Many people are familiar with advance directives:  legal documents that convey personal decisions about end-of-life care ahead of time. They may provide a way to communicate wishes and avoid confusion if the person who completed the document becomes unable to express wishes and make medical decisions.    

While state laws and form vary from state to state, in general advance directives include:

• Written Instructions for Medical Care:  Called a Living Will in many states, this document describes the type of medical interventions a person wants withheld or used if they are close to death from a terminal illness or permanently comatose.  The descriptions and language vary significantly in these documents state to state.  However, living wills generally include person’s desire to avoid or receive “life prolonging” or “life sustaining” medical procedures such as mechanical ventilation, artificial nutrition and hydration and or cardiopulmonary resuscitation.  Some living wills also offer the option of expressing wishes about organ and tissue donation and mental health directives that most often take effect in cases of Alzheimer’s or dementia. 
  

• Written Authorization of Decision-Maker:  Called a Durable Power of Attorney for Healthcare or a Healthcare Proxy in many states, this document names a person who will make medical decisions if the individual is unable to do so.  Many states allow the person completing the document to name alternates if the primary named is not available.  
  

Some states have separate forms for the instructions and authorizations.  Others such as California and Texas combine the two into one form often called a Directive to Physicians.   

The barriers that keep people from accessing end of life care, such as fear of death, also keep people from completing advance directives.

In addition, people often do not complete these legal documents because they do not fully understand end-of-life decision-making and are not familiar with state forms and laws that relate to them. 
 
Many people who have completed advance directive documents, often as part of estate planning or at the request of a family member, still have questions about them.  Even the most informed persons who have completed documents often still have highly technical questions about them and express concerns that their wishes may still not be honored.  

This concern is well-founded.  While having completed documents is important, it is often not enough to ensure that a person’s health care wishes will be honored.  According to the American Bar Association, studies show that advance directive forms do little to influence end-of-life decisions unless they are accompanied by informed, thoughtful reflection about wishes and values and personal communication with key potential decision-makers before a crisis.  For these documents to have their maximum power, it is important for everyone to engage in a more comprehensive approach to planning ahead, often called advance care planning.

Advance care planning is a multi-step process that takes place over time.  It helps people:  

• explore end of life choices
• reflect on end of life wishes in the light of personal beliefs and values
• talk about choices with selected decision-makers, family members and professionals
• complete advance directive documents
• reassess end of life choices over time  

While these steps do not always take place in the same order, all five are important.