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
• Discussion of these reflections and
decisions with those who might need to carry out the plan
Why do I need to do Advance Care Planning?
Documents and Tools
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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
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 and verbal instructions about your future medical care in
the event you are unable to express your medical wishes.
Directives typically refer to two legal documents, both recommended for anyone
over the age of 18 years:
- Durable Power of
Attorney for Healthcare (Also referred to as Health Care Proxy, Health Care
Agent, or Surrogate Decision Maker)
- Healthcare Directive
(Also referred to as a Living Will)
Power of Attorney for Health Care (DPOA) - Also referred to as Health Care
Agent, Health Care Proxy, or Surrogate Decision Maker.
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.
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
Durable Power of Attorney for Health Care
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) – all must come to agreement
- Your parents– all must
come to agreement
- Your adult brothers
and sisters – all must come to agreement
2. Health Care Directive - also known as a Living Will.
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
“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
For your advanced 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
One great option is to register
your documents with the U.S. Advance Care Planning 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 Planning
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
Planning 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 Planning 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
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Now That You Have
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 Planning 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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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
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- How do I Start?
- 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:
you go to college
you get married or divorced
you have children
you become eligible for Medicare
you are going on a major trip
you are newly diagnosed with a serious illness
Do I need an attorney?
is not needed to complete ACP and Advance Directives.
Power of Attorney for Health Care must be notarized or witnessed by two people.
Witnesses cannot be:
providers for the individual completing this document
providers at an adult family home or long-term care facility if you live there
you or the designated Health Care Agent by blood, marriage, or state registered
Directive must be witnessed by two people
Witnesses cannot be:
of the attending physician or health care facility in which the declarer is a
who has a claim against any portion of the individual’s estate (Named in a will)
What do I do with my Advance Care Planning documents?
*Keep your original documents in a secure but easily accessible
*Provide copies of your documents to the following:
*Your Health Care Agent/Proxy
*Your family members who could be involved in end of life
*Your primary care physician (At Valley Medical Center, we are
eager to receive your documents! Feel free to bring them in at your next
- 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.
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.
What is a Mental
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
- What is informed
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.
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.”
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. AdvanceCare Planning Registry (PDF)
Health Care Directive (Spanish-PDF)
U.S. Advance Care Planning Registration Agreement (PDF)
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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.
Advance Care Planning 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
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.
Search for Advance Care Planning under ALL
Doc Talk, Classes and Events.
Care Planning Coordinator
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