Advance Medical Directives
Please Note: The information provided on this page is not a substitute for legal advice. Please visit with your attorney, a case manager, the Cowley County Council on Aging, or Wichita Medical Research & Education Foundation for more information.
Advance medical directives are documents that state a patient’s choices about medical treatment including decisions like refusing treatment, or stopping treatment at a point the patient chooses. They may also include requesting or refusing life-sustaining treatment, and the decisions about organ donation.
There are several kinds of advance directives. Three are mentioned most often. They are living will, durable power of attorney for health care decisions and anatomical gifts. Through advance directives, patients can make legally valid decisions about their medical treatment.
The durable power of attorney for health care (DPOA-HC) covers ONLY health care decisions. The general durable power of attorney covers financial matters and property decisions.
Yes, you may choose the same person to be your DPOA for health care and finances. You must make sure to use separate documents for each DPOA position. Your health care facilities and physicians will only need the DPOA for Health Care documents.
In Kansas, you may go to the website: wichitamedicalresearch.org. Click on the menu item titled Kansas Advance Directives, then locate the form you wish to print. You may also request forms at any admissions office of any local hospital. If you need another state’s forms, go to the website www.nhpco.org, click on advance directives, and select the specific state’s forms.
Yes. All 50 states have advance directives. Advance directives travel with you and are honored in all states.
You may have the forms witnessed OR notarized. Some states require notary. Kansas does not require notary. Two persons who recognize that you are the person you say you are. They do not have to understand the form or what you are signing. They are only recognizing you and your signature.
When you have signed the forms, make at least five or more copies of your documents and give them to your DPOA-HC (agents), your physicians, your lawyer, your spiritual leader, or anyone else who may be involved with your health care. Make sure your agent(s), family members, and friends know where your documents are kept. Please keep your originals in a safe place. Keep one copy where it is easy to find and make more copies if needed. A copy of these documents has the same effect as the original. It is your responsibility to have a copy ready when it is needed. Take a copy with you when you go into a hospital, nursing home, hospice, or other care facility.
The physician is required to recognize the durable power of attorney for health care as the legal decision-maker for the patient. If there is discord/disagreement about what you want and what the family members think you want, then the physician will continue to speak with the DPOA-HC and family members until an agreement is made about your wishes. Understand the chosen DPOA-HC (agents) are the only ones with the legal right to make decisions for you. It is important that you discuss your wishes and values now with your family so they will know what you want done at the end of life.
HIPAA stands for Health Insurance Portability and Accountability Act established in 1996 to protect patient’s health care information. No, a HIPAA release is not an advance directive. In the HIPAA release document, you can designate those whom may receive your health care information from the physician or health care professionals. These persons may or may not be your DPOA-HC.
If needed, you can get a HIPAA release form from the staff at the office of your health care provider (physician or clinic’s office).
The Living Will
The Kansas living will is found in a statute titled “The Natural Death Act.” The statute allows any adult to sign a form (relating to themselves only) which states that life-sustaining procedures should be withheld or withdrawn when decision making capacity is lost and when such procedures would merely prolong death.
Medical procedures deemed necessary to provide comfort or alleviate pain are not considered “life-sustaining procedures” under the act.
For the living will or Natural Death Act Declaration to be effective, two physicians must personally examine the patient and determine that the patient has a terminal illness. The physicians must agree that death will occur whether or not the medical procedure or intervention is done. If the patient is pregnant, specific limitations apply.
The living will must be witnessed by two adults who are not related to and will not inherit from the person making the living will, and who are not directly financially involved.
A Living Will is a declaration that is applicable to situations where you would “have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have examined you.” Each of the 50 states of the U.S.A. has this advance directive, Living Will. This document applies to terminal conditions where patients are expected to die and “where the application of life-sustaining procedures would serve only to artificially prolong the dying process.” Many feel the Living Will helps to identify someone’s wishes about end-of-life care, but it is not specific.
