An advance directive is a legal document that allows a person to express healthcare preferences and, in many states, designate a healthcare decision-maker before a situation arises in which they cannot speak for themselves. It is most useful when the healthcare team can find it, understand it, and connect it to the patient's current goals.
An advance directive is not a DNR order, not a POLST, and not a substitute for ongoing goals-of-care conversations. It is a starting point — a record of preferences that should be revisited as diagnosis, prognosis, and patient priorities evolve.
CLINICAL PRINTABLE
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A clinical reference for this topic is in development.
1 · Components
Living Will
A living will documents a person's preferences regarding specific medical interventions — such as mechanical ventilation, artificial nutrition, or CPR — in defined clinical circumstances. It speaks for the patient when the patient cannot speak.
Healthcare Power of Attorney / Healthcare Proxy
This component designates a person to make medical decisions on behalf of the patient when the patient lacks decision-making capacity. It is often included within an advance directive document, though it can also be a separate instrument.
Treatment Preferences
Advance directives may address preferences regarding resuscitation, mechanical ventilation, artificial nutrition and hydration, hospitalization, dialysis, and other interventions — though the specificity varies by state form and individual document.
2 · What an Advance Directive Is Not
Not a DNR Order
An advance directive expresses preferences — it is not an actionable medical order. A DNR order must be written by a clinician and entered into the medical record or documented on a POLST form to be immediately actionable.
Not a POLST
A POLST is a medical order for patients with current serious illness. An advance directive is a planning document for future scenarios. They serve different functions and can coexist.
Not a Substitute for Ongoing Conversation
An advance directive captures preferences at a point in time. Goals and priorities can change — the document should be revisited, not treated as a permanent final answer.
3 · When to Revisit
- New serious diagnosis or significant change in prognosis.
- Significant functional decline or loss of independence.
- Hospitalization — particularly for a serious illness.
- Patient expresses a change in values, priorities, or preferences.
- Transition to a new care setting or care team.
4 · Practical Considerations
- The most common reason an advance directive fails to guide care is that the healthcare team cannot find it when it is needed.
- Patients should share copies with their healthcare agent, primary clinician, and any care settings where they receive regular care.
- Some states have advance directive registries — patients should be aware of whether their state offers this option.
- State law governs what an advance directive can address, required signatures, and whether it is legally portable across state lines.
Bottom Line
The most common reason an advance directive fails to guide care is that the healthcare team cannot find it when it is needed.
EVIDENCE & REFERENCES
- Silveira MJ, Kim SY, Langa KM. Advance Directives and Outcomes of Surrogate Decision Making before Death. N Engl J Med. 2010;362(13):1211-1218. doi:10.1056/NEJMsa0907901
- Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. doi:10.1136/bmj.c1345
- Sudore RL, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-832. doi:10.1016/j.jpainsymman.2016.12.331