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You have the right to make decisions about your own medical treatment. These decisions become more difficult if, due to illness or a change in mental condition, you are unable to tell your doctor and loved ones what kind of health-care treatments you want. That is why it is important for you to make your wishes known in advance.
A living will, health care surrogate and durable power of attorney are the legal documents that allow you to give direction to medical personnel, family and friends concerning your future care when you cannot speak for yourself. You do not need a lawyer to complete Advance Directives.
For more information about Advance Directives or to obtain forms, please speak with your nurse.
Types of Advance Directives
- Living Will (LW) - This is the most popularly known type of advance directive. It relates only to end-of-life issues. A Living Will goes into effect when you become incapacitated (unable to make decisions) and when your physician has diagnosed you with a terminal illness, in an end-stage condition, or in a permanent vegetative state.
- Health Care Surrogate - As with the Living Will, this type of advance directive goes into effect when you become incapacitated. Unlike the Living Will, however, the Health Care Surrogate may be used to deal with any illness situation in addition to end-of-life issues. As a result, its scope is broader than that of a Living Will. It also permits you to appoint a specific person (surrogate) who will make decisions on your behalf as well as a backup surrogate if you wish.
- Durable Power of Attorney for Health Care - This type of advance directive is essentially the same as the Health Care Surrogate, except it requires notarization.
- A Do-Not-Resuscitate Order(DNR), a Do-Not-Intubate Order (DNI), or Organ Donation commitments are also advance directives that can stand alone. For our purposes, each can be included in one of the three types of ADs discussed above.The DNR, DNI, and Organ Donation are discussed in the section about information you should put into your AD.
Common Questions about Advance Directives
When should I prepare my advance directive?
The best time to prepare your advance directive is when you are healthy and not anticipating a health crisis. This allows you the time to make preparing the advance directive a thoughtful process.
When you read further you will be aware of what is involved in preparing and making your advance directive effective.
Do I need help preparing my advance directive?
Florida law does not require you to have the assistance of anyone in preparing your advance directive. However, as you read through this information, you will see that it is advisable to speak with several different persons as you prepare, particularly your immediate family members.
Some persons may want to consult with their attorney, but it is not required by law.
You may choose either of these alternatives. Regardless, you will have to go through a thoughtful process in order to know what your preferences are and be able to communicate them to your family. There is no one form or type of advance directive that is universally accepted as the correct one.
If you are preparing your advance directive at a time when you are healthy, we encourage you to consider using a "Health Care Surrogate" type of advance directive, whether you are writing your own or using an existing form. It has the advantage of allowing you to name a specific person who will be your decision maker. And, it pertains to any illness when you are incapacitated and health care decisions must be made for you, not just end-of-life issues. If this type of advance directive is your choice, then our section on information about advance directive will be particularly helpful to you.
Our section on examples of advance directive used by Shands provides copies of the two types of advance directives that Shands makes available to patients/families. You may find them useful if you do not want to write your advance directive completely. In Section O several examples of forms are available online. It might be helpful to review each.
Advance directives are made up of two basic parts. One part provides instructions to your physician and to your family. The other component identifies someone to make medical treatment decisions for you in the event that you cannot speak for yourself. We recommend that your advance directive include both of these parts. Examples are presented below.
Examples of "instructions" that may be included in your advance directive
- End-of Life-Information: Think about what quality of life would be acceptable to you when you are approaching death. If you could still speak with and be aware of your loved ones, would you want medical assistance to continue? What if you could no longer be aware that your loved ones were present, would you want to continue life under those circumstances? Other specific information you might include would be whether you want food and water provided through a tube and, if so, under what conditions. Do you want to be pain free with the provision of comfort care, even if pain medication were to reduce your alertness or awareness?
- Do Not Resuscitate and/or Do Not Intubate information: These treatments also pertain to end-of-life, but need to be addressed independently from the previous decisions. If you are dying, and either your heart stops beating or you stop breathing, your physician is obligated to resuscitate you unless you have indicated you don't want either chest compressions and/or a tube placed down your throat. Requesting DNR and/or DNI in your directive informs your physician that you do not wish to be given CPR or other emergency treatments if your heart stops beating or you stop breathing.
- If you have a long term or progressive illness, you should consult your health care provider for information concerning the likely success of resuscitation efforts.
- Organ/Tissue Donation information: After you die, if you wish to donate any organs, tissues, skin, bone, etc., that may be useful in the treatment of other persons, then you would include these instructions in your advance directive.
Examples of "identifying"who will be your decision maker if you are incapacitated:
A "proxy"decision maker - If you do not have a specific person you wish to be your decision maker, then you need only provide instructional information in your advance directive. When you are not able to communicate and have not named a specific person, your physician will use a list provided by the State of Florida (765.401) to determine who will make decisions for you.
