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Advance Care Planning

Advance Care Planning (ACP) is a process of communication for planning for your future medical decisions. To be effective, this process includes:

  • Reflection on your goals, values and beliefs (including cultural, religious, spiritual and personal)
  • Understanding of possible future situations and decisions
  • Sharing of these reflections and decisions with those who might need to carry out the plan

  

Click to hear Amran and Paul's stories about Advance Care Planning.

Watch Make Your Wishes Known: Advance Care Planning Workshop (Updated March 2020)

Advance Directives 

You have the right to make your own healthcare decisions. Often these decisions are made together with your family and the advice of your doctor. It is usually best to include family and physicians in this process to avoid conflict when end-of-life decisions arise: family members may have personal beliefs that differ from yours and physicians may give insight to end-of-life issues not previously considered.

How can you be sure that your choices will be honored if you are incapacitated? Before you become ill, make your choices known by completing written instructions about your future medical care in the event you are unable to express your medical wishes.

Advance Directives typically refer to two legal documents, both recommended for anyone over the age of 18 years:

  • Durable Power of Attorney for Health Care (Also referred to as Health Care Proxy, Health Care Agent, or Surrogate Decision Maker) 
  • Health Care Directive (Also referred to as a Living Will)  

Durable Power of Attorney for Health Care (DPOA)

Also referred to as Health Care Agent or Health Care Proxy, this document reflects who you would want to make medical decisions on your behalf in the event you are too ill to make decisions for themselves. Washington state law requires that this directive be notarized and/or witnessed. You may change or cancel this directive at any time.

Durable Power of Attorney for Health Care Form

Your Health Care Agent needs to be someone willing to:

  • Accept the role 
  • Talk about your goals, values, and preferences 
  • Follow your decisions (even if they do not agree with them), and  
  • Make decisions in difficult moments.  

Washington State Surrogate decision making hierarchy:

  • A guardian with healthcare decision-making authority, if one has been appointed 
  • The person named in the durable power of attorney with healthcare decision-making authority 
  • Your spouse or state-registered domestic partner  
  • Your adult children (over 18)*
  • Your parents* 
  • Your adult brothers and sisters* 
  • Adult grandchildren*
  • Adult nieces/nephews*
  • Adult aunts/uncles*
  • Close adult friend (with requirements and limitations)

*Any group that has more than one person: all available individuals in the group must agree to the care.


Health Care Directive

Also known as a Living Will, this document outlines your wishes and preferences for medical care in the event of a fatal illness or permanent state of unconsciousness. It serves as a guide for health care providers and surrogate decision-makers when you are unable to make decisions for yourself.

Health Care Directive Form

Why do I need to do Advance Care Planning?

“I have an Advance Directive not because I have a serious illness, but because I have a family.” – Ira Byock, M.D.

Having your wishes known to your doctors and loved ones, not only means that you are ensuring that you will receive medical treatment consistent with your values, preference and goals, but it also takes away elements of uncertainty and stress from your loved ones who may have to make decisions on your behalf. You can give them the gift of advance care planning.

Even if you’re in good health, it’s still important to make sure your healthcare team knows your wishes, since anyone’s health status can change suddenly. Don’t wait until there’s a crisis. And don’t wait for your doctor to bring it up. It always seems too early, until it’s too late.

What To Do With The Advance Directive Forms

For your advance directive to be useful, it must be accessible. When the time comes to find the document, it is usually unavailable, placed away long ago for safekeeping. Keep your original in a safe place and give copies to your health care agent, other family members who could be involved in decision making, your primary care physician and your attorney.

We are eager to receive your advance directives here at Valley! Please bring a copy to your next appointment and we can get it into your medical record so that it can be accessed in the case of an emergency.

There are also various online databases that allow you to store your wishes and send links for your loved ones to access. Please check out the online document storage options in Resources below.

Patients can now upload their advance care planning documents through MyChart. For instructions on how to do this, click here. 

Planning for Your Estate

In addition to planning your future medical care, you may also want to make arrangements in advance for the distribution of your estate in the event of your death. Consider consulting an attorney or planned giving specialist at Valley or other trusted charity. They can help pursue planned giving options that reflect your priorities, values, and financial objectives.

 

FAQs

Advance Care Planning Steps

  1. Think through and talk with your loved ones about your known goals, values and preferences related to end of life care. Use “Your Conversation Starter Kit”.

  2. Identify who you would want would want to be your Health Care Agent/Proxy. Use “How to Choose a Health Care Proxy”.

  3. When you’ve chosen an Agent, and thought about your preferences, complete the “Health Care Directive” and “Durable Power of Attorney” forms.

