Advance Directives: A Counseling Guide

To improve advance health care planning, the American Bar Association’s Commission on Law and Aging developed advance care planning principles for attorneys as set forth in the publication found below, entitled “Advance Directives: Counseling Guide for Lawyers.”

The advance care planning principles in the guide provide a conceptual framework and guidelines for lawyers and health care professionals to help insure that advance health care planning is effective in medical settings. I think readers will find the guide useful in thinking through health care options.

As described in the guide, advance health care planning takes place over a lifetime. It changes as one’s goals and priorities in life change through different stages of life and health conditions. Reflection, discussion, and communication with one’s proxy and clinical professionals, along with family, friends, and advisors is essential to having one’s wishes understood and honored.

The most important legal component of advance care planning is careful selection and appointment of a health care agent/proxy in a valid power of attorney for health care document. Persons who cannot or do not want to identify a proxy should delineate their wishes in an advance directive. In advance directives created in New Jersey, you can both delineate your wishes in an “Instruction Directive” and appoint a health care agent in a “Proxy Directive.”

The Advance Directives guide contains many powerful suggestions to help in the preparation of health care directives. For example, the guide contains the following, designated as the “tough questions:”

In your current state of health, how do you rate the importance of: living as long as possible versus quality of life and being comfortable?

A. If you were so sick that you may die soon:

(1) How would you then rate the importance of those two goals?

(2) Which of the following experiences, if any, would make you want to focus on comfort rather than trying to live as long as possible?

  • Being in a coma & not able to wake up or talk to loved ones.
  • Not being able to live without being hooked up to machines.
  • Not being able to recognize loved ones, as in the case of dementia.
  • Not being able to feed, bathe, or take care of yourself.
  • Not being able to live on your own.
  • Having constant, severe pain or discomfort.
  • Something else: OR, are you willing to live through all these for a chance of living longer?

(3) What would be most important to you? (e.g., Being with loved ones? Certain settings or experiences? Religion?)

(4) What would be most unacceptable to you?

(5) What would you prefer regarding the use of life support treatments (such as CPR or tube feeding or use of a ventilator)?

  • Try all life support treatments that your doctors think might help and stay on life support treatments even if there is little hope of getting better or living a life you value.
  • Do a trial of life support treatments that your doctors think might help. But, not stay on life support treatments if the treatments do not work and there is little hope of getting better or living a life you value.
  • Avoid all life support treatments and focus on being comfortable. Prefer to have a natural death.

B. Have you ever documented your wishes about organ or tissue donation? If you’d like, your wishes can be included in an advance directive.

C. How much flexibility do you want to give your health care proxy in making medical decisions for you? Important to be clear about this.

D. How do you prefer to make medical decisions with your doctors?

  • Prefer to make all decisions on your own, with all information available?
  • Prefer that your doctors and you share decision making equally?
  • Prefer that your doctors’ recommendations be followed?

E. How much does your family or loved ones know about your personal priorities and wishes? How much do you want them to know?

F. Is there anyone you do NOT want involved in your medical care and decision- making, and you do not want to have access to your medical information

Once an advance directive is prepared setting forth instructions concerning future health care and a health care proxy is appointed, the guide encourages the client to share and review the completed advance directive with family and primary health care providers.

The ABA guide can assist clients in grappling with the thorny issues involved in preparing advance directives.

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