Advance Directives, Living Wills and Power of Attorney
One way to exercise your rights as a patient is to prepare an advance directive. There are two types of advance directives, a Living Will and a Durable Power of Attorney for Health Care.
In accordance with the Patient Self-Determination Act, you will be asked if you have an advance directive when you are admitted to the Hospital. If you have an advance directive, please share it with your physician and your Hospital staff. If you would like more information about advance directives or other healthcare decisions, such as an organ donation, please call the Department of Social Work at 215-955-7175 or 5-7175 (from inside the Hospital); the Department of Pastoral Care at 215-955-6336 or 5-6336 (from inside the Hospital); or the Office of Patient and Family Experience at 215-955-7777 or 5-7777 (from inside the Hospital).
What You Need to Know About Advance Directives, Living Wills and Durable Powers of Attorney for Health Care
Thomas Jefferson University Hospitals (which includes Thomas Jefferson University Hospital — Center City, Methodist Hospital and Jefferson Hospital for Neuroscience) provide medical, surgical and psychiatric services, and inpatient and outpatient care. A full array of homecare services is also available in association with The Home Care Network, which serves as the homecare coordinating agency for the Jefferson Health System member hospitals. A Medicare-certified hospice, hospital-based ambulatory services and physician practices, support groups, educational programs and physician referral service help meet our community's health needs. For information on hospital or homecare services at any of these organizations, please call 1-800-JEFF-NOW. Deaf or hearing-impaired callers can access JEFF NOW by calling 1-800-654-5988 (voice-relay service) or 1-800-654-5984 (TDD).
Medical options and the quality of life
In today's world, you and your physicians have a wider range of treatment options than ever before. Our staff is dedicated to using these treatments to promote your physical and emotional well-being. In cases of serious illness, advanced life-sustaining equipment, medications and surgery are used appropriately for your needs.
The use of advanced life-support treatments is normally of great help, but sometimes it may seem to you and your family that these same treatments are too distressing, or do not aid in recovery, or seem only to prolong the process of dying. In such cases, you may prefer not to avail yourself of life-sustaining treatment. We hope you will gain a better understanding of the choices you can make and the ways you can make them using advance directives. The members of our staff will honor all advance directives to the extent the law in the Commonwealth of Pennsylvania permits.
Q: What kinds of healthcare decisions will I face?
When you go to a modern hospital, you expect the highest quality and safest care available, and this may include a variety of tests and treatments. There may be very little discussion about "routine care"– for example, X-rays, blood tests and medications. However, some treatments may be painful, some may have considerable risks and still others may have little benefit; such treatments require thoughtful discussion and should be explored carefully.
Your physician must discuss such treatments with you and explain them as fully as possible. He or she will explain the diagnosis, the treatments and the options. Weighing the physician's explanations and advice, you, as the patient, will make the choice. Naturally, you will consider your physician's advice, and you will often be guided by that advice. Your physician must respect your decision or withdraw from your care so that another physician may treat you as you have directed. If that happens, the Hospital can help you find another physician.
You have the right and the responsibility to accept or refuse any form of treatment – and the right to change your mind. In fact, many physicians have found that the patient who helps make his or her decisions makes better medical progress.
Q: Who makes my medical decisions?
You do! So long as you are able to communicate. When you can't, your appointed spokesperson and, in certain situations, your living will, will make it possible for you to receive the care you have chosen.
Q: What happens if I can't communicate directly?
You can prepare in advance for the time when you can't express your wishes. You can let those who are caring for you know your wishes by communicating those wishes to them. In addition, you can put your wishes or directions in writing in the form of an advance directive. There are two ways for you to do so. You can prepare a document commonly known as a living will, or you can prepare a document known as a durable power of attorney for health care, in which you would appoint a spokesperson to make healthcare decisions for you in the event that you should be unable to make them yourself. Many people use both a living will and a durable power of attorney in their healthcare planning, and you should consider doing so because the documents apply in different situations, as will be more fully discussed.
You can also combine both in a single document, if you wish. By having both a living will and durable power of attorney for health care, your wishes can be clear to all. Someone who knows you well and has discussed these matters with you will be prepared to speak for you and to help interpret your written directives, if necessary.
Even though you have made a living will and have appointed someone to make healthcare decisions for you, you remain in charge so long as you are able to communicate. You do not need an advance directive to receive care.
Q: What is a living will?
A living will is your written statement of your healthcare choices in limited circumstances. You develop the statement at a time when you are able to decide medical issues and are thinking clearly about the types of healthcare treatments desired. A living will would apply only if you are permanently unconscious or in a terminal condition and are unable to communicate. With a living will, you can refuse or accept life-sustaining treatment in those circumstances in advance.
