Life-sustaining procedures' means medications, machines, or other medical procedures orinterventions which, when applied to a declarant in a terminal condition or in a state ofpermanent unconsciousness, could in reasonablemedical judgment keep the declarant alivebut cannot cure the declarant andwhere, in the judgment of the attending physician and asecond physician, deathwill occur without such procedures or interventions. The term 'life-sustaining procedures' shall not include the provision of nourishment or hydration but adeclarant may direct the withholding or withdrawal of the provision of nourishment orhydrationinanadvancedirectiveforhealthcare.Theterm'life-sustainingprocedures'shallnotinclude theadministrationofmedication toalleviatepainor theperformanceofanymedicalproceduredeemednecessarytoalleviatepain.Living will' means a written document voluntarily executed by an individual directing thewithholding or withdrawal of life-sustaining procedures when an individual is in a terminalcondition,coma,orpersistentvegetativestateinaccordancewithyourstate’schapter.‘Physician' means a person lawfully licensed in your state to practicemedicine and surgerypursuant toyour stateCodesections;and if thedeclarant is receivinghealthcare inanotherstate,apersonlawfullylicensedinsuchstate.'Provisionofnourishmentorhydration'meanstheprovisionofnutritionor fluidsbytubeorothermedicalmeans.

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'State of permanent unconsciousness'means an incurable or irreversible condition inwhichthe declarant is not aware of himself or herself or his or her environment and inwhich thedeclarantisshowingnobehavioralresponsetohisorherenvironment.'Terminal condition'means an incurable or irreversible conditionwhichwould result in thedeclarant´sdeathinarelativelyshortperiodoftime.

CertificationofaterminalconditionorstateofpermanentunconsciousnessBefore any action can be taken to withdraw or withhold life sustaining procedures or towithdraw or withhold nourishment or hydration for a declarant in a state of permanentunconsciousnessor is ina terminalcondition, thatconditionmustbecertified inwriting.Theattendingphysicianandoneotherphysicianmustpersonallyexaminethedeclarantandcertifyinwritingbaseduponthedeclarant’scondition foundduring thecourseof theirexaminationandinaccordancewithcurrentacceptedmedicalstandardsthatthedeclarantdoesmeetthecriteriaforterminalconditionorstateofpermanentunconsciousnessasdefinedabove.

ThedifferencebetweenthisadvancedirectiveformandtheLivingWillandDurablePowerofAttorneyforHealthCareTheAdvanceDirectiveforHealthCareisanattempttocombinethebestfeaturesoftheLivingWillandDurablePowerofAttorneyforHealthCareintoonewrittendocument.Anefforthasalsobeenmade tomake theexecution (signingandwitnessing)of thisdocumenteasier andmoreconvenient.Theeffectof thisnewdocumentstilldoesnotconstitutesuicide,physicianassistedsuicide,homicideoreuthanasia.Completingonehasnoaffectoninsurance,annuitiesor anything else contingent on the life or death of the personmaking the advance directive(hereafter,“thedeclarant”).

NolimitationontheuseofotheradvancedirectivesformsUsing this form of advance directive for health care is completely optional. Other forms ofadvance directives for health care that substantially comply with this formmay be used inapplicablestates.Thisincludesusingformsfromotherstates.

ThreePartsoftheAdvanceDirectiveforHealthCarePart One: allows an agent to be appointed to carry out health care decisions (formerly theDurablePowerofAttorneyforHealthCare)

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Part Two: allows choices about withholding or withdrawing life support and accepting orrefusingnutritionand/orhydration(formerlytheLivingWill)PartThree:allowsonetonominatesomeonetobeappointedasGuardianifacourtdeterminesthataguardianisnecessary.

Requirementsforthepersonmakinganadvancedirectiveforhealthcare

§ Mustbeofsoundmind§ Mustbe18yearsofageorolderOrAnemancipatedminor

Executingtheadvancedirectiveforhealthcare

§ thedeclarantmustsignorexpresslydirectsomeoneelsedoitforhim/her§ twowitnessesrequired,whoare:

o ofsoundmindo 18yearsofageorolder

• Witnessesdonothavetoseethedeclarantsign• Witnesses do not have to see each other sign the

advancedirective§ thedeclarantmustseebothwitnessessign

o Restrictiononwitnesseso Notthehealthcareagento Notknowinglybeinlinetoinheritanythingfromorbenefitfrom

thedeathofthedeclaranto Notdirectlyinvolvedinthehealthcareofthedeclaranto Onlyoneof thetwowitnessescanbeanemployee,agentoron

themedicalstaffofthehealthcarefacilitywherethedeclarantisreceivinghis/herhealthcare

RestrictionsonthehealthcareagentAphysicianorhealthcareproviderdirectlyinvolvedinthecareofthedeclarantmaynotserveashealthcareagent.

