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

 

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Advance Directives 
Why do I need to do Advance Care Planning?
FAQS
Documents and Tools
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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)  
  
  

1. Durable Power of Attorney for Health Care (DPOA) - Also referred to as Health Care Agent, 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.

Your Health Care Agent needs to be someone willing to:

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

Durable Power of Attorney for Health Care

Washington State Surrogate Decision Making Hierarchy

•  A guardian with health care decision-making authority, if one has been appointed 
• The person named in the durable power of attorney with health care 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.

2. 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

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.

One great option is to register your documents with the U.S. Advance Care Plan Registry (USACPR). You can be rest assured that hospitals and healthcare providers have access when necessary. Valley Medical Center is a member of the U.S. Advance Care Plan Registry. The registry is a free service to you, and it eliminates worries about carrying your advance directive with you, as well as problems finding it should you become ill. Store your advance directive with the U.S. Advance Care Plan Registry by completing one of the following:

Option 1. If you have an existing advance directive, obtain a copy and attach it to the completed registration agreement. (The registration agreement gives the registry permission to store your advance directive.) Mail to: U.S. Advance Care Plan Registry, 523 Westfield Ave, PO Box 2789, Westfield, NJ, 07091-2789 or fax to 1-908-654-1919. 

Option 2. If you do not have an advance directive, complete the applicable form(s), attach to the registration agreement, and mail. Once you are registered, you may upload your Advance Care Planning documents from your personal computer.

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Now That You Have Registered

Once registered, you are registered for life. If you register your advance directive, you will receive an update form annually so that your information will always be current.

The registry provides this service free of charge through its member healthcare providers and community partners, so cost will never prevent anyone from registering these important documents. Because only healthcare providers (hospitals, doctors, skilled nursing facilities, nursing facilities, home health agencies, providers of home healthcare, ambulatory surgery centers, and hospices) have access to your documents, your privacy and confidentiality are always maintained.

After your document is registered, you will receive notification by mail, along with labels to attach to your driver's license and insurance card stating that you are registered with the U.S. Advance Care Plan Registry. Once registered, your documents and emergency contact information will be available to healthcare providers across the country. You will have peace of mind knowing that your wishes will be available whenever and wherever they are needed. Your family will not have to make difficult decisions on your behalf.

To obtain a list of the member healthcare providers and community partners in your area, visit http://www.usacpr.net/

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Mobile Application

Download the mobile application on any Apple or Android device. This app allows registrants to quickly download, fax, or email their advance care planning documents, including DNR, POLST, advance directives, organ donor information, and more! You must have an account with USACPR to login to the app.

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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 a trusted charity. They can help pursue planned giving options that reflect your priorities, values, and financial objectives.

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FAQS

1.  How do I Start?  
   
   
   
   
2. When is the right time to do Advance Care Planning?  

   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 you go to college

   *When you get married or divorced

   *When you have children

   *When you become eligible for Medicare

   *When you are going on a major trip
   
   *When you are newly diagnosed with a serious illness 

    

3. Do I need an attorney? 

   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)

    

4. What do I do with my Advance Care Planning documents?

   
   

    *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 Medical Center, we are eager to receive your documents! Feel free to bring them in at your next appointment.)

    *Your Attorney

    
5. What is a POLST? 
   

   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.

6. What is a code?

   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.

7.  What is a Mental Health Directive?  
   
   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. 

8. What is informed consent?  
   

   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. 

9. How do I incorporate organ and tissue donation into my advance care plans?

   
   
   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.”

Documents and Tools

Health Care Directive and Durable Power of Attorney for Healthcare(PDF)   
Conversation Starter Kit 
How to Choose Health Care Proxy 
Information Flyer about Advance Directives and the U.S. Advance Care Plan Registry (PDF)
Health Care Directive (Spanish-PDF)  
U.S. Advance Care Planning Registration Agreement (PDF) 

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