  4. Have your Durable Power of Attorney form notarized or witnessed and your Health Care Directive witnessed.

  5. Let your loved ones, and your physician, know about your Advance Directives and your wishes.

  6. Give copies to: Your Health Care Agent, other involved loved ones, your Primary Care Physician and your Attorney

  7. Review and update Advance Care Planning at decades and major life events.

  • Early: Advance Directives can be completed at 18 years and older
  • Often: It is good practice to review Advance Directives at the start of each decade 20, 30, 40, 50, 60, 70…
  • At major life events:
    • When going to college
    • When getting married or divorced
    • When having children
    • When becoming eligible for Medicare
    • When going on a major trip
    • When newly diagnosed with a serious illness

An attorney is not needed to complete ACP and Advance Directives. 

Durable Power of Attorney for Health Care must be notarized or witnessed by two people. Witnesses cannot be:

  • Home care providers for the individual completing this document
  • Care providers at an adult family home or long-term care facility if you live there
  • Related to you or the designated Health Care Agent by blood, marriage, or state registered domestic partnership  

Health Care Directive must be witnessed by two people. Witnesses cannot be:

  • The attending physician
  • An employee of the attending physician or health care facility in which the declarer is a patient
  • Any person who has a claim against any portion of the individual’s estate (Named in a will)

  • Keep your original documents in a secure but easily accessible place.
  • Provide copies of your documents to the following:
    • Your Health Care Agent/Proxy
    • Your family members who could be involved in end of life decision making
    • Your primary care physician (At Valley, we are eager to receive your documents! Feel free to bring them in to your next appointment.)
    • Your Attorney

The Physician Orders for Life Sustaining Treatment (POLST)form is a ‘portable’ medical order that describes your current wishes in the event your heart stops. It must be signed by a provider to be valid. It includes the following: your wishes for resuscitation, medical interventions, antibiotics and artificial feedings. 

This form is not for everyone! It is designed for people living with a serious illness or in very poor health. If you do have one, you should keep it on your refrigerator or in a designated place where family and medics can locate it quickly.

A code (resuscitation) is a set of potentially life-saving procedures performed on a person whose heart and/or lungs have suddenly stopped functioning. Current healthcare practice requires that attempts at resuscitation must be made unless otherwise specified.

Calling 911 will activate all resuscitation efforts despite previous decisions, unless you have executed a "Physician Orders for Life-Sustaining Treatment (POLST)" form or bracelet. It is always a good idea to keep a copy of your wishes in a readily accessible location for emergency medical staff, such as keeping it on top of the refrigerator.

The Mental Health Advance Directive is only for individuals living with mental illness. A mental health advance directive is a legal written document that describes what you want to happen if your mental health problems become so severe that you need help from others. This might be when your judgment is impaired, and/or you are unable to communicate effectively. It can inform others about what treatment you want or don't want, and it can identify a person to whom you have given the authority to make decisions on your behalf. 

Under the principle of "informed consent," your medical care must be explained so you can understand it and can make informed decisions. Upon admission to the hospital for a procedure, you will be asked to sign an informed consent verifying that you understand and agree to the procedures and/or treatment that is planned for you.

It is important to let your physician and loved ones know your wishes for treatment should you ever be near death and unable to express them. Most health facilities assume you want all available medical treatment, including life-sustaining care, unless you direct otherwise.

Learn about some of your options. 

Organ and tissue donation are not included in the WSMA advance directives. You may choose to add an amendment to your health directive stating that you would like to donate your organs. However, consider that in some cases, it might be necessary to use machines to keep the heart beating until medical staff is ready to remove the donated organs. If you have a health directive stating the wishes of withholding treatment, medical staff will honor those documents above donation of organs unless stated otherwise. If you would like your desire to donate organs to supersede refusal of treatment wishes described in your health directive, consider the following amendment:

“Let it be known that I expressly desire any medical procedures, including those that are life-prolonging, that shall be necessary in order to make organ or tissue procurement more effective, unless the person named as health care agent considers these procedures too burdensome for me.”

Resources

Washington State Medical Association Access Washington State advance directive forms and other useful information.

The Conversation Project  Find tools to help you start an advance care planning conversation with your loved ones.

Honoring Choices PNW Explore various tools, find notaries, and other resources for advance care planning.

Prepare for Your Care Engage in a step by step program with video stories to help you talk with your family, doctors and fill out your documents. 

End of Life Washington Learn more about Advance Care Planning and explore other tools and resources.

U.S.Advance Care Plan Registry Store your advance care planning documents in a national database.

Other online document storage options: Store your WSMA advance directives in these online tools that can be accessed through the internet.

My Directives This online advance care planning digital directive allows you to store your values, treatment goals, health care agents, share your plan with your agents, and much more, all from an online database. There is also an application for your phone, MyDirectives MOBILE™ that allows you to sign and update your plan with the touch of your hand.

Cake This online advance care planning digital directive allows you to store your values, treatment goals, health care agents, share your plan with your agents, and much more, all from an online database. It also includes estate, legacy and financial planning. This online site can be accessed through your mobile internet.

 

Contact Us

Sarah Peterson
Director of Supportive & Palliative Care
sarah_peterson@valleymed.org
ph:  425.690.3126