Below are some commonly asked questions about Advance Care Planning. If you don’t see an answer to your question, click here to connect with us.
Find answers to thinking about and discussing your wishes.
Talking with your loved ones and health care providers is the best way to make sure your voice is at the center of your health care.
- What is advance care planning (ACP)?
Advance care planning is a process of thinking about and sharing your wishes for future health care. It is for all adults 18 and older. Advance care planning includes deciding who you would want to make health care decisions for you if you cannot (called a health care agent) and sharing your values and goals.
It is important to write down your wishes using documents called advance directives. These documents should be updated regularly and shared.
Talking about future health care decisions and naming a health care agent makes sure that the treatments you want, happen – and the treatments you don’t want, don’t happen.
Your health care agent and advance directive would only guide your medical care if you are not able to. As long as you are capable of making decisions, then you remain in control of your medical care.
Watch a video that explains advance care planning.
- What is a health care agent?
A health care agent is a person you identify to make your health care decisions for you if you are unable to make them for yourself.
In Washington, a health care agent must act in “good faith” for the other person. “Good faith” means that the health care agent makes decisions that you would want or are in your best interest.
Watch a video that explains the role.
- How should I choose a health care agent?
When selecting a health care agent, there are a few important things to think about:
- A health care agent should be someone you
- know and trust to follow your wishes about future health care
- must be over 18 years old
- cannot be your doctor or an employee of your doctor or health care facility unless they are a close family member to you
- A health care agent should be able to answer “yes” to these questions:
- Are you willing to take on this role and responsibility?
- Do you understand my wishes for future health care?
- Can you make the decisions I would want to make, even if you disagree?
- Can you make important health care decisions under stressful circumstances?
It’s important to talk with the person you want as a health care agent before writing it down in a document. Ask if they can say yes to the questions above.
- A health care agent should be someone you
- What happens if I don’t choose a health care agent?
If you don’t choose a health care agent, Washington State law sets the following order for health care decision-makers:
- State-Appointed Guardian (if any; this is rare and occurs if no one listed below is available to help make medical decisions)
- Health Care Agent (with written and signed Durable Power of Attorney Health Care)
- Spouse or Registered Domestic Partner (even if separated)
- Adult Children
If any group (like Adult Children) has more than one person), all the people in the group must agree to the same care. You can download a chart that illustrates the order here.
- What choices should I make?
First, we recommend you explore your wishes, so you can talk about them with others. Click here to learn where to start.
- What medical decisions should I think about?
There are some common treatment options to consider. They include:
- CPR or Cardiopulmonary resuscitation is a procedure used when your heart or breathing stops.
- Artificial hydration and nutrition is a treatment to provide food and water when you have difficulty swallowing or are too sick to eat on your own.
- Help with breathing may include medicine to machines, including a ventilator.
- Dialysis is used when your kidneys are no longer working.
- Palliative care is specialized medical care for people with serious illness that focuses on symptom relief.
- Hospice care focuses on the quality of life rather than length. It provides care for people in the last phases of incurable disease.
- What if I develop Alzheimer’s or another type of dementia?
Many people have clear ideas about the medical care they would want if they were to develop Alzheimer’s or another type of dementia. Standard advance directives don’t usually cover dementia. Yet dementia is the number one reason people lose the ability to guide their own care. We recommend visiting dementia-directive.org to learn more and to access a free advance directive for dementia.
Once signs of cognitive impairment have already appeared, it can be difficult for someone to complete a Dementia Directive. So it’s best for everyone to be given the chance to fill one out, before they develop dementia. This is especially important for people over age 60. If you fill it out before age 60, make sure to make a reminder to yourself to review your answers when you get into your 60’s or 70’s, and to fill out a new form at that time to best reflect your more up to date wishes.
- What does DNR mean?
DNR stands for “Do Not Resuscitate.” A DNR Form directs whether CPR should be tried and can be filled out in advance by a patient and physician in case the patient has a heart attack or breathing failure.
- What is the Death with Dignity Act?
The Death with Dignity Act became Washington state law in 2009 and allows terminally ill adults seeking to end their life to request lethal doses of medication from medical and osteopathic physicians. For more information, click here.
Find answers about documenting your wishes.
Once you have thought about your wishes, it is important to write them down in a legal document.
- What is an advance directive?
An advance directive is a legal document that gives directions about your future medical care. With an advance directive you can guide your medical care even when you are too ill to communicate or are unconscious. You may also use an advance directive to name a person to make health care decisions for you if you cannot.
The following documents are advance directives:
- Durable Power of Attorney for Health Care is a legal document where you can select a health care agent to make health care decisions for you if you cannot.
- Health Care Directive (Living Will) is a legal document completed by you that lets you you’re your doctor what you do or do not want if you are diagnosed with a terminal condition or are permanently unconscious and unlikely to recover.
You may complete one or both documents. Click here for the Honoring Choices PNW advance directive; this advance directive has both documents and you can fill out which ones you want.
