"A MODEL ADVANCE DIRECTIVE" Reprinted from The Patient Self-Determination Act: A Training Program for Health Care Professionals by Lawrence P. Ulrich, Ph.D. (Breckenridge Bioethics, 1991)

Introduction:

The following outline is intended as a model which can be used in drafting an advance directive. It contains suggestions of items which can be incorporated into a document which one wishes to make both credible and specific. It can stand alone or be used as a supplement to an official form which one's local state may mandate as part of its advance directive legislation. To check one's local state requirements and forms, go to . [http://www.caringinfo.org/stateaddownload] or

[http://www.guardianinsurance.com.au/ArticleLibrary/Facts-Health-Care-Advance-Directives.aspx]

It can also be used to give specific directions to one's attorney-in-fact with health care decision-making authority. In this way the attorney-in-fact will have some documented evidence of the principal's wishes which will add credibility to any decision which he/she might make on the principal's behalf.

Discussion of an advance directive with one's physician and family is vital while the document is being prepared. The physician can give the author information which is essential to the document and can communicate to the author his/her commitment to honoring it. Family members can discuss differences of opinion about the decisions reflected in the document and, hopefully, resolve those differences before the advance directive needs to be applied. Copies of the final advance directive should be given to one's physician and appropriate family members or significant others.

Any advance directive should be reviewed periodically to be sure that it represents the current thinking of the author and conforms to state law. It should be revised when it is appropriate to do so.

It is not necessary to address all of the items listed in the outline. This may be too much detail for many individuals. They may eliminate whatever they choose not to include. Others may add more specificity to this general orientation. It is strongly suggested, however, that those writing an advance directive pay special attention to addressing the items related to the values history (#5), the quality of life (#5d), outcomes (##7 and 8), pain control (##2d, 10h, and 11h), medically administered nutrition and hydration (##10f and 11f), and CPR/DNR (##10k and 11k).

The rule of thumb is that the more specific and credible the document is, the greater the likelihood of its being honored.

1. Purpose of the document.

a) To supplement the standard form.
b) To give guidance to caregivers and family members about the author's wishes regarding healthcare decisions.
c) To eliminate second guessing by others.
d) To provide clear and convincing evidence in case of legal disputes.
e) To avoid wasting personal economic resources.

a) Course of the disease.
b) Symptoms.
c) Possible complications.
d) Tolerable pain levels.
e) Realistic expectations concerning the disease.

a) Loss of physical function.
b) Loss of mental function.
c) Relation of death to personal life.
d) Realistic expectations about aging.

a) Family history of disease.
b) Personal history of disease.
c) Concerns and fears about disease or disability.
d) Risk of injury as a factor in one's lifestyle.

a) What has been important.
b) What is important now.
c) What is most important when values conflict.
d) The minimal quality of life which can be tolerated.

a) Personal understanding of a terminal condition.
b) Personal understanding of the loss of decisional capacity.
c) Personal understanding of what constitutes futile treatment.

a) Most desirable level of functioning.
b) Return to a previous level of functioning.
c) Acceptable level of functioning.

a) Least desirable level of functioning.
b) Borderline levels of functioning.
c) Unacceptable level of functioning.

a) Permanent loss of mental orientation.
b) Permanent loss of consciousness.

a) Antibiotics.
b) Cardiac medications.
c) Chemotherapy.
d) Dialysis.
e) Level of care (hospital, home, nursing home, hospice).
f) Medically administered nutrition and hydration.
g) Oxygen.
h) Pain control.
i) Radiation therapy.
j) Respirators.
k) Resuscitation (CPR/DNR).

a) Antibiotics.
b) Cardiac medications.
c) Chemotherapy.
d) Dialysis.
e) Level of care (hospital, home, nursing home, hospice).
f) Medically administered nutrition and hydration.
g) Oxygen.
h) Pain control.
i) Radiation therapy.
j) Respirators.
k) Resuscitation (CPR/DNR).

a) What interventions should be tried and for how long.
b) What interventions should not be tried.

a) Acceptance of death.
b) Acceptance of responsibility for decisions.
c) Relieving family members and caregivers of guilt.