Advance Directives: Frequently Asked Questions

Department of Bioethics
The Cleveland Clinic Foundation
(216) 444-8720

What are Advance Directives?
Advance Directives are legal documents in which patients' express their wishes about the kind of health care they want to receive should they become unable to make their own treatment decisions. There are two types of Advance Directives in Ohio: the Living Will and the Durable Power of Attorney for Health Care.

What is a Living Will?
A Living Will is a legal document in which patients are able to state in advance their desire to receive or their desire to withhold life support procedures when they are permanently unconscious or terminally ill and unable to make informed decisions.

When does it apply?
The Living Will applies only when two physicians determine that the patient is either in an irreversible coma or is suffering from a terminal illness. The Living Will only applies when the patient is unable to make decisions for him/herself. As long as a patient is able to make health care decisions, the Living Will cannot be used.

What treatments are covered?
The Living Will permits the withholding or withdrawal of any treatment that might be considered life prolonging or that artificially extends the dying process. Ohio law has special provisions that permit the withholding or withdrawal of artificial nutrition and hydration for patients who suffer from an irreversible coma. The Ohio Living Will statute requires that comfort measures always be provided.

Who can complete a Living Will?
Anyone over the age of 18 years who is of sound mind can complete a Living Will. It must be witnessed by two adults or can be notarized.

Can a Living Will be revoked?
A Living Will can be revoked at any time and in any manner, e.g., by the patient simply tearing the Living Will document, expressing orally the desire to revoke the document, or in writing by the patient. Health care professionals who witness such revocations should document them in the medical record.

What is a Durable Power of Attorney for Health Care?
The Durable Power of Attorney for Health Care is a document that allows patients to specify in advance who should make health care decisions for them should they become unable to make their own health care decisions. The individual named is the "agent" or "attorney-in-fact" for the patient.

When does a Durable Power of Attorney for Health Care take effect?
The Durable Power of Attorney for Health Care takes effect anytime the patient loses the ability to make his/her own health care decisions. Unlike the Living Will, the patient does not need to be terminally ill or suffering from an irreversible coma.

What treatments are covered?
The Durable Power of Attorney for Health Care document allows a patient to name an "agent" or "attorney-in-fact" with broad or specific powers to provide consent or refusal for any type of health care. Durable Powers of Attorney for Health Care are thus very flexible documents allowing both the naming of an agent to make decisions for the patient when the patient is unable to do so and the specification of the treatments that the patient wants or does not want to receive.

Who can be named as an agent?
Anyone over the age of 18 years can be named as the agent except for the physician (and those in the employ of the physician) who is providing care to the patient. The agent named has no legal obligation to serve and the agent is not responsible for the financial costs associated with treatment.

Who can complete a Durable Power of Attorney for Health Care?
Any adult of sound mind may complete a Durable Power of Attorney for Health Care. Living Wills and Durable Powers of Attorney for Health Care are frequently prepared without the assistance of lawyers by using standard forms available from the Ohio State Medical and Bar Associations. The Durable Power of Attorney for Health Care document must be witnessed by two adults or notarized.

Can more than one agent be named?
Only one agent can serve at a time, but other individuals can be named as successor agents if the first individual named as the agent is not able or is unwilling to serve.

Can a Durable Power of Attorney for Health Care be revoked?
A Durable Power of Attorney for Health Care can be revoked at any time and in any manner, e.g., by the patient simply tearing the Durable Power of Attorney for Health Care document, expressing orally the desire to revoke the document, or in writing by the patient. Health care professionals who witness such revocations should document them in the medical record.

How is the Living Will and Durable Power of Attorney for Health Care implemented?
Both documents require that two physicians determine that the patient in question has lost the capacity to make health care decisions. A Living Will has the additional requirement that the patient must be suffering from a terminal condition or is in an irreversible coma.

What are some other differences between the Durable Power of Attorney for Health Care and the Living Will?
The Living Will simply requires the withholding or withdrawal of life prolonging treatment whereas the Durable Power of Attorney for Health Care names a specific an agent who is authorized to make decisions for the patient. Specific instructions may be given to the agent in the Durable Power of Attorney for Health Care, but they are not required.

Who can I call for help regarding Advance Directives?
Questions about the applicability of Advance Directives or conflicts in their interpretation or implementation or other questions involving the withholding and withdrawing life-sustaining treatment can be referred to the Department of Bioethics, Extension 4-8720, Pager #22512. Assistance for patients in completing Advance Directives is available from The Department of Pastoral Care [4-2518] or the Department of Social Work [4-6552].

Are there other resources that I might use?
The back pages of the Telephone Directory and Page Directory contain summaries of applicable CCF Ethics Policies. Other resources include the following pamphlets or booklets:

Dealing with Ethical Questions in Health Care
Your Guide to Managing Personal Health Care Decisions
You Have the Right: Stating Your Wishes Regarding Medical Treatment.

How will I know if a patient has an Advance Directive?
CCF policy and procedures include asking the patient or family upon admission about the existence of Advance Directives. The existence of an Advance Directive is documented in the Demographic Sheet on the Chart. Copies of Advance Directives should be placed on the chart in the tabbed section for Advance Directives. Also, health professionals should document the content of discussions about the patient's end of life desires or any expression of treatment preferences.

Immunity
Ohio law accords physicians and health care providers immunity from civil, criminal, and disciplinary action if they follow the Advance Directive statute in good faith and meet its provisions.

Do Not Resuscitate (DNR) Orders
Advance Directives are not DNR orders. DNR orders are written by physicians to indicate that a patient should not be resuscitated. The order may be written to reflect a patient's or surrogate's expressed wishes about resuscitation or because the patient will not benefit from resuscitation. For example, for someone with a Living Will or Durable Power of Attorney for Health Care, CPR may be appropriate if they are suffering from an acute life threatening condition. Patients with Advance Directives may want aggressive treatment for potentially reversible conditions.

Points to Remember

  • Advance Directives only take effect when the patient loses decisional ability. Before that time, the patient's current expressed wishes should be followed.
  • Advance Directives do not replace active communication with patients and their families. Patients and families should be provided appropriate and sufficient information to make informed health care decisions. Patients' expressed preferences about health care treatments should be documented as they evolve in the course of treatment.
  • CCF policy supports the use of Advance Directives by patients, but does not require that any patient complete an Advance Directive as a condition for treatment.
  • Assessment of and attention to patients' spiritual needs is an important part of quality end-of-life care and should be a routine part of patient care.
  • Quality medical care also includes providing patients with the supportive atmosphere in which to reflect on end of life choices and to allow their wishes to be communicated to their health care providers and to their families.

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