A DPOA-HC designates whom you want to make health care decisions for you when you are not able to make decisions for yourself. A Living Will is a document applied to terminal conditions and it is for you to sign about your desire “that my dying shall not be artificially prolonged…if you have an incurable injury, disease or illness…” The Living Will does not have the names of your DPOA-HC on the form. You need the DPOA-HC form for many different situations other than terminal conditions when you cannot make decisions for yourself and it designates your decision-makers.
The Durable Power of Attorney for Health Care Decisions
The durable power of attorney for health care decisions is a document in which a person gives someone else the right to make decisions about health care for them. The person who would make the decisions is known as an “agent” and can be any adult except a physician or other health care provider (including people who work, own or are directors for hospitals and other health care institutions) unless the health care provider is related by blood or marriage to the person signing the document. Most people select a close relative as an agent.
The powers which can be granted include: the power to make decisions, give consent, refuse consent or withdraw consent for organ donation, autopsy or the treatment of any physical or mental condition. The agent may also make all necessary arrangements for hospitalization, physicians or other care, and to request and receive all information and records and to sign releases for records.
The person signing the durable power of attorney for health care decisions can choose which of the above powers the agent will have. Specific instructions can be given. For example, a specific treatment may be prohibited. Requests for treatment, including life-sustaining care, can also be included. The special instructions allow the durable power of attorney for health care decisions to be specific for each individual’s needs.
The agent and the health care providers must follow the patient’s expressed wishes. This means that they must also respect any wishes that are stated in a living will. Unless limited, the durable power of attorney for health care decisions allows the agent to make decisions about withholding or withdrawing life-sustaining treatment in all types of illnesses (including comas or persistent vegetative states) and is not limited to terminal illness.
To be effective, the document must be either acknowledged in the presence of a notary public, or witnessed by two adults who are not related to and who will not inherit from the person signing the document.
Choose someone you trust to listen to your wishes, ask questions of the health care staff, and make decisions that you would want made. You will need to share health care information with this person(s) to assist them in making decisions if you were unable to make them for yourself.
- The DPOA-HC must be 18 years or older.
- Your DPOA-HC cannot be your healthcare provider or a person who works for your healthcare provider (unless you are related by blood or marriage).
- Your DPOA-HC does not have to live in the U.S.A. or near you. The important thing is that the person be available by phone to discuss decisions when they need to be made.
- Your DPOA-HC will need to make decisions for you when you are unable to do so. If the person you choose as your DPOA-HC is mentally handicapped or has other limitations, you must ensure they can understand situations and questions posed by the physician and health care team and make decisions for you. You may wish to choose a friend or someone from your church or other contacts to appoint as your DPOA-HC if this person is unable to make decisions for you.
Here are a few tips to consider when selecting your DPOA-HC:
- Make sure they meet the legal needs in your state
- Are they willing to speak on your behalf?
- Can they act on your wishes without letting their feelings take away from your wishes
- Do they live close by or can they reach you easily when needed?
- Do they know you well and know what you want?
- Can they handle making decisions?
- Will they talk with you right now about issues for your care and will they listen to you?
- Will they be able to help you for a long time?
- Can they handle family members, friends, and medical people if there are problems?
- Can they be strong in facing a doctor or an institution if they do not answer\act in a way that helps you?
No, you may not sign a DNR form for your mother or anyone else. In Kansas, the Do Not Resuscitate (DNR) form is a directive which means the DNR Directive may be signed by the patient only and the patient’s physician. IF your mother loses capacity (ability to make decisions for herself), and the physician or you feel a DNR status is appropriate, after discussion, when agreed upon by patient decision makers(s) and the attending physician, the physician can sign a DNR ORDER on the chart. IF the patient is at home, a DNR order can be written on a prescription pad by the attending physician and posted in the home.