The living will may also include a statement appointing someone to make medical treatment decisions for you in the event that you cannot speak for yourself. That person must consider your wishes, as stated in the living will. In your living will, you may have a general statement about whether or not life-sustaining treatment should be withheld or withdrawn if you should become permanently unconscious. Similarly, you might have a general statement about withholding or withdrawing treatment if it will only prolong the process of dying. You may also want to be more specific and indicate the types of treatment that you do or do not want under particular circumstances, including such things as artificial feeding, artificially providing water, mechanical breathing machines, surgery, certain diagnostic tests, kidney dialysis or cardiopulmonary resuscitation (CPR).
You must sign your living will. If you are unable to do so, you must have someone else sign it for you. You must also have two people who are at least 18 years old sign your living will as witnesses. Neither of these witnesses may be the person who signed your living will on your behalf if you were unable to sign it yourself. You should also date your living will, even though the law does not require it. In Pennsylvania, you are not required to have your living will notarized; however, if you are considering using the document in another state, you should find out if the other state requires notarization.
Q: Who can make a living will?
Any competent person who is at least 18 years old, is a high school graduate or is married, can make a living will.
Q: What if I change my mind after I have written a living will?
A living will can be changed or revoked at any time as long as you are able to communicate for yourself. Even if a written document exists, it has no force so long as you are able to communicate your wishes. If you change your mind after you have written down you instructions, you should destroy your written instructions or revoke them and write new ones. You should also consider telling everyone who participated in your decision-making process that you have changed your mind, and give a copy of any new instructions to your physician, healthcare provider and anyone else who had a copy of your old instructions.
Q: Is a living will effective during pregnancy?
Pennsylvania law generally does not permit a physician or other healthcare provider to honor the living will of a pregnant woman who has directed that she not be kept alive. The terms of such a living will may be honored, however, if the woman's physician determines that life-sustaining treatment will do any of the following:
- Not maintain the woman in a manner that will allow for the continued development and birth of the unborn child
- Physically harm the pregnant woman
- Cause her pain, which could not be relieved by medication
If your living will is not honored because you are pregnant, the Commonwealth must pay all of the usual, customary and reasonable expenses of your care.
Q: Will emergency ambulance staff honor a living will?
The laws regarding the effect of a living will in an emergency are the same as those that apply when there is no emergency. That is, a living will is operative only if you are terminally ill or in a permanent state of unconsciousness. If a living will is otherwise operative, its provisions will apply to care given to a patient by either of the following methods:
- An original signed document that is presented to the emergency medical services personnel, who must immediately notify the medical command physician of the presence of a living will
- The medical command physician, who based on prior notification by the attending physician that a valid and operative living will exists, directs the emergency medical services personnel according to the provisions of the document
Emergency personnel are otherwise required to initiate life-support measures in an emergency situation. Once started, life support would continue until admission to the Hospital. At that time, the medical staff would evaluate the patient's condition, review the living will and other expressed wishes of the patient and then honor the advance directive to the fullest extent possible.
You and your family should consult with your caregivers to ensure that the provisions of an otherwise operative living will may be honored by emergency medical services personnel and the command physicians who are directing them.
Q: What is a durable power of attorney for health care?
A durable power of attorney for health care is a document appointing someone to make medical decisions for you if you cannot act for yourself. This person is called your attorney-in-fact. Such an appointment takes effect and continues to be effective when you are no longer able to make your medical decisions. All powers of attorney executed on or after Dec. 16, 1992, are deemed to be durable unless they specifically provide otherwise.
If you do appoint someone to make medical decisions for you, it is important that you speak candidly with that person about your wishes. Your attorney-in-fact is expected to speak for you and to know what you would have wanted. You may also revoke or modify a durable power of attorney for health care.
The law says that the attorney-in-fact can:
- Authorize your admission to a medical, nursing, residential or other facility
- Enter into agreements for your care
- Make an anatomical gift of all or part of your body in accordance with Pennsylvania law governing anatomical gifts
- Authorize medical and surgical procedures
Q: What happens if I do not have a living will or durable power of attorney for health care?
Pennsylvania law does not require you to write a living will or execute a durable power of attorney for health care. If you cannot communicate your requests, your treatment will be based upon the medical facts, what you have said orally about treatment you would want and your family's information about your wishes. Bear in mind, though, those previous casual or general statements by you about healthcare treatments will be of little use to your family and your physician in carrying out your specific wishes; it is crucial that you take the time and effort to discuss these issues in detail with your family and physician.
Q: If I refuse certain types of life-sustaining therapy, how will that affect my other medical treatments?