In order of priority, the list is:
- The judicially appointed guardian or guardian advocate of the patient
- The patient's spouse
- The adult child or adult children who are reasonably available
- A parent of the patient
- The adult sibling or adult siblings of the patient who are reasonably available
- An adult relative of the patient who cares and has regular contact
- A close friend of the patient
- A clinical social worker approved for the decision maker role
The disadvantage of this approach is that the first person on the proxy list may not know what your preferences are or may not agree with these preferences. He or she may not feel comfortable serving as your decision maker.
A "Surrogate" decision maker - You may name a specific person to be your decision maker - the person who will express your wishes. This person is called a surrogate. The advantage of this approach is that you can name someone you are confident understands and will represent your preferences for treatment when you cannot speak for yourself.
In Florida law, a surrogate is presumed to know the patient's wishes, more so even than the proxy. So, if you are married and you are comfortable with your spouse being your proxy, it would be wise to formally appoint him/her as your surrogate.
Completing Your Advance Directive
You now have enough basic information to begin completing your advance directive. To complete your advance directive, follow these recommended steps carefully:
- You must first give careful thought to your values about quality of life when you are dying. Most individuals have personal preferences that make a "one size fits all"advance directive impossible to write. Use some of these questions and instructions to prompt your thinking. Once you have considered some of your preferences, try writing a paragraph or two describing what treatments you would or would not want, and under what circumstances. In your writing, try to be very simple and clear, and don't worry about grammatical correctness. Several of the Web sites listed on our resources page may be useful to you.
- When you have written several paragraphs you like, contact one or two trusted friends or advisors and ask them to read what you have written. Does it make sense to them? Is there anything that confuses them instead of providing information about your wishes? Do they think of any additional questions you should think about?If so, then revise your paragraphs and ask for a fresh review. Continue this writing/review process until you are satisfied that the statements represent your basic treatment preferences at the end-of-life. Remember, your goal is to make a document that is likely not misunderstood.
- Meet with your family members and share what you have written. If possible, have a conversation with them about any questions or concerns you or they might have. It is possible that some revisions to your paragraphs may occur as a result of this sharing. You might also discuss the question of who your decision maker will be.
- Decide whether or not you want to name a surrogate decision maker or rely on the proxy list. Carefully consider your decision. If you wrote 100 pages of paragraphs about your treatment preferences, you wouldn't be able to directly address every issue that might need to be decided. You will need a person who knows you, understands your preferences, and will steadfastly represent you and your wishes.Once you have written instructions about your treatment preferences, and have either identified a surrogate, or left this blank, then you are ready for signatures. Your name and date come first. Then you want two witnesses, one of which may be a family member. The other must not be a family member. Each should date his/her signature.
- You should now make sure that key persons in your life receive a copy of your AD. Family members should be in this group. If you have a minister, attorney, or close friend, these are good persons to get a copy of your AD. When you go to your physician and/or are admitted to a hospital, take a copy and ask that it be placed in your medical record. Make sure that the original signed document can be easily located by your surrogate or family member.
- Make a plan to review your AD every 2-3 years. This is to make sure that it still reflects your wishes. If not, then revise it and share these revisions with your selected Surrogate and family. If no changes are required, then simply reinitial it with the current date. Give family members, etc. an updated or new copy of your AD.
- You will need two witnesses when you sign your advance directive. One of them can be a family member, but the other must not be a family member.
- You may cancel or revise your advance directive any time you are capacitated and able to make your own decisions.
- Your advance directive does not go into effect until you can no longer understand and speak for yourself. Prior to your becoming incapacitated, your physician should ask you to make your treatment decisions.
- Just because you have a written advance directive does not mean that your loved ones understand your treatment preferences. You must talk with them about your wishes before your advance directive goes into effect.
- An advance directive is not the same as a Legal Will, which lists your finances, property, possessions, etc., and what you wish to be done with those.
- Laws about advance directives vary from state to state, but usually each state will respect an advance directive from another state. However, if you completed an advance directive in a state other than Florida, and you now reside in Florida, it would be advisable to complete an advance directive that reflects Florida law. All of the information presented to you about ADs is compliant with current Florida law.
You may change your AD any time you wish. This includes altering a paragraph, changing a surrogate, or writing an entirely new AD.
If you decide to alter your AD at any time, be sure to retrieve all copies of your old AD and distribute copies of your new AD. If the information regarding your preferences has changed or you have decided to select a new decision maker (surrogate), it is important to inform your loved ones of these differences.
Advance Directive Resources
The following resources might be helpful for you as you prepare your AD:
- www.leg.state.fl.us/statutes/index.cfm (See Chapter 765, "Civil Rights")
Commitment to Patient Care
Our goal is to provide the best patient care. If at any time you have questions or concerns about the quality of care that you or a family member are receiving or have received at our hospital, do not hesitate to speak with your nurse or the nursing supervisor.
If you feel that your issue wasn’t resolved, please contact a Patient Representative at 352-265-0123 with your compliments, complaints, or concerns. You may call at any time during or after your stay.