You've received an advance directive to review, or you've been asked to sign one, or someone in your family has one and you're trying to understand what it means. These documents make decisions about your medical care when you can't make them yourself — and getting them right matters more than most people realize.
The Document Landscape: Four Different Things
People use these terms interchangeably, but they're not the same document:
Advance Directive
"Advance directive" is an umbrella term covering any legal document that expresses your healthcare wishes in advance. A living will and a healthcare proxy designation are both types of advance directives.
Living Will
A living will specifies the types of medical treatment you do or don't want if you're incapacitated and unable to communicate. It speaks directly to doctors and hospitals about your treatment preferences — not to a designated person.
Common instructions in a living will:
- Whether you want CPR if your heart stops
- Whether you want mechanical ventilation if you cannot breathe on your own
- Whether you want artificial nutrition (feeding tube) or hydration
- Whether you want dialysis
- Whether you want antibiotics and other life-prolonging medications
- Comfort care (palliative care) preferences
A living will is most relevant when you are in a terminal condition, a persistent vegetative state, or an end-stage condition — the specific legal trigger varies by state. It does not apply to most medical situations.
Healthcare Proxy / Medical Power of Attorney (MPOA)
A healthcare proxy (also called a medical power of attorney, durable power of attorney for healthcare, or healthcare agent) designates a specific person to make medical decisions on your behalf when you cannot make them yourself.
This is more flexible and more powerful than a living will alone. Your agent:
- Can respond to real-time medical situations a living will can't anticipate
- Can communicate with doctors, review your medical records, consent to or refuse treatment
- Can navigate situations where your living will language is unclear or ambiguous
The authority is typically springing — meaning it takes effect only when you become incapacitated (as certified by one or more physicians), not before. Your agent has no authority while you're capable of making your own decisions.
POLST (Physician Orders for Life-Sustaining Treatment)
A POLST is not a patient-generated document — it is a medical order signed by a physician based on your expressed wishes. It is bright pink (in most states) and travels with you in medical settings.
Unlike a living will, a POLST is immediately actionable by emergency responders and medical staff. Paramedics can follow a POLST; they cannot read and interpret a living will in an emergency.
A POLST is typically used by:
- Patients with a serious illness or advanced age
- People in nursing facilities or receiving home health care
- Anyone who wants immediate clarity on resuscitation and hospitalization wishes
DNR (Do Not Resuscitate) Order
A DNR is a specific type of medical order (like a POLST) instructing medical personnel not to perform CPR. A DNR in a hospital is an in-hospital order. A POLST that includes a DNR preference applies outside the hospital as well.
A DNR in your living will is not the same as a medical order. Emergency responders follow physician orders, not self-generated documents.
What a Healthcare Proxy Can and Cannot Do
Can Do:
- Consent to surgery, procedures, and treatments
- Refuse treatments (including life-sustaining treatment) based on your expressed wishes or best interests
- Access your medical records
- Speak with your care team on your behalf
- Make decisions in situations your living will doesn't address
Cannot Do (absent your specific authorization):
- Authorize psychiatric treatment (in most states)
- Authorize sterilization
- Override your clearly expressed prior wishes
- Make decisions while you're still capable (the authority springs only upon incapacity)
- Act outside the scope of healthcare decisions (they can't manage your finances under a healthcare proxy — that requires a separate financial POA)
Choosing Your Agent
Choose someone who:
- Is emotionally able to make difficult decisions under pressure
- Understands your values and wishes (have the conversation explicitly)
- Is geographically available or can get to where you are
- Will advocate for your wishes, not their own
- You trust completely
Name an alternate agent in case your primary agent is unavailable, unwilling, or has predeceased you.
Specific Instructions You Can Include
The more specific your living will, the less ambiguity your family and doctors face. Consider including instructions about:
- CPR: Do you want it attempted? CPR has a significantly lower success rate than portrayed on television, particularly for patients with serious underlying illness.
- Mechanical ventilation: Do you want a breathing machine used short-term (for recovery), long-term, or not at all?
- Artificial nutrition and hydration: Feeding tube for a defined period? Indefinitely? Not at all?
- Dialysis: Do you want kidney dialysis if your kidneys fail?
- Hospital transfer: If you're in a nursing facility, do you want to be transferred to a hospital, or prefer comfort care in place?
- Organ and tissue donation: Express your wishes here as well — this often requires a separate form but can be noted
- Pain management: Even if you decline life-prolonging treatment, you can request aggressive pain and comfort management
How to Make It Legally Valid
Execution requirements vary by state, but most states require:
- Your signature (or your direction to another person to sign if you cannot)
- Two adult witnesses who are not your healthcare agent, not related to you by blood or marriage, not your healthcare provider, and not entitled to inherit from you
- Notarization: Some states require notarization instead of or in addition to witnesses; others make it optional
If your document is not properly executed under your state's law, it may not be legally effective when you need it. Use your state's official form — available through your state's health department, bar association, or hospital system — to ensure compliance.
What Happens If You Don't Have One
If you are incapacitated with no advance directive:
- Doctors make decisions based on clinical judgment and what they believe is in your best interest
- Family conflict is common — different family members may have different views about what you would want, and hospitals may not know whose wishes to follow
- Courts may intervene through guardianship or conservatorship proceedings in disputed cases
- Default is typically toward life-sustaining treatment — hospitals err on the side of intervention when there is no documented patient preference
- Your wishes may not be honored — what you told family members verbally carries no legal weight in most states
How to Update or Revoke
You can revoke an advance directive at any time while you have decision-making capacity:
- Destroy all copies of the document physically
- Create a new advance directive that explicitly states it supersedes previous ones (date it)
- Inform your healthcare agent, family members, and doctors of the revocation
- If the document was filed with a hospital or registry, notify them as well
Update your documents when your health status changes significantly, you change your mind about treatment preferences, you change your healthcare agent, or when you move to a different state (advance directives executed in one state are generally recognized by other states, but using your current state's form avoids any ambiguity).
Got an advance directive, living will, or healthcare power of attorney you're trying to understand? Upload it to PaperLens for a plain-English explanation of what each section authorizes and requires. Scan your document →