Advance directives are documents you create to describe the extent of medical treatment you want to receive—or not to receive—should you become unconscious or too ill to communicate.
Though the topic may be difficult to discuss, your wishes are important. We recommend that you discuss advance directives with your spouse, other family members, physicians, nurses, and clerics while you are feeling well and thinking clearly.
There are two common types of advance directives:
Individual instructions, otherwise known as a “living will,” give specific information about procedures you would like or not like to be performed if or when you become terminally ill. The durable power of attorney for health care decisions gives a proxy (someone you have appointed) the power to make health care decisions for you. The power of attorney will not go into effect until it has been determined that you can no longer communicate your wishes yourself.
Please bring a signed advanced directive with you to the medical center.
Health Care Proxy Appointment
A health care agent is a capable adult over 18 years of age who has been selected and legally appointed by the patient, and empowered to make health care decisions on behalf of the patient when the patient is temporarily or permanently unable to do so. An agent’s decision-making authority is not limited to end-of-life situations and includes any health care decisions that a capable person may make. A lower level of capacity is required to appoint a health care agent than to make the clinical decisions that the agent will make. For that reason, an individual who lacks the capacity to make complex treatment decisions may still be able to appoint an agent. Because an agent is specifically chosen and appointed by a capable individual, a patient’s next of kin is not automatically the health care agent. As a result, the person who knows the patient best may be unable to guide treatment plans if not appointed as the agent. The decisional authority of the agent and alternate replaces that of anyone else, including next of kin. If the patient’s prior instructions do not address the clinical situation at the time of decision making, the agent has the power to determine what the patient would have chosen or what is in the patient’s best interest and help guide decisions about the goals and plan of care.
Because a living will is a list of instructions about specific treatments that would be wanted or rejected, usually at the end of life, its provisions may not apply to the patient’s current clinical situation. A living will is most useful as a guide to decision making for patients who have no one to appoint as a health care agent.
How Advance Directives Are Used
The best time to complete an advance directive, especially the appointment of a health care agent, is when the individual is healthy, capable and able to carefully consider the appointment and instructions. Selection of an agent should consider the responsibilities of decision making for another person, as well as the individual’s wishes and values. The content of advance directives should be discussed with the patient’s physician, family and trusted others. Copies of advance directives should be given to the agent and alternate agent, physician and family, and should be brought to the hospital or other care-providing facility for inclusion in the medical record. Federal and state law mandate that all care-providing facilities ask patients on admission whether they have an advance directive and, if so, to ensure that a copy is in the medical record to guide decisions. If the patient does not have an advance directive, the facility must offer information and assistance in completing a directive if patients wish to do so. At Hackensack University Medical Center, the Consumer Affairs Department (551-996-2010) is available to assist in completing advance directives.
The provisions of an advance directive, including the powers of the health care agent, are activated only when: The patient has been determined to have temporarily or permanently lost decisional capacity, and in the case of a living will, the patient is in the clinical condition(s) specified in the directive. If and when the patient regains decisional capacity, he or she resumes making health care decisions. Advance directives can be changed at any time and the most recent directive replaces all prior directives. If a patient is admitted to a care-providing facility without a previously completed advance directive, a new directive can be completed, which will replace previous directives.
At Hackensack University Medical Center, patients will be asked about advance directives:
- Upon admission (either through the admissions department or through the emergency trauma department)
- During nursing assessment
- During the initial discussion with the admitting physician
In addition, patients will be reminded by the scheduling department to bring their advance directives when they come for elective admissions. Advance directives will be scanned into the institution’s electronic information system so that they can be retrieved and referred to on subsequent admissions.
An informal surrogate is a capable adult over 18 years of age who, although not specifically chosen or legally appointed, assumes responsibility for making health care decisions on behalf of a patient who has lost capacity and does not have an advance directive. Typically, family members, specifically next of kin, assume this responsibility. The decision-making authority of informal surrogates differs according to the state in which the patient is receiving care.
The Clinical Ethics Consultation Service is available to meet with patients, families and the care team to address and resolve uncertainties and conflicts related to the interpretation and implementation of advance directives.