Dutyofthehealthcareagenttoact

§ Ahealthcareagenthasnodutytoact,evenifnamed.§ Ifthehealthcareagentdoeschoosetoact,s/hemustnotmakedecisionsthat

aredifferentorthatcontradictthedecisionsofthedeclarant.§ Allofthehealthcareagent’sactionsmustbeconsistentwiththeintentionsand

desiresofthedeclarant.

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§ Ifthoseintentionsanddesiresarenotclear,thehealthcareagent’sactionsmustbeinthebestinterestsofthedeclarantconsideringallofthebenefits,burdens,risksandtreatmentsoptions.

Authorized responsibilities/duties of the health care agent related to thenecessarycareofthedeclarant

§ Consent to, authorize,withdraw consent from, refuse,withhold, any and all types ofmedical/surgical care, treatment, programs and/or procedures Sign and deliver allinstruments(documents)

§ Negotiateandenterintoallagreementsandcontractsbindingthedeclarant§ Accompanyhim/herinanambulanceorairambulance§ Admittoordischargethedeclarantfromanyhealthcarefacility§ Visitandconsultwiththedeclarantasnecessary§ Examine,copyandconsenttodisclosureofallthedeclarant’smedicalrecordsdeemed

relevant§ Do all other acts reasonably necessary and carry out duties and responsibilities in

person or through those employed by the health care agent; this does not includedelegatingtheauthoritytomakehealthcaredecisions

§ Consenttoananatomicalgiftofthedeclarant´sbody,inwholeorpart,anautopsyanddirect the final disposition of declarant´s remains, including funeral arrangements,burial,orcremation(Note:thelawstatesthattheagentcanbindthedeclaranttopaybutdoesnotexpresslymentionbinding theestateof thedeclarant. Itmaybeagoodideatomakeallarrangementspriortothedeathofthedeclarant.)

ProhibitedactionsbythehealthcareagentThe health care agent may not consent to psychosurgery, sterilization, or involuntaryhospitalizationortreatmentundertheMentalHealthCode.

Whentheattendingphysician,healthcareproviderand/orhealthcarefacilityrefusetohonortheadvancedirectiveforhealthcareThelawstates:Forhealthcaredecisionswithwhichhealthcareprovidersareunwilling tocomply,after thisdecision is communicated with the agent, the agent is responsible for arranging for thedeclarant´stransfertoanotherhealthcareprovider.Thissectionofthelawdoesnotexpresslyincludelife-sustainingprocedures,nourishmentorhydrationin“healthcaredecisions.”For a declarant´s decision towithhold orwithdraw life-sustaining procedures orwithhold orwithdrawtheprovisionofnourishmentorhydration,attendingphysicianswhofailorrefuseto

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complyareresponsibleformakingagoodfaithattempttoeffectthetransferofthedeclaranttoanotherphysicianwhowillcomplyormustpermittheagent,nextofkinorlegalguardiantoobtainanotherphysicianwhowillcomply.Ifitisthehealthcarefacilitythatrefusestocomplywiththedeclarant´sdecisiontowithholdorwithdrawlife-sustainingproceduresornutritionorhydration,thelawdoesnotexpresslystatewhoseresponsibilityitistoensurethedeclarantistransferredtoanotherhealthcarefacility.

RevokingthisadvancedirectiveforhealthcareThe Advance Directive for Health Care may be revoked at any time, regardless of thedeclarant´smentalstateorcompetency.ItremainseffectiveevenifaGuardianisappointedforthedeclarantunlessacourtspecificallyordersotherwise.Revocationcanoccurinanyofthefollowingways:

§ Bycompletinganewadvancedirectiveforhealthcare§ Byburning,tearingup,orotherwisedestroyingtheexistingadvancedirectivefor

healthcare§ By writing a clear statement expressing the intent to revoke the advance

directiveforhealthcare§ Byorallyexpressingtheintenttorevoketheadvancedirectiveforhealthcarein

thepresenceofawitness18yearsofageorolderwhoconfirmsthis inwritingwithin 30 days. The revocation is effective when the treating physiciandocumentsitinthemedicalrecord.

