DEMYSTIFYING
ADVANCE DIRECTIVES

Advance directives are legal documents that allow you to convey your decisions about health care for when you are incapacitated. They provide a way for you to communicate your wishes to family, friends, and health care professionals, and to avoid confusion later on. 

 

Legal documents can be prepared by an attorney, but many can be found for free online. Most require signatures by witnesses (two non-interested parties) or notarization. Each U.S. state has designated forms that can be found online. As an example, Texas Health and Human Services contains most of Texas’ state forms on the following webpage:  https://www.hhs.texas.gov/formas/advance-directives

 

It’s important to follow each state’s specific guidelines. If you move to a new state, it’s a good idea to either consult with a will and estate attorney to determine if you need new forms, and/or just simply complete new forms for your new state of residence.

 

Advance directives can be the greatest gift you give to the people you leave behind after you die. We at ABODE feel that it’s never too early to get started on creating your advance directives – in fact, it’s best to work on them when you’re physically and mentally healthy.  Too many people wait until they’ve received their terminal diagnosis to start, and this can be a tremendous burden on the family or loved ones.  

 

We Doulas can help our Clients identify which advance directives are needed for their situation, where to find them, and why they need to be done. We can also guide them through completion of forms that do not require an attorney. Again, using Texas as an example, none of the forms that are contained on the above-linked webpage require an attorney to complete. 

 

Have you completed your advance directives? Why or why not? No judgment here!

 

Why do you think people shy away from advance directives?

 

A quick and dirty list of advance directives (and then we’ll dive deeper into them):

• Medical Power of Attorney (MPoA)

• Directive to Physicians and Family or Surrogates (Sometimes called a Living Will)

• Out of Hospital Do Not Resuscitate Order (OOH-DNR)

• Body Disposition Authorization

• Appointment for Disposition of Remains

• Physician Orders for Life-Sustaining Treatment (POLST)

 

Other forms to consider (may not apply to all):

• Organ Donation Form

• Body Donation Form

• Certificate of Transfer

 

In addition to advance directives, it’s also helpful to think about Estate Planning. Similar to advance directives, these forms help you communicate your wishes regarding your assets and liabilities.

• Will

• Living Trust

• Statutory Durable Power of Attorney (Financial or Property Power of Attorney)

• Designation of Guardian in the Event of Later Need

 

Other forms to consider (may not apply to all):

• Declaration of Appointment of Guardian for my Child in the Event of my Death or Incapacity

• Pet Directive

• Declaration for Mental Health Treatment 

 

It’s important to note that as Doulas, we are not acting as an attorney or any other legal representative when it comes to these forms. Instead, we’re here to educate our clients about the importance of these forms, where to find them, how to fill them out, who in your circle of family and friends needs copies, and where to store them. 

 

It’s a good idea to have an attorney who specializes in will and estate planning in your list of resources.  

 

Medical Power of Attorney (Sometimes called a “Medical Proxy”):

This document designates those who will make healthcare decisions for you if you are unable to make them yourself, and it does not become effective until you are incapacitated as certified by your physician in writing (per Texas statutes). 

 

There are several advance care planning tools on the Internets that walk you through the many considerations for these decisions. Five Wishes, one of the more well-known ones, can help you think through specific scenarios with space to write freely about what is important to you regarding: 

• Choosing your healthcare agent (Medical Power of Attorney), and 

• What type of treatment you want to receive should you become unable to make decisions on your own (Directive to Physicians and Family or Surrogates - Living Will). 

 

Directive to Physicians and Family or Surrogates (Sometimes called a Living Will)

This document allows you to decide in advance if you wish to have artificial measures used to sustain life when you are near death and what types of treatments you prefer in certain medical scenarios. Being clear about your wishes is a great gift you can give your MPoA, so they know exactly what kind of care you want if you are incapacitated.

 

You can attach as many addendums to the Living Will as needed to ensure that your wishes are accurately expressed. The most common ones Doulas review with clients are:

• Dementia Addendum - Reviews the stages of dementia and captures your preferences. There are no specific state forms, but many organizations offer templates to use. Since some can go into considerable detail, we recommend keeping them at a high level, while still effectively conveying end of life treatment choices for this condition.

 

• Secular Addendum - If a patient has specific religious beliefs and is taken to a medical facility that, due to the provider’s ethical, religious, or moral policies, refuses to follow the Client’s wishes for treatment, this addendum lists acceptable alternative facilities.

 

Out of Hospital Do Not Resuscitate Order (OOH DNR)

When EMS is called, it’s their legal obligation to resuscitate you if they feel it’s needed. This resuscitation can be quite hard on the body and painful – but if you want to remain alive under any condition, it’s probably worth it.

 

If that’s not what you want, you must complete an OOH DNR – and it requires a doctor’s signature to be effective. The OOH DNR directs emergency medical personnel to refrain from resuscitation efforts. 

 

It’s a good idea to place some sort of notice on your door explaining where this document is – perhaps you want to hang it on your fridge. And make sure everyone in your circle of support is aware of it. Also, in the state of Texas, if a person is wearing a state-approved bracelet or pendant, EMS is required to accept them in lieu of the presence of a completed and signed OOH-DNR form.

 

The OOH DNR does not impact the delivery of other emergency care, including comfort measures. In Texas, it requires the signature of your attending physician to be considered a valid document by EMS.

 

Body Disposition Authorization

This form conveys your choice for your body’s final disposition – meaning where your body will be laid to rest. If you’ve chosen to donate your body and if, for whatever reason your body donation isn’t accepted, it’s good to have a back-up option or two.