No. You need to fill out new forms. The DPOA-HC form is a legal form and it is not recommended to mark things out on a legal form. If you have capacity, you can fill out new forms. IF you lose capacity, you cannot change the form and no one can change the form for you or fill out a new form for you. Be sure to communicate with your children why you are changing the DPOA-HC so there is less chance of disagreement about decisions.
The WMREF form has three (3) spaces for agents’ names and information. You may choose 1 or more. Choose individuals whom you believe will honor your wishes, be available and be assertive in representing your health care wishes.
- Talk to your agent/DPOA-HC about what they do for you.
- Ask if they are willing to be your agent.
- Talk about your healthcare wishes, values, and fears.
- Write down your “agent” and “fears.”
- Make sure your agent gets the first copy of your wishes and gets a copy of any attachments.
- Tell family members and friends who you select.
Remember, by Kansas State Law, your DPOA-HC can:
- Consent, refuse consent, or withdraw consent to care
- Decide which of these you should have: hospital, hospice, nursing home, or home health care
- Employ or fire healthcare personnel
- Ask for and get healthcare information
- Decide about organ donation, an autopsy, and what to do with your body when you die.
Your DPOA-HC cannot:
- Stop or change any decisions you have made in a Living Will declaration
Understanding a DNR
If you have found someone without a pulse or not breathing, Call 911, then begin CPR unless otherwise indicated by a DNR (Do Not Resuscitate) directive or DNR bracelet.
Cardio-Pulmonary Resuscitation (CPR) is a group of procedures that may include:
• Forcing oxygen into the lungs by mouth-to-mouth breathing or by mechanical means.
• Medically assisted respiration and intubation to support or restore breathing (ventilator)
• Chest compressions or the use of electrical stimulation (“the paddles”)
• Administration of medications
DNR means that if your heart stops beating or if you stop breathing, no medical procedure to restart breathing or heart functioning will be started.
This DNR decision will NOT prevent you from receiving other medical care by healthcare workers.
You can revoke/cancel this DNR at any time.
Have a conversation with your doctor regarding DNR if your health status changes.
In order to be valid and honored, a physician has to sign and date the DNR.
A DNR Directive is a form signed by the patient that directs that no CPR is desired. In Kansas, this DNR Directive must be signed by the patient and a physician.
This DNR Directive will stop resuscitation from happening if the DNR Directive is visible to emergency personnel.
A DNR order is a physician’s written order that instructs other healthcare workers not to do resuscitation, also called “no code.” If this order is not written, it is assumed that CPR is wanted, no matter what the condition of the patient. A DNR order is used when the patient is already in a hospital or a nursing home. A DNR order can be written on a prescription pad for home use and can be requested by the patient or the patient's family member/healthcare agent (the family member/healthcare agent CANNOT sign the directive).
Even if you have a DNR directive, some hospitals and nursing homes require a DNR order to be written by your doctor each time you are admitted.
• Terminal illness state
• Chronic disease
• Severe incapacity, mentally or physically
• Requested by patient
• Advanced age of patient
• Poor prognosis of health
• Poor quality of life before CPR
• Poor likelihood of success
Resuscitation refers to restarting a person’s breathing and blood circulation when breathing and/or the heart stops. An elderly person might stop breathing or their heart may stop because of health issues like a heart attack. Resuscitation is very important because when the heart stops beating, the person will lose consciousness and brain cells will stop receiving oxygen within a matter of minutes, which can lead to death.
So, what can be the effects of resuscitation on the elderly? Do elders benefit from resuscitation?
If the elder person’s brain cells have lacked oxygen for many minutes, the effects of resuscitation on that elder person could have long-term effects. This is because if the elder person is revived, the person will suffer from some degree of brain damage depending on how long it took to resuscitate him.
The effects of resuscitation on anyone will vary from one person to the next. This is because it depends on the state of the body’s health and how soon resuscitation may have some effect. However, if the body is frail, the elderly person might suffer from another heart attack, stroke, or cardiac arrest. The person may not return to the state of health they had prior to the heart or breathing stopping.