§ Marryingafterexecutinganadvancedirectiveforhealthcarerevokesanyagentotherthanthedeclarant´sspouse

§ Divorcingorotherwisedissolvingamarriageafter theexecutionofanadvancedirectiveforhealthcarerevokesthedesignationofthespouseasthehealthcareagent

WhattodowiththecompletedformYou should give a copy of your completed form to peoplewhomight need it, such as yourhealthcareagent,yourfamily,andyourphysician.Keepacopyofthiscompletedformathomeinaplacewhereitcaneasilybefoundifitisneeded.Reviewyourcompletedformperiodicallyto make sure it still reflects your preferences. If your preferences change, complete a newadvancedirectiveforhealthcare.Copiesofthisformanditsinstructionsareavailableatnocostfrommoststatesandacopyofyourstate’sadvancedDirectiveform,seeaconvenientlinkat:http://www.caringinfo.org,clickon“DownloadYourStatespecificAdvanceDirective”

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§ KnowwhatanAdvanceDirectiveforHealthCareformlookslike.§ BeabletocompleteyourownAdvanceDirectiveform.§ BeabletosummarizetheimportantpointsaboutAdvanceDirectives.

7AdvanceDirectiveforHealthCare–“Forms”Alawyercanpreparethesepapers,oryoucandothemyourself.FormsareavailablefromyourlocalorStategovernment,fromprivategroups,orontheInternet.Often,theseformsneedtobewitnessed.Thatmeansthatpeoplewhoarenotrelatedtoyouwatchasyousignanddatethepaperworkandthensignanddateitthemselvesasproofthatthesignatureisindeedyours.Makesureyougivecopies toyourprimarydoctorandyourhealthcareproxy.Havecopies inyour filesaswell.Hospitalsmightask foracopywhenyouareadmitted,even ifyouarenotseriouslyill.You should also give permission to your doctors and insurance companies to share yourpersonalinformationwithyourhealthcareproxy.Thisletsyourproxydiscussyourcasewiththedoctorandhandleinsuranceissuesthatmaycomeup.Sometimes,peoplechangetheirmindsastheygetolderoraftertheybecome ill.Reviewthedecisionsinyouradvancedirectivesfromtimetotime,andmakechangesifyourviewsoryourhealthneedshavechanged.Besuretodiscussthesechangeswithyourhealthcareproxyandyour doctor. Replace all copies of the older version with the updated ones, witnessed andsignedifappropriate.DoyouliveinoneState,butspendalotoftimeinanother?MaybeyouliveinthenorthandspendwintermonthsinasouthernState.Or,perhapsyourchildrenandgrandchildrenliveinadifferentStateandyouvisitthemoften.BecauseStates’rulesandregulationsmaydiffer,makesure your forms are legal in both your home State and the State you travel to often. If not,makeanadvancedirectivewithcopiesforthatState,too,andbesureyourfamilytherehasacopy.

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Foracopyofyourstate’sadvancedDirectiveform,GoogleyourStateDepartment/AgencyonAgingto“DownloadYourStatespecificAdvanceDirective”

AdvanceDirectiveForm–“Sample”

Advance Directive for Health Care

By: Date of Birth: (Print Name) (Month/Day/Year)

