---
title: Advance Directive Documentation
description: A clinical reference on the importance and components of advance directive documentation for healthcare providers.
keywords: [advance directives, living will, healthcare proxy, POLST, end-of-life care]
category: clinical
---

## Introduction to Advance Directives

Advance directives are legal documents that allow patients to specify their healthcare wishes and preferences, particularly regarding end-of-life care. These directives empower patients to maintain autonomy and control over their medical treatment in the event they become incapacitated and unable to make decisions for themselves. Advance directives typically include a living will, which outlines the patient's preferences for life-sustaining treatments, and a healthcare power of attorney, which designates a proxy decision-maker. 

Discussing and documenting advance directives is a critical component of patient-centered, high-quality care. Clinicians should initiate these conversations early, as part of routine care, to ensure a patient's wishes are known and honored. Advance directive documentation should be regularly reviewed and updated as a patient's health status or preferences change over time.

## Components of Advance Directive Documentation

A comprehensive advance directive document typically includes the following key elements:

1. **Living Will**: This document specifies the patient's preferences for life-sustaining treatments, such as mechanical ventilation, cardiopulmonary resuscitation (CPR), artificial nutrition and hydration, and other interventions. Patients can indicate whether they wish to receive or decline these treatments under certain clinical circumstances, such as a terminal illness, persistent vegetative state, or irreversible coma.

2. **Healthcare Power of Attorney**: Also known as a durable power of attorney for healthcare, this component designates a trusted individual (the healthcare proxy) to make medical decisions on the patient's behalf if they become incapacitated. The proxy should be someone who understands the patient's values and can advocate for their wishes.

3. **Do Not Resuscitate (DNR) or Do Not Intubate (DNI) Orders**: These orders explicitly state the patient's desire to forgo CPR or endotracheal intubation in the event of cardiopulmonary arrest or respiratory failure. DNR and DNI orders are typically included as part of the advance directive document or as separate medical orders.

4. **Physician Orders for Life-Sustaining Treatment (POLST)**: The POLST form is a portable medical order that travels with the patient and outlines their preferences for end-of-life care, including the use of life-sustaining treatments. POLST forms are particularly useful for patients with advanced illness or frailty who are nearing the end of life.

5. **Personal Statements**: Patients may also include personal statements or letters to their healthcare proxy or loved ones, expressing their values, beliefs, and specific wishes regarding their care.

## Advance Directive Documentation Process

Clinicians should initiate discussions about advance directives during routine care, especially for older adults, patients with chronic or life-limiting illnesses, and those nearing the end of life. These conversations should be documented in the patient's medical record, and the advance directive document should be readily accessible.

When discussing advance directives, clinicians should:
- Explain the purpose and importance of advance directives
- Provide educational materials and resources to the patient and their family
- Encourage the patient to reflect on their values and preferences for end-of-life care
- Assist the patient in completing the advance directive document
- Ensure the document is properly signed, witnessed, and notarized as required by state law
- Provide the patient with a copy of the advance directive and upload it to their electronic medical record
- Review and update the advance directive at regular intervals or as the patient's health status changes

## Incorporating Advance Directives into Clinical Care

Advance directive documentation should be integrated into the patient's comprehensive care plan and referenced during key clinical decision-making points. Clinicians should:

- Ensure the advance directive is prominently displayed in the patient's medical record and easily accessible to the healthcare team
- Review the advance directive during hospital admissions, transitions of care, and significant changes in the patient's condition
- Discuss the advance directive with the patient and their healthcare proxy, as appropriate, to ensure alignment with the patient's current wishes
- Follow the patient's documented preferences for life-sustaining treatments, as outlined in the advance directive, unless the situation warrants a deviation based on clinical judgment and ethical considerations

## Ethical and Legal Considerations

Advance directive documentation is subject to various ethical and legal considerations. Clinicians should be aware of the following:

- Capacity and Competency: Patients must have decision-making capacity to execute a valid advance directive. Clinicians should assess capacity and document their findings.
- Surrogate Decision-Making: If a patient lacks capacity and has not designated a healthcare proxy, state laws determine the appropriate surrogate decision-maker, typically a close family member or friend.
- Conflicts and Disputes: Disagreements among family members or between the healthcare team and the patient's proxy should be resolved through mediation or, if necessary, legal channels.
- Conscientious Objection: Clinicians who have moral or religious objections to a patient's advance directive preferences may be able to opt-out of participating in the patient's care, but they must ensure the patient's wishes are still respected.

## Conclusion

Advance directive documentation is a crucial component of patient-centered, high-quality care. By proactively discussing and documenting a patient's preferences for end-of-life care, clinicians can help ensure the patient's autonomy and dignity are preserved, even in the face of incapacity. Integrating advance directives into routine clinical practice and honoring a patient's documented wishes are essential for providing compassionate, ethically-sound care.