Types of Advance Directives

Why This Matters

Advance directives sit at the intersection of patient autonomy, informed consent, and legal documentation—three pillars you'll see tested repeatedly in healthcare law. These documents don't just express preferences; they create legally binding instructions that healthcare providers must follow, raising critical questions about capacity, agency authority, scope of treatment, and state law variations. Understanding how each directive functions helps you analyze scenarios where patient wishes, family desires, and medical recommendations may conflict.

You're being tested on more than definitions here. Exam questions will ask you to distinguish between documents that express wishes versus those that create actionable medical orders, identify who has authority to make decisions and when, and recognize which directives apply in specific clinical situations. Don't just memorize what each document is—know what legal principle each one demonstrates and how they work together in real healthcare settings.

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Documents That Express Wishes

These directives communicate an individual's preferences but require interpretation or activation by others before they affect care. They establish intent and guide decision-makers but don't function as direct medical orders.

Living Will

• Specifies end-of-life treatment preferences—addresses decisions about ventilators, feeding tubes, dialysis, and other life-sustaining interventions when the patient cannot communicate
• Requires proper execution under state law, including signatures, witnesses, and sometimes notarization to be legally valid
• Only activates under specific conditions—typically when the patient is terminally ill, permanently unconscious, or otherwise meets state-defined triggering criteria

Organ and Tissue Donation Directive

• Documents anatomical gift intentions—expresses the individual's wish to donate organs, tissues, or their entire body after death
• Can be standalone or integrated into a living will, driver's license designation, or state donor registry enrollment
• Creates a legally binding gift under the Uniform Anatomical Gift Act—in most states, family members cannot override a documented donation decision

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Documents That Delegate Authority

These directives transfer decision-making power to another person, creating an agency relationship with specific legal obligations. The focus shifts from what the patient wants to who decides when the patient cannot.

Healthcare Power of Attorney

• Designates a surrogate decision-maker (called an agent, proxy, or healthcare representative) who gains authority when the patient loses capacity
• Scope can be customized—the principal can grant broad authority over all medical decisions or limit the agent's power to specific situations
• Agent must follow substituted judgment standard—deciding as the patient would have decided, not based on the agent's own preferences

Mental Health Advance Directive

• Addresses psychiatric treatment specifically—allows individuals to document preferences for medications, hospitalization, ECT, and other mental health interventions during a crisis
• Can appoint a separate mental health proxy—this agent may be different from a general healthcare agent, recognizing that mental health decisions require specialized understanding
• Overcomes capacity challenges unique to psychiatric conditions—provides guidance when the patient's mental illness itself impairs their ability to make treatment decisions

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Documents That Create Medical Orders

These directives go beyond expressing preferences—they translate patient wishes into actionable physician orders that healthcare providers follow directly. They carry the weight of medical orders, not just patient statements.

Do Not Resuscitate (DNR) Order

• Physician order prohibiting CPR—instructs providers not to perform chest compressions, defibrillation, intubation, or cardiac medications if the patient arrests
• Must be signed by a licensed physician and documented in the medical record; patient or surrogate consent is required but the order itself is a medical document
• Narrow scope by design—affects only resuscitation efforts and does not limit other treatments like antibiotics, surgery, or pain management

Physician Orders for Life-Sustaining Treatment (POLST)

• Converts patient preferences into portable medical orders—covers resuscitation status, level of medical intervention, and artificial nutrition decisions in one standardized form
• Designed for seriously ill patients—appropriate when death within one year would not be surprising, not for healthy individuals planning ahead
• Follows the patient across care settings—recognized by EMS, hospitals, nursing homes, and hospice, unlike facility-specific orders

Medical Orders for Scope of Treatment (MOST)

• Regional variation of POLST—functions identically but uses different terminology in certain states (some jurisdictions use MOLST, POST, or other acronyms)
• Addresses broader scope than DNR alone—includes preferences about hospitalization, ICU transfer, and intensity of treatment beyond just resuscitation
• Requires healthcare provider signature—like POLST, this is a medical order that must be signed by a physician, nurse practitioner, or physician assistant depending on state law

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Quick Reference Table

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Self-Check Questions

1. A patient has both a living will and a healthcare power of attorney. The living will says "no ventilator," but the designated agent requests intubation. Which document controls, and why?

2. Which two advance directives require a physician's signature to be valid, and what does this requirement tell you about their legal function?

3. Compare and contrast a DNR order and a POLST form. In what clinical scenario would a POLST provide guidance that a DNR alone could not?

4. A patient with bipolar disorder wants to ensure their treatment preferences are followed during a manic episode when they may refuse all care. Which advance directive best addresses this situation, and what makes it different from a standard healthcare power of attorney?

5. An FRQ describes a seriously ill patient being transferred from a hospital to a nursing home. Which advance directive is specifically designed to ensure their treatment preferences are honored across this transition, and what execution requirements must be met?