Other medical care will be totally unaffected by any choices you may make to forego specific treatments. We are committed to making you as comfortable as possible and to providing treatment in a dignified fashion. Treatments that are medically appropriate will be given until they are either no longer medically indicated or it is clear that they are against your expressed wishes.
Q: May I include direction about organ donation in my living will?
Yes! Including your wish to donate organs in your living will and informing your family and physician about your wishes may save the lives of several people. Organs and tissues that can be transplanted include kidneys, corneas, heart, lungs, liver, pancreas, bone, bone marrow and skin.
Recent legislation requires hospitals to notify the Gift of Life Donor Program about every impending death to determine a person's suitability as an organ donor. Your generous declaration of your wish to make an anatomical gift releases your family from making another difficult decision. However, neither the Gift of Life Donor Program nor Jefferson will proceed with organ donation if a family member refuses to give consent, even if an organ donation card has been signed.
Our staff can assist you with questions about organ donation. Our organization is a member of the Gift of Life Donor Program.
Q: With whom should I discuss my intentions?
You should discuss all of these issues in detail with your family and your physician and seek guidance regarding specific treatments that you may choose or decline. It is not necessary to consult with a lawyer to write a living will or durable power of attorney for health care. Your current living will should be on file with your physician, your lawyer and one or more members of your family. If your wishes change, be certain to update each person who has an original copy. Your physician will be helpful in developing specific guidelines regarding treatment options. A member of the clergy or your religious advisor also may be of great benefit.
Q: If I have more questions about living wills or durable powers of attorney for health care, whom should I contact?
There are many individuals and groups who can provide you with information about such documents. Here are some that you may wish to consult:
Your local long-term care ombudsman, who can be reached by calling your community's Area Agency on Aging (AAA). The AAA phone number is in the blue pages of your phone book.
- Commonwealth of Pennsylvania: Department of Aging - 555 Walnut Street, Fifth Floor, Harrisburg, PA 17101-1919, Phone 1-800-346-2929
- Pennsylvania Council on Aging - 555 Walnut Street, Fifth Floor, Harrisburg, PA 17101, Phone 717-783-1549
- AARP Pennsylvania State Office - 30 N. Third Street, Suite 750, Harrisburg, PA 17101, Phone 1-866-389-5654
- AARP Pennsylvania State Office - One Liberty Place, 1650 Market Street, Suite 675, Philadelphia, PA 19103, Phone 1-866-389-5654
- The Pennsylvania Medical Society: Division of Communications and Public Affairs - 777 East Park Drive, P.O. Box 8820, Harrisburg, PA 17105-8820, Phone 717-558-7750
For more information about advance directives
- Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience - Contact the Social Work Department at 215-955-7173
- Methodist Hospital Division - Contact the Social Work Department at 215-952-9176 or the Department of Pastoral Care at 215-952-9133
- The Home Care Network - Contact the Central Access Department at 1-888-JEFF-999
Here are some terms that may not be familiar to you, but terms you may wish to know when talking with your family, physician or lawyer:
- Advance Directive - A document in which a person either states choices for medical treatment or appoints someone to make choices for him or her – a living will or durable power of attorney for health care.
- Artificial Nutrition and Hydration - Methods of delivering food and water when a patient is unable to eat or drink. The patient may be fed through a tube inserted directly into the stomach, or a tube put through the nose or mouth into the stomach. Nutrition and hydration can also be given by a tube placed in a vein.
- Cardiopulmonary Arrest - A medical term indicating that a patient's heart and breathing have stopped.
- Cardiopulmonary Resuscitation (CPR) - Medical procedures including artificial breathing, chest compression, administration of drugs and electric shock. These procedures are used to try to restore the heartbeat and breathing in the case of cardiopulmonary arrest.
- Competence (decision-making capacity) - In a healthcare setting, competence refers to a person's ability to make informed decisions regarding one's medical care. A competent patient can weigh the risks and benefits of suggested treatments; the wisdom of his or her choice is not the issue. When the competence of a patient is not clear, the physician will consult with other physicians to be sure that a sound judgment is made. If a patient is found to be incompetent, and is judged unable to communicate, then the decision-making processes discussed in this brochure will apply.
- Kidney Dialysis - A medical procedure to remove waste products from the blood when the kidneys are unable to do so.
- Mechanical Ventilator (respirator) - A machine that moves air in and out of the lungs for a patient who is unable to breathe adequately.
- Surrogate - A person appointed by way of a durable power of attorney for health care or a living will to make decisions for someone else. Also called a proxy or attorney-in-fact.
- Terminal Condition - A condition that is incurable or irreversible and in which death will occur within a short time.