What should I consider when setting up an advance care directive?

You may want to consider including a do-not-resuscitate order (DNR) as part of your advance care directive (ACD), which consists of a living will and a power of attorney for healthcare to ensure that your wishes are carried out at the end of your life, since an ACD does little to protect you from unwanted emergency care such as cardiopulmonary resuscitation (CPR). Paramedics are required by law to attempt resuscitation on unresponsive patients in emergency situations outside of a healthcare institution and transport you to the hospital for stabilization unless they are shown a valid DNR form.

Alternately, you may want to consider setting up a Physician's Orders for Life Sustaining Treatment (POLST). These were developed in response to concerns that traditional ACDs and DNRs don't adequately communicate patients' wishes for end-of-life care, particularly with regard to resuscitation measures. A POLST allows you to specify whether or not you wish to receive CPR or be transferred to hospital, so that emergency medical personnel have clear orders on which actions to take.

Your ACD will include a document that names a healthcare proxy who can take steps to ensure that your wishes are carried out. Your proxy would be the one to ask difficult questions of your doctors and make decisions about tube feeding, breathing machines, resuscitation and other end-of-life options. You don't need a lawyer to complete a healthcare proxy.

A proxy can be a spouse, child or other relative, or a close friend, and you should discuss with him or her the quality of life that is important to you and medical treatments you would rather not have. Keep in mind that your proxy may have to be assertive about asking questions of your doctors and make decisions under difficult circumstances even if other members of your family disagree with your requests. Make it clear to your family and your doctor that your proxy is the person you want to make potentially difficult decisions about how to interpret your ACD. For practicality, your proxy needs to live near you, so he or she can meet with your doctors, and it makes sense to choose someone who shares your end-of-life morals and ethics.