Advance Care Planning

Tips from the National Institute on Aging

Advance care planning is not just about old 

age. At any age, a medical crisis could leave 

you too ill to make your own healthcare decisions. 

Even if you are not sick now, planning for 

health care in the future is an important step 

toward making sure you get the medical care 

you would want, if you are unable to speak for 

yourself and doctors and family members are 

making the decisions for you.

Many Americans face questions about medical 

treatment but may not be capable of making 

those decisions, for example, in an emergency or 

at the end of life. This tip sheet will explain the 

types of decisions that may need to be made in 

such cases and questions you can think about 

now so you’re prepared later. It can help you think 

about who you would want to make decisions 

for you if you can’t make them yourself. It will 

also discuss ways you can share your wishes with 

others. Knowing who you want to make decisions 

on your behalf and how you would decide might 

take some of the burden off family and friends. 

What Is Advance Care Planning?

Advance care planning involves learning about 

the types of decisions that might need to be 

made, considering those decisions ahead of 

time, and then letting others know—both your 

family and your healthcare providers—about 

your preferences. These preferences are often 

put into an advance directive, a legal document 

that goes into effect only if you are incapacitated 

and unable to speak for yourself. This could be 

the result of disease or severe injury—no matter 

how old you are. It helps others know what type 

of medical care you want.

An advance directive also allows you to express your 

values and desires related to end-of-life care. You 

might think of it as a living document—one that you 

can adjust as your situation changes because of new 

information or a change in your health.

Research shows that advance directives can 

make a difference, and that people who document their preferences in this way are more 

likely to get the care they prefer at the end of 

life than people who do not.

Decisions That Could Come Up

Sometimes decisions must be made about the 

use of emergency treatments to keep you alive. 

Doctors can use several artificial or mechanical 

ways to try to do this. Decisions that might 

come up at this time relate to:

• CPR (cardiopulmonary resuscitation)

• Ventilator use

• Artificial nutrition (tube feeding) and artificial

hydration (IV, or intravenous, fluids)

• Comfort care
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CPR. Cardiopulmonary resuscitation might 

restore your heartbeat if your heart stops or is in 

a life-threatening abnormal rhythm. It involves 

repeatedly pushing on the chest with force, while 

putting air into the lungs. This force has to be quite 

strong, and sometimes ribs are broken or a lung 

collapses. Electric shocks, known as defibrillation, 

and medicines might also be used as part of the 

process. The heart of a young, otherwise healthy 

person might resume beating normally after CPR. 

Often, CPR does not succeed in older adults 

who have multiple chronic illnesses or who are 

already frail.

Ventilator use. Ventilators are machines that 

help you breathe. A tube connected to the 

ventilator is put through the throat into the 

trachea (windpipe) so the machine can force 

air into the lungs. Putting the tube down the 

throat is called intubation. Because the tube 

is uncomfortable, medicines are often used to 

keep you sedated while on a ventilator. If you 

are expected to remain on a ventilator for a 

long time, a doctor may perform a tracheotomy 

or “trach” (rhymes with “make”). During this 

bedside surgery, the tube is inserted directly 

into the trachea through a hole in the neck. For 

long-term help with breathing, a trach is more 

comfortable, and sedation is not needed. People 

using such a breathing tube are not able to 

speak without special help because exhaled air 

does not go past their vocal cords. 

Artificial nutrition and hydration. If you are 

not able to eat, you may be fed through a feeding tube that is threaded through the nose down 

to your stomach. If tube feeding is still needed 

for an extended period, a feeding tube may be 

surgically inserted directly into your stomach. 

Hand feeding (sometimes called assisted oral 

feeding) is an alternative to tube feeding. This 

approach may have fewer risks, especially for 

people with dementia. 

If you are not able to drink, you may be provided 

with IV fluids. These are delivered through a 

thin plastic tube inserted into a vein.

Artificial nutrition and hydration can be 

helpful if you are recovering from an illness. 

However, studies have shown that artificial 

nutrition toward the end of life does not meaningfully prolong life. Artificial nutrition and 

hydration may also be harmful if the dying 

body cannot use the nutrition properly.

Comfort care. Comfort care is anything that 

can be done to soothe you and relieve suffering 

while staying in line with your wishes. Comfort 

care includes managing shortness of breath; 

limiting medical testing; providing spiritual 

and emotional counseling; and giving medication 

for pain, anxiety, nausea, or constipation.

Getting Started

Start by thinking about what kind of treatment you 

do or do not want in a medical emergency. It might 

help to talk with your doctor about how your 

current health conditions might influence your 

health in the future. For example, what decisions 

would you or your family face if your high blood 

pressure leads to a stroke? You can ask your doctor 

to help you understand and think through your 

choices before you put them in writing. Medicare 

or private health insurance may cover advance care 

planning discussions with your doctor.

If you don’t have any medical issues now, your 

family medical history might be a clue to help 

you think about the future. Talk with your 

doctor about decisions that might come up if 

you develop health problems similar to those 

of other family members.

In considering treatment decisions, your 

personal values are key. Is your main desire 

to have the most days of life? Or, would 

your focus be on quality of life, as you see it? 
TIPS FROM THE NATIONAL INSTITUTE ON AGING

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What Is Palliative Care? What Is Hospice Care?

Palliative care treats the symptoms of a serious illness, such as pain and discomfort. It is offered 

alongside medical treatment for the illness itself (for example, chemotherapy for cancer or 

dialysis for kidney failure). In addition to helping with symptoms, palliative care can help patients 

understand their choices for medical treatment. The organized services available through 

palliative care may be helpful to any older person having a lot of general discomfort and 

disability with serious illness. 