Sometimes an electric ‘shock’ may be given externally to stimulate the muscle of the heart to start beating. This may cause burns on the elder person’s chest. Cardio-pulmonary Resuscitation (CPR) may fracture the ribs or breastbone (sternum) due to pressure given with chest compressions. There is great difficulty in predicting the outcome of CPR on anyone.
The decision to resuscitate or Do Not Resuscitate (DNR) is very individual. Talk with the attending physician about your questions and concerns.
NO. In Kansas, the DNR is a directive signed by the patient only. If the patient has lost capacity or cannot sign the DNR Directive, you may talk to the physician and if appropriate, the physician can sign a DNR Order on the order sheet of the health care facility. If the patient is at home, the physician can sign a DNR Order on a prescription pad and this is posted in the home.
My father cannot sign documents (he is not mentally of capacity) and needs a DNR. What can I do to get a DNR in place?
Ask the attending physician (the private doctor for your father, or medical director of the nursing home, or the physician caring for your father) about your father’s need for a DNR. The physician can sign a DNR ORDER if appropriate and agreed upon.
With guardianship, you must talk to the attending physician who completes a form required by the court system. You should talk to your patient’s case manager and your attorney and ask about the steps to proceed to court to obtain a DNR for your relative. A judge will have to decide if the DNR is necessary. Sometimes this may take several weeks.
YES. For a patient/resident to obtain a DNR bracelet, you must send in the DNR Directive or Order signed by a physician to the appropriate company you are buying the bracelet from. A DNR bracelet can be worn at all times and you do not have to have the DNR paper with you.
Anatomical Gifts
Advances in medicine and the subsequent growth of organ transplantation has resulted in a scarcity of donor organs. The federal and state governments has responded by making efforts to increase public awareness about the benefits of organ donation.
Health care providers are required to ask surviving family members if there is to be an anatomical gift. A person has the opportunity and the right to make an advance directive on anatomical gifts either in writing or verbally. Such instructions may also be addendums to a living will or the durable power of attorney document.
How It Works
- If you are an inpatient, you will be asked if you currently have an advance medical directive. If you would like, a representative of the hospital will talk to you about your rights regarding refusal of medical and/or surgical interventions and your right to make advance directives. You also have the right not to make advance directives. That is your choice.
- You may choose between a durable power of attorney for health care and a living will, or you may have both. The basic difference between the two is that the durable power of attorney for health care designates a particular person to make decisions for you when you are not able to decide for yourself and can cover all health care decisions. A living will states your wishes about withholding or withdrawing life-sustaining care.
- If you choose to make advance medical directives, the hospital may provide the necessary forms. If the hospital does not provide the forms, this brochure lists several resources for obtaining them. You do not need a lawyer in order to make an advance directive. However, legal advice is certainly appropriate. There are options other than the forms provided in the Kansas statute that are legal and can be used.
- A living will must be witnessed by two adult people. A durable power of attorney for health care may be witnessed or notarized. Although it is not necessary for the forms to be legal, it is recommended that the documents be both witnessed and notarized. This is in case you travel to another state that might require advance directives to be notarized.
- If you make advance directives, you should discuss them with your physician. You are responsible for making copies available to him or her and all other doctors you deal with. You should also discuss and share copies of your advance directives with your family members. It is always a good idea to keep copies yourself.
- If you wish to change your mind about your advance directives at a later date, you may do so. You can revoke the old document(s) and make new advance directives that must also be witnessed and notarized. A living will may be revoked by destroying the document, signing a written revocation or by telling an adult that the document no longer expresses your wishes. For a verbal revocation to be effective, the adult who heard the verbal revocation must confirm it in writing. This document must be given to the attending physician. A durable power of attorney for health care must be formally revoked in writing with a witnessed or notarized statement.
Information from Kansas Health Ethics, Inc. and the Wichita Medical Research & Education Foundation