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Advance Directive: Meaning, Content and How to Create One

An advance directive is a legal document in which a person specifies in advance which medical treatments they wish to receive or refuse if they become unable to make decisions for themselves.

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Things worth knowing about "Advance Directive"

An advance directive is a legal document in which a person specifies in advance which medical treatments they wish to receive or refuse if they become unable to make decisions for themselves.

What Is an Advance Directive?

An advance directive is a legally binding document that competent adults can prepare in advance to specify which medical treatments they want or do not want in certain situations. It comes into effect when the person is no longer able to communicate their wishes due to illness, accident, or loss of consciousness. An advance directive ensures that a person's medical preferences are respected even when they cannot speak for themselves.

Legal Framework

In many countries, advance directives are legally recognized documents. In Germany, the advance directive (Patientenverfügung) has been regulated by law since 2009 under the German Civil Code (§ 1827 BGB). In the United States, advance directives are governed by state laws and may include a living will, a healthcare proxy, or a durable power of attorney for healthcare. Regardless of jurisdiction, medical teams are generally required to follow the stated wishes of the patient as expressed in a valid advance directive.

What Can an Advance Directive Include?

An advance directive can address a wide range of medical decisions, including:

Life-sustaining treatment: Preferences regarding cardiopulmonary resuscitation (CPR), mechanical ventilation, or intensive care.
Artificial nutrition and hydration: Whether the person consents to or refuses feeding tubes or intravenous fluid administration.
Palliative and comfort care: A wish to prioritize pain relief and quality of life, even if this may affect life expectancy.
Specific medical conditions: Instructions for scenarios such as terminal illness, severe brain damage, or persistent vegetative state.
Organ and tissue donation: A statement of willingness or unwillingness to donate organs after death.

When Does an Advance Directive Apply?

An advance directive applies when a person is no longer able to give informed consent for medical treatment. Common situations include a severe stroke, advanced dementia, a coma following an accident, or another condition that impairs decision-making capacity. If a person is still capable of expressing their wishes directly, those spoken or written decisions take precedence over the advance directive.

Advance Directive vs. Healthcare Proxy and Power of Attorney

An advance directive specifically addresses medical treatment preferences. It is often used alongside other planning documents:

Healthcare proxy / durable power of attorney for healthcare: Designates a trusted person to make healthcare decisions on your behalf if you are unable to do so.
Living will: A type of advance directive focused on end-of-life care preferences.

It is recommended to prepare both an advance directive and a healthcare proxy together to ensure comprehensive coverage of all care decisions.

How to Create and Store an Advance Directive

An advance directive should be written in clear and specific language. Consulting a physician during preparation can help ensure accurate use of medical terminology. The completed document should be stored in an easily accessible location and shared with trusted family members and the treating physician. In Germany, documents can be registered with the central advance care register of the Federal Chamber of Notaries (Bundesnotarkammer). In other countries, similar registration systems may be available.

References

World Health Organization (WHO): Palliative Care and Advance Care Planning. Available at: www.who.int
National Institute on Aging (NIA): Advance Care Planning - Healthcare Directives (2023). Available at: www.nia.nih.gov
Bundesministerium der Justiz: Patientenverfügung - Leiden, Krankheit, Sterben (2023). Available at: www.bmj.de

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