 

This form eliminates the need for your legal next-of-kin’s approval for your chosen disposition, including cremation.  

 

Appointment for Disposition of Remains

This document allows you to appoint an agent to be in charge of your body after your death. It’s important to know that the agent is financially responsible for your final arrangements to the extent they are able to pay. We recommend that you prepay for your final arrangements if you are able. 

 

Physician Orders for Life-Sustaining Treatment (POLST)

This form is a medical order issued by your doctor that specifies your treatment preferences. It covers choices like CPR, the use of breathing machines, and whether the emergency personnel should transport you to a hospital. These require a doctor’s signature to be valid.

 

Organ Donation Form

Organ donation is the act of giving certain organs to another person after your death. Every state maintains its own donor registry. To become an organ donor, you need to register with your state’s specific registry. If, for whatever reason your organ donation isn’t accepted due to circumstances of your death, it’s good to have a back-up option or two. The site for tissue, eye and organ donation in Texas is Donate Life Texas: https://www.donatelifetexas.org/. Because there are so many factors that determine whether an organ or a body is able to be accepted, it is a good idea to have back-up options.

 

Body Donation Form

Whole body donation allows medical researchers and educators to use your body for scientific research. To do this, you must choose and authorize this option and have your  legal next of kin responsible for carrying out your wishes. If you’ve chosen to donate your body and if, for whatever reason your body donation isn’t accepted, it’s good to have a back-up option or two. Because there are so many factors that determine whether an organ or a body is able to be accepted, it is a good idea to have back-up options.

 

Will

This document specifies how your assets and liabilities will be distributed at the time of death. It names an Independent Executor and alternates to serve without bond and with minimal court supervision. Probate is the legal process of proving the will in court, settling the estate, and distributing the assets.

 

Living Trust

This is a trust created while you are alive. A living trust is another way of specifying how your assets and liabilities will be distributed at your death. A living trust also allows you to name someone to manage your financial affairs if you are incapacitated.

 

Statutory Durable Power of Attorney

This document gives an individual the authority to manage your financial affairs.  It can be effective only if you become disabled or incapacitated.

 

Designation of Guardian in the Event of Later Need

This document allows you to designate in advance who you would want for a guardian should you ever need one. It also allows you to disqualify certain individuals from ever becoming a guardian.

 

Declaration of Appointment of Guardian for My Child in the Event of My Death or Incapacity

This document allows you to appoint a guardian of your children in case you die or become incapacitated while they are minors. Usually parents designate the guardian to serve in the event of death in their Will. However, your Will takes effect only upon your death. This document is valuable because your preferred guardian can step in to serve if you become incapacitated but do not die.

 

Pet Directive

The document gives you a place to set down your wishes as well as list critical information regarding your pet's age, medical condition, medication, allergies, and other conditions, such as anxieties and fears.

 

Declaration of Mental Health Treatment

This document allows you to make decisions in advance about specifically three types of mental health treatment: psychoactive medication, convulsive therapy, and emergency mental health treatment. (Here is a link to Texas HHS’s version of the document).

 

Post Death Activities

 

Important Information to Have Handy:

• Birthdate

• Social Security Number

• Parents’ full legal names (including mother’s maiden name)

• Parents’ dates of birth

• Parents’ places of birth

• How long you have lived in the country

• Dates of marriage

• Dates of divorce

• Dates of military service

• Citizenship in other countries

 

Important Documents to Have Handy:

• Birth Certificates

• Death Certificates of Relatives

• Social Security Cards

• Driver’s License (in Texas you’re supposed to notify Texas DPS of a death)

• Citizenship or Naturalization Certificates

• Passports

• Marriage Certificates

• Divorce Decrees

• Wills/Trusts/Estate planning documents

• House deeds and mortgage documents, if applicable

• Car titles and lease or purchase docs, if applicable

• Any documents of ownership

• Life insurance policies

• All types of insurance policies (rental, auto, home, personal property, etc.)

• Retirement / Pension Accounts

• Credit card and/or installment statements

• Most recent utility bills

• Most recent billings from any type of service provider such as, utilities, internet, cell, newspaper/periodicals, storage, memberships, etc.

• Last seven years of income tax returns

 

Financial Accounts

Compile a list of bank accounts, financial institutions, types of account, account numbers, and make sure a Payable on Death (POD) person is noted. A POD is someone who can have access to the funds in your bank account after you die.

 

Email and Other Online Accounts

Pay special attention to online accounts that hold credit card and payment information. Have a place where passwords and other login information is kept, especially for email. A master password application works really well to unlock passwords and keep everything stored safely.

 

Social Media Digital Proxy

So many of us live our lives online these days, and our social media presence is a large part of how we present to the outside world.  It is important to take steps to secure all social media accounts by making sure passwords are shared with loved ones and specific directives are given to those who can post on our profiles after our death.
 

Electronics

How do we log on to our phones and computers? Fingerprint? Iris scan? Face recognition?  Make sure the password is shared.

 

Possessions 

The things we leave behind can take on a life of their own and have specific weight and meaning to our loved ones.  Clothes that still smell like a grandmother, the specific texture of mom’s favorite sweater can hold beautiful memories for our loved ones.  However, leaving our possessions behind for our loved ones to sift through can be complicated.  It could feel like an intrusion of privacy, or they are afraid of finding something they don’t want to find.  Family dynamics come into play, as loved ones cast lots for the valuable items.  While it may not be possible to find homes for all of our possessions before we die, it may be a good idea to have a gameplan.  A doula can help navigate this tricky arena.