Because advance directives are good until cancelled by you, you should update them regularly and share with your health care agent, loved ones, doctors, and hospital.
Watch a video on Advance Directives.
- Is a lawyer required to complete an advance directive?
No, a lawyer is not required to complete an advance directive. You may hire a lawyer if you want or contact one with any specific questions or concerns you may have.
- How do I legally complete my advance directive?
It is important that once you fill out one or both of advance directive documents that you make sure they are legally valid. The instructions can be found in the Advance Directive document. Each document type has different requirements to complete the form legally.
Durable Power of Attorney for Health Care
Washington residents must have their signature on the Durable Power of Attorney for Health Care form either acknowledged by a notary public or witnessed by two people.
- If using witnesses, they:
- Must be at least 18 years of age and competent.
- Must watch you sign this form and complete their section of the form below.
- Cannot be related to you or your health care agent by blood, marriage, or state registered domestic partnership.
- Cannot be your home care provider or a care provider at an adult family home or long-term care facility where you live.
- Cannot be your designated health care agent(s).
- If using witnesses, they:
Health Care Directive
Washington residents must have their signature on the Health Care Directive witnessed by two people who:
- Must be at least 18 years of age and competent.
- Must watch you sign this form.
- Cannot be related to you by blood or marriage.
- Would not be entitled to any portion of your estate upon your death.
- Cannot be your attending physician or an employee of your attending physician or health care facility where you are a patient.
- Cannot be any person who has claim against any portion of your estate at the time of signature of this document.
Please pay attention: the witness requirements for the Durable Power of Attorney for Health Care are different from the witness requirements Health Care Directive. The Health Care Directive cannot be notarized. These laws are in place to ensure it is truly your voice that is heard if you are unable to communicate.
- Durable Power of Attorney for Health Care
- What happens if I change my mind about what I want after I have completed an advance directive?
You can change your mind at any time and update your advance directive.
It is important to tell your loved ones, health care agent, health care providers, and anyone else who knows about your wishes when you change or cancel your advance directive. You should destroy all old copies. It also important to share copies of your new advance directive with the same people.
- Is one advance directive valid everywhere in the United States?
Advance directives are created to fulfill specific state laws. For example, the Honoring Choices PNW advance directive meets Washington state laws. If you spend a lot of time outside in different states, we suggest completing other state advance directives as well.
If you are traveling overseas, it may be useful to carry your Advance Directive. Different countries have different laws, but the information could be useful for decision-making.
- My family and friends already know my wishes. Why do I need to fill out an advance directive?
Congratulations! Talking about your wishes is so important!
Putting your wishes down on paper and naming your health care agent is just as important. Your health care agent needs to be clearly identified and given legal authority to act on your behalf.
It is also important to give your health care agent clearly documented direction about your care preferences. An advance directive can help avoid confusion and conflict regarding the care you want.
- Is there an advance directive for dementia?
- Are there advance directives in other languages? How can I ensure my cultural beliefs will be incorporated?
We plan to translate the Honoring Choices PNW advance directive into several languages over the next year. In the meantime, you can find a Spanish Advance Directive from PREPARE here.
A good advance directive will reflect your wishes and beliefs, including cultural ones.
- What is a POLST?
POLST stands for Physician Orders for Life Sustaining Treatment. A POLST is a medical order which states the individual’s preferences for care. This voluntary form is completed by a doctor with a patient. POLST forms are usually for seriously ill or frail individuals and they travel with the patient from location to location (like home to hospital to a nursing home). The POLST is not intended for healthy adults. To complete a POLST form, it is good to complete an advance directive first to identify wishes and preferences.
- There are so many different documents. Can you tell me the differences and which one I should fill out?
When planning for health care options, especially near the end of life, there can be many different documents. There are living wills, POLST forms, and advance directives.
Find answers about letting others know about your decisions.
- How do I store my forms? Who should have a copy?
After filling out your advance directive with signature, it is a legal document. So, store a copy in a safe place that you can easily get to. Some people put them in a health binder or store in the freezer where they will be safe from fire. You do not need to keep them in a safe deposit box.
You should also share copies with your health care agent or anyone else who may be asked to make decisions for you, included loved ones. Copies should be made a part of your medical record at your doctor’s office and any hospital you regularly visit. Of course, if you have a personal lawyer or another trusted person who might be contacted in an emergency, it is important for them to have a copy as well.
- Are there times when my advance directive and wishes may not be followed?
Every situation is unique. The best way to make sure you get the care you want is to name a health care agent, talk about your wishes, fill out an advance directive, and share your thoughts and documents with loved ones and medical providers.
There may be times when your advance directive may not be followed.
For example, receiving emergency treatment outside of a hospital or care facility may not reference your advance directive. Also, some health care organizations may have times when an advance directive is suspended, like during a surgery
Health care providers and organizations must inform you of any known reason that would prevent them from honoring your advance directive and wishes. You have the right to change providers and/or locations.