This advance directive for health care has four parts: PART ONE—Health Care Agent. This part allows you to choose someone to make health care decisions for you when you cannot (or do not want to) make health care decisions for yourself. The person you choose is called a health care agent. You may also have your health care agent make decisions for you after your death with respect to an autopsy, organ donation, body donation, and final disposition of your body. You should talk to your health care agent about this important role. PART TWO—Treatment Preferences. This part allows you to state your treatment preferences if you have a terminal condition or if you are in a state of permanent unconsciousness. PART TWO will become effective only if you are unable to communicate your treatment preferences. Reasonable and appropriate efforts will be made to communicate with you about your treatment preferences before PART TWO becomes effective. You should talk to your family and others close to you about your treatment preferences. PART THREE—Guardianship. This part allows you to nominate a person to be your guardian should one ever be needed. PART FOUR—Effectiveness and Signatures. This part requires your signature and the signatures of two witnesses. You must complete PART FOUR if you have filled out any other part of this form. You may fill out any or all of the first three parts listed above. You must fill out PART FOUR of this form in order for this form to be effective. You should give a copy of this completed form to people who might need it, such as your health care agent, your family, and your physician. Keep a copy of this completed form at home in a place where it can easily be found if it is needed. Review this completed form periodically to make sure it still reflects your preferences. If your preferences change, complete a new advance directive for health care. Using this form of advance directive for health care is completely optional. Other forms of advance directives for health care may be used. You may revoke this completed form at any time. This completed form will replace any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that you have completed before completing this form. PART ONE—Health Care Agent PART ONE will be effective even if PART TWO is not completed. A physician or health care provider who is directly involved in your health care may not serve as your health care agent. If you are married, a future divorce or annulment of your marriage will revoke the selection of your current spouse as your health care agent. If you are not married, a future marriage will revoke the selection of your health care agent unless the person you selected as your health care agent is your new spouse.

60 1. Health Care Agent I select the following person as my health care agent to make health care decisions for me:

Name: Address: Telephone Numbers: (Home, Work, and Mobile)

2. Back-Up Health Care Agent This section is optional. PART ONE will be effective even if this section is left blank. If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable efforts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-up health care agent(s):



3. General Powers of Health Care Agent My health care agent will make health care decisions for me when I am unable to communicate my health care decisions or I choose to have my health care agent communicate my health care decisions. My health care agent will have the same authority to make any health care decision that I could make. My health care agent´s authority includes, for example, the power to: • Admit me to or discharge me from any hospital, skilled nursing facility, hospice, or other health care

facility or service; • Request, consent to, withhold, or withdraw any type of health care; and • Contract for any health care facility or service for me, and to obligate me to pay for these services (and

my health care agent will not be financially liable for any services or care contracted for me or on my behalf).

My health care agent will be my personal representative for all purposes of federal or state law related to privacy of medical records (including the Health Insurance Portability and Accountability Act of 1996) and will have the same access to my medical records that I have and can disclose the contents of my medical records to others for my ongoing health care. My health care agent may accompany me in an ambulance or air ambulance if in the opinion of the ambulance personnel protocol permits a passenger and my health care agent may visit or consult with me in person while I am in a hospital, skilled nursing facility, hospice, or other health care facility or service if its protocol permits visitation. My health care agent may present a copy of this advance directive for health care in lieu of the original and the copy will have the same meaning and effect as the original.

61I understand that under state law: • My health care agent may refuse to act as my health care agent; • A court can take away the powers of my health care agent if it finds that my health care agent is not

acting properly; and • My health care agent does not have the power to make health care decisions for me regarding

psychosurgery, sterilization, or treatment or involuntary hospitalization for mental or emotional illness, mental retardation, or addictive disease.

4. Guidance for Health Care Agent When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO (if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options. 5. Powers of Health Care Agent After Death (A) AUTOPSY My health care agent will have the power to authorize an autopsy of my body unless I have limited my health care agent´s power by initialing below. _________ (Initials) My health care agent will not have the power to authorize an autopsy of my body

(unless an autopsy is required by law). (B) ORGAN DONATION AND DONATION OF BODY My health care agent will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Anatomical Gift Act, unless I have limited my health care agent´s power by initialing below. Initial each statement that you want to apply. _________ (Initials) My health care agent will not have the power to make a disposition of my body for

use in a medical study program. _________ (Initials) My health care agent will not have the power to donate any of my organs. (C) FINAL DISPOSITION OF BODY My health care agent will have the power to make decisions about the final disposition of my body unless I have initialed below. _________ (Initials) I want the following person to make decisions about the final disposition of my body:


62 I wish for my body to be: _________ (Initials) Buried OR _________ (Initials) Cremated PART TWO—Treatment Preferences PART TWO will be effective only if you are unable to communicate your treatment preferences after reasonable and appropriate efforts have been made to communicate with you about your treatment preferences. PART TWO will be effective even if PART ONE is not completed. If you have not selected a health care agent in PART ONE, or if your health care agent is not available, then PART TWO will provide your physician and other health care providers with your treatment preferences. If you have selected a health care agent in PART ONE, then your health care agent will have the authority to make all health care decisions for you regarding matters covered by PART TWO. Your health care agent will be guided by your treatment preferences and other factors described in Section (4) of PART ONE. 6. Conditions PART TWO will be effective if I am in any of the following conditions: Initial each condition in which you want PART TWO to be effective. _________ (Initials) A terminal condition, which means I have an incurable or irreversible condition that

will result in my death in a relatively short period of time. _________ (Initials) A state of permanent unconsciousness, which means I am in an incurable or

irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment.

My condition will be determined in writing after personal examination by my attending physician and a second physician in accordance with currently accepted medical standards. 7. Treatment Preferences State your treatment preference by initialing (A), (B), or (C). If you choose (C), state your additional treatment preferences by initialing one or more of the statements following (C). You may provide additional instructions about your treatment preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state your specific preferences regarding pain relief in the next section. If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences, then: (A) _________ (Initials) Try to extend my life for as long as possible, using all medications, machines, or

other medical procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.

OR (B) _________ (Initials) Allow my natural death to occur. I do not want any medications, machines, or other

medical procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.

OR (C) _________ (Initials) I do not want any medications, machines, or other medical procedures that in

reasonable medical judgment could keep me alive but cannot cure me, except as follows:

63 Initial each statement that you want to apply to option (C). _________ (Initials) If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other

medical means. _________ (Initials) If I am unable to take fluids by mouth, I want to receive fluids by tube or other

medical means. _________ (Initials) If I need assistance to breathe, I want to have a ventilator used. _________ (Initials) If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR)

used. 8. Additional Statements This section is optional. PART TWO will be effective even if this section is left blank. This section allows you to state additional treatment preferences, to provide additional guidance to your health care agent (if you have selected a health care agent in PART ONE), or to provide information about your personal and religious values about your medical treatment. For example, you may want to state your treatment preferences regarding medications to fight infection, surgery, amputation, blood transfusion, or kidney dialysis. Understanding that you cannot foresee everything that could happen to you after you can no longer communicate your treatment preferences, you may want to provide guidance to your health care agent (if you have selected a health care agent in PART ONE) about following your treatment preferences. You may want to state your specific preferences regarding pain relief.

9. In Case of Pregnancy PART TWO will be effective even if this section is left blank. I understand that under state law, PART TWO generally will have no force and effect if I am pregnant unless the fetus is not viable and I indicate by initialing below that I want PART TWO to be carried out. _________ (Initials) I want PART TWO to be carried out if my fetus is not viable. PART THREE—Guardianship 10. Guardianship PART THREE is optional. This advance directive for health care will be effective even if PART THREE is left blank. If you wish to nominate a person to be your guardian in the event a court decides that a guardian should be appointed, complete PART THREE. A court will appoint a guardian for you if the court finds that you are not able to make significant responsible decisions for yourself regarding your personal support, safety, or welfare. A court will appoint the person nominated by you if the court finds that the appointment will serve your best interest and welfare. If you have selected a health care agent in PART ONE, you may (but are not required to) nominate the same person to be your guardian. If your health care agent and guardian are not the same person, your health care agent will have priority over your guardian in making your health care decisions, unless a court determines otherwise. State your preference by initialing (A) or (B). Choose (A) only if you have also completed PART ONE. (A) _________ (Initials) I nominate the person serving as my health care agent under PART ONE to serve as

my guardian. OR (B) _________ (Initials) I nominate the following person to serve as my guardian:

Name:

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Address: Telephone Numbers: (Home, Work, and Mobile)

PART FOUR—Effectiveness and Signatures This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions. This form revokes any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date. Unless I have initialed below and have provided alternative future dates or events, this advance directive for health care will become effective at the time I sign it and will remain effective until my death (and after my death to the extent authorized in Section (5) of PART ONE). _________ (Initials) This advance directive for health care will become effective on or upon

_____________________ and will terminate on or upon _____________________. You must sign and date or acknowledge signing and dating this form in the presence of two witnesses. Both witnesses must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be together or present with you when you sign this form. A witness: • Cannot be a person who was selected to be your health care agent or back-up health care agent in PART ONE; • Cannot be a person who will knowingly inherit anything from you or otherwise knowingly gain a financial benefit

from your death; or • Cannot be a person who is directly involved in your health care. Only one of the witnesses may be an employee, agent, or medical staff member of the hospital, skilled nursing facility, hospice, or other health care facility in which you are receiving health care (but this witness cannot be directly involved in your health care). By signing below, I state that I am emotionally and mentally capable of making this advance directive for health care and that I understand its purpose and effect. _________________________________________________________ __________________________ (Signature of Declarant) (Date) The declarant signed this form in my presence or acknowledged signing this form to me. Based upon my personal observation, the declarant appeared to be emotionally and mentally capable of making this advance directive for health care and signed this form willingly and voluntarily. _________________________________________________________ __________________________ (Signature of First Witness) (Date)

Print Name: Address:

_________________________________________________________ __________________________ (Signature of Second Witness) (Date)

Print Name: Address:

This form does not need to be notarized.

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§ Gainincreasedawarenessoftypesandclassificationsofannuities.§ Howannuitytypesworkandaffectclientswhoownorbuythem.

8WhattoDoNow

SuggestionsHere are some suggestions to help ensure that your wishes for your final health care arefollowed:

• MakesurethepersonyouhavenamedasyourHealthCareAgentandyourback-upAgentknowwhatyouwant. Ifyouhavenotsharedyourwisheswith theseindividuals,talktothemthefirstchanceyouget.

• KeepyoursignedoriginalIndividualWorksheetandAdvanceDirectiveforHealthCare some place where they can be found easily. Do not put them in a safedepositboxwhichrequiresakeyorcombinationtoopen.TellyourHealthCareAgentandotherlovedoneswheretofindyouroriginaldocuments.

• GivecopiesofyourIndividualWorksheetandAdvanceDirectiveforHealthCaretoyourAgent,back-upAgents,andanyoneelseyouthinkshouldknowwhatyouwant(familymembers, lawyer,spiritualadvisor,etc.).Keepa listofthepeopleyougivethemtoincaseyouchangeyourmind.

• Tell your doctor you have completed a AdvanceDirective forHealth Care anddiscussyourdecisionswithhimorher.Ifyouwouldlike,haveyourdoctorputacopyofyourAdvanceDirectiveforHealthCareinyourmedicalrecord.

• UseaWalletCardto indicatethatyouhavecompletedaAdvanceDirectiveforHealthCareandwhereitcanbefound.Carryitwithyou.

• If you are being admitted to a hospital or nursing home, take a copy of yourAdvanceDirectiveforHealthCarewithyou.Askthatitbeplacedinyourmedicalrecord.

• PlantoreviewandupdateyourIndividualWorksheetandAdvanceDirectiveforHealth Care occasionally. As the circumstances of your life change (growingolder,beingdiagnosedwithanillness,etc.),yourviewsmaychange.

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• Marriage,thebirthofachildorthedeathofalovedonemayalsoinfluencehowyou feel. Your loved ones will want to know that your Advance Directive forHealthCareisatrueexpressionofyourwishesandmayhavequestionsaboutadocument that is several years old. Initial and date the forms each time youreviewthemsoyourlovedoneswillknowyouhavenotchangedyourmind.

• If youdochangeyourmind, youcancancel yourAdvanceDirective forHealthCareatanytime.Besuretonotifyeveryonewhohascopiesthatyouarewritinganewadvancedirective,therebycancelingthedocumenttheyhave.

• Ifyouareterminallyillandwishtodieathome,youshouldtalktoyourdoctor,othercaregivers,andfamilymembersaboutsituationswhenyoumightormightnotwantanambulance called. If anambulance is called, theemergency teammust give you life-prolonging care until you can get to a hospital and beevaluated by a doctor, unless you have a Do Not Resuscitate/ Allow NaturalDeath order that is clearly visible in your homeor you arewearing an orangearm band or necklace indicating that you have a Do Not Resuscitate/AllowNaturalDeathorder.

• If you become terminally ill, you can call a hospice in your area and ask forinformationaboutthecaretheycangivetoyouandyourfamily.Manyoftheseprogramswillworkdirectlywithyourdoctortoarrangeforyoutohavehospiceservicesinadditiontoyourmedicalcare.

