What is Advance Care Planning?

The decisions discussed in the previous section are all part of advance care planning. There are several kinds of Advance Directives, which are written instructions that a patient gives for future medical care, should they become unable to make decisions for himself (e.g., unconscious, too ill to communicate). There are two types of advance directive: a Living Will and a Durable Health Care Power of Attorney, or Health Care Proxy. Each patient has the right to change his mind and has the responsibility to keep others informed of those wishes. Patients and caregivers should discuss these decisions - and any changes in them - and keep the health care team posted. Anyone involved in caring for your loved one should also be aware of his or her treatment preferences.

Someone with advanced progressive disease will want to cover the following points in detail:

Naming a surrogate
Stating treatment goals
Talking about what to do in an adverse event
Stating preferences for time-limited trials
Talking to physicians and surrogates about preferences

How will you know when the advance care plans are complete, that you've covered all the bases? A truly complete plan will:

Be very specific and detailed and cover what is to be done in a variety of medical situations
Name a health care proxy
Be recorded in the medical record
Be readily available to any caregiver in the home, nursing home, or hospital

Advance care planning is an ongoing process. As disease progresses and circumstances change, your loved one may want to modify her or his preferences. If so, be sure to update all written instructions and share the changes with health care providers and anyone who assists with care.

What is a Living Will?

A Living Will explains a patient's wishes for medical care in case he or she becomes unable to communicate. State law may define when a living will goes into effect and may restrict the medical interventions to which it applies. One organization has developed a document called "Five Wishes" [ Web site: http://www.state.fl.us/awd/ ] which is easier to read and complete than most other advance directives. Five Wishes is legal in more than 30 states.

What is a Durable Health Care Power of Attorney or Health Care Proxy?

By naming a health care proxy, your loved one gives that person authority to make medical decisions on her or his behalf. This decision is extremely important. Your loved one's doctor should always know who to turn to for decisions when the patient cannot decide for himself.

The terms "health care proxy" and "health care agent" are used interchangeably. These designations are considered "durable" because they remain in effect even if your loved one is unable to make decisions for himself. Most people appoint a close friend or family member. Some people turn to a minister or lawyer. The designated person should be able to support the patient's decisions, understand his treatment choices, and know what the patient values. In some states, this person is allowed to make medical decisions for the patient only at the end of life, while in others he or she can make decisions at any time the patient is unable to do so. The doctor should be able to explain the law in your state.

Durable power of attorney forms do not give explicit guidance to the proxy about what decisions to make. Many states have developed forms that combine the intent of the durable power of attorney (to have an advocate) and the intent of the living will (to state choices for treatment at the end of life). These combination forms will probably be more effective than either of the two used individually.

How do we get started?

Each state regulates Advance Directives differently, so you'll need to consult with the physician, nurse, social worker or family lawyer to know what is required. While you're at it, take the time to make sure that financial matters, including wills and life insurance policies, are in order.

Keywords: Advance care plan, advance care planning, living will, durable power of attorney for health care, dpoa, health care proxy, health care agent