Hospice care is comfort care and support that is provided after attempts to cure or treat an illness 

have stopped. It may be offered in the home, a hospice facility, a skilled nursing facility, or a 

hospital. A team of healthcare providers works together to provide the care and support. The goal 

is to ensure the best quality of life in a patient’s final days, weeks, or months. After death, the 

hospice team continues to offer support to the family. 

Hospice and palliative care are not the same thing, but both have the same goal: to keep you 

comfortable. If you are receiving hospice care, you can choose to move back to curative care if 

you decide to pursue treatments to cure your illness. 

For more information, see the NIA booklet End of Life: Helping with Comfort and Care.

What if an illness leaves you paralyzed or in 

a permanent coma and you need to be on a 

ventilator? Would you want that?

What makes life meaningful to you? If your 

heart stops or you have trouble breathing, would 

you want to undergo life-saving measures if 

it meant that, in the future, you could be well 

enough to spend time with your family? Would 

you be content if the emergency left you simply 

able to spend your days listening to books on 

tape or gazing out the window?

But, there are many other scenarios. Here are a 

few. What would you decide?

• If a stroke leaves you unable to move and 

then your heart stops, would you want CPR? 

What if you were also mentally impaired by a 

stroke—does your decision change? 

• What if you are in pain at the end of life? 

Do you want medication to treat the pain, 

even if it will make you more drowsy and 

lethargic?

• What if you are permanently unconscious 

and then develop pneumonia? Would 

you want antibiotics and to be placed on a 

ventilator?

For some people, staying alive as long as medically 

possible, or long enough to see an important event 

like a grandchild’s wedding, is the most important 

thing. An advance directive can help to make that 

possible. Others have a clear idea about when 

they would no longer want to prolong their life. 

An advance directive can help with that, too. 

Your decisions about how to handle any of these 

situations could be different at age 40 than at 

age 85. Or, they could be different if you have an 

incurable condition as opposed to being generally 

healthy. An advance directive allows you to provide 

instructions for these types of situations and then 

to change the instructions as you get older or if 

your viewpoint changes. 
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Making Your Wishes Known

There are two main elements in an advance 

directive—a living will and a durable power of 

attorney for health care. There are also other 

documents that can supplement your advance 

directive. You can choose which documents to 

create, depending on how you want decisions 

to be made.

Living will. A living will is a written document 

that helps you tell doctors how you want to be 

treated if you are dying or permanently unconscious and cannot make your own decisions 

about emergency treatment. In a living will, 

you can say which of the procedures described 

above you would want, which ones you wouldn’t 

want, and under which conditions each of your 

choices applies.

Durable power of attorney for health care.

A durable power of attorney for health care 

is a legal document naming a healthcare proxy, 

someone to make medical decisions for you at 

times when you are unable to do so. Your proxy, 

also known as a representative, surrogate, or agent, 

should be familiar with your values and wishes. 

This means that he or she will be able to decide 

as you would when treatment decisions need 

to be made. A proxy can be chosen in addition to 

or instead of a living will. Having a healthcare 

proxy helps you plan for situations that cannot 

be foreseen, like a serious auto accident.

Some people are reluctant to put specific health 

decisions in writing. For them, naming a healthcare 

proxy might be a good approach, especially if there 

is someone they feel comfortable talking with 

about their values and preferences. A named 

proxy can evaluate each situation or treatment 

option independently.

Other advance care planning documents.

You might also want to prepare documents 

to express your wishes about a single medical 

issue or something not already covered in your 

advance directive. A living will usually covers 

only the specific life-sustaining treatments 

discussed earlier. You might want to give your 

healthcare proxy specific instructions about 

other issues, such as blood transfusion or 

kidney dialysis. This is especially important 

if your doctor suggests that, given your health 

condition, such treatments might be needed in 

the future.

Medical issues that might arise at the end of 

life include DNR orders, organ and tissue 

donation, and POLST or MOLST forms.

A DNR (do not resuscitate) order tells medical 

staff in a hospital or nursing facility that you 

do not want them to try to return your heart 

to a normal rhythm if it stops or is beating 

unsustainably using CPR or other life-support 

measures. Sometimes this document is referred 

to as a DNAR (do not attempt resuscitation) 

or an AND (allow natural death) order. Even 

though a living will might say CPR is not wanted, 

it is helpful to have a DNR order as part of your 

medical file if you go to a hospital. Posting a 

DNR next to your bed might avoid confusion in 

an emergency situation. Without a DNR order, 

medical staff will make every effort to restore your 

breathing and the normal rhythm of your heart. 

A similar document, called a DNI (do not 

intubate) order, tells medical staff in a hospital 

or nursing facility that you do not want to be 

put on a breathing machine.

A non-hospital DNR order will alert emergency 

medical personnel to your wishes regarding 

measures to restore your heartbeat or breathing 

if you are not in the hospital. 

Organ and tissue donation allows organs or 

body parts from a generally healthy person 

who has died to be transplanted into people 

who need them. Commonly, the heart, lungs, 
TIPS FROM THE NATIONAL INSTITUTE ON AGING

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pancreas, kidneys, corneas, liver, and skin are 

donated. There is no age limit for organ and 

tissue donation. You can carry a donation card 

in your wallet. Some states allow you to add 

this decision to your driver’s license. Some 

people also include organ donation in their 

advance care planning documents. 

At the time of death, family members may be 

asked about organ donation. If those close to 

you, especially your proxy, know how you feel 

about organ donation, they will be ready to 

respond. There is no cost to the donor’