• Ifyouaretravelingoutsideofyourstate,itisagoodideatotakeacopyofyourAdvanceDirective forHealth Carewith you.Most stateswill honor an out-of-statedocument,butsomerequirethatitconformtotheirownlaws.Ifyouaregoingtoreceivemedicalcareoutofstate,askthemedicalfacilitywhereyouwillbetreatedtogiveyouinformationabouttheirlawsandrequirements.

ImportantPointstoRememberAboutAdvanceDirectives:

§ ApatientmustbeafullycompetentadulttocompleteanAdvanceDirective.§ These documents are only in effect if you are not able to express your own

thoughtsandwishesabouttreatmentissues.§ AdvanceDirectivesonlycoverhealthcaredecisionsandhavenothingtodowith

yourfinancialaffairs.§ You can change yourmind at any time, by completing a new form, or telling

someonethatyouhavedifferentwishes.§ Youdonot need a lawyer to complete the forms and they do not have to be

notarized.§ Youwillneed twocompetentadults towitness these formsand thewitnesses

cannotbemembersofyourfamily.Bylaw,hospitalemployeescanactasoneofyourwitnessesbuttheothermustbeanobjectivethirdparty.

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RResourcesForMoreInformationaboutGettingYourAffairsinOrderAARP1-888-687-2277(toll-free)1-877-434-7598(TTY/toll-free)1-877-342-2277(español/líneagratis)[email protected](email)www.aarp.orgCaringInfo1-800-658-8898(toll-free)[email protected](email)www.caringinfo.orgCentersforMedicare&MedicaidServices1-800-633-4227(1-800-MEDICARE/toll-free)1-877-486-2048(TTY/toll-free)www.medicare.govEldercareLocator1-800-677-1116(toll-free)www.eldercare.govNationalElderLawFoundation1-520-881-1076info@nelf.org(email)www.nelf.orgFor more information on health and aging, including their free booklets Long-DistanceCaregiving: TwentyQuestions and Answers and End of Life: Helpingwith Comfort and Care,contact:

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NationalInstituteonAgingInformationCenterP.O.Box8057Gaithersburg,MD20898-80571-800-222-2225(toll-free)1-800-222-4225(TTY/toll-free)[email protected]/espanolSignupforregularemailalertsaboutnewpublicationsandotherinformationfromtheNIA.Visitwww.nihseniorhealth.gov,a senior-friendlywebsite fromtheNational InstituteonAgingand the National Library ofMedicine. This website has health and wellness information forolderadults,includinginformationaboutplanningforend-of-lifecare.Specialfeaturesmakeitsimpletouse.Forexample,youcanclickonabuttontomakethetypelarger.NationalInstituteonAgingNationalInstitutesofHealthU.S.DepartmentofHealthandHumanServicesForMoreInformationOtherfederalandnon-federalresourceswithinformationaboutadvancedirectivesinclude:CaringConnectionsNationalHospiceandPalliativeCareOrganization1-800-658-8898(toll-free)1-877-658-8896(toll-free/multilingual)www.caringinfo.orgCaringConversationsCenterforPracticalBioethicsHarzfeldBuilding1111MainStreet,Suite500KansasCity,MO64105-21161-800-344-3829(toll-free)www.practicalbioethics.orgAmericanBarAssociation321NorthClarkStreetChicago,IL606541-800-285-2221www.americanbar.org

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(searchfor"Consumer'sToolKitforHealthCareAdvancePlanning")DonateLifeAmerica701EastByrdStreet,16thfloorRichmond,VA232191-804-377-3580www.donatelife.netNationalLegalResourceCenterwww.nlrc.aoa.govOrganDonor.govHealthResourcesandServicesAdministration1-888-275-4772(toll-free)www.organdonor.govPOLST(PhysicianOrdersforLife-SustainingTreatment)www.polst.orgPutItInWritingAmericanHospitalAssociation155NorthWackerDriveChicago,IL606061-800-424-4301(toll-free)www.putitinwriting.orgTheLivingBankP.O.Box6725Houston,TX772651-800-528-2971(toll-free)www.livingbank.orgNationalInstituteonAgingInformationCenterP.O.Box8057Gaithersburg,MD20898-80571-800-222-2225(toll-free)1-800-222-4225(TTY/toll-free)www.nia.nih.govwww.nia.nih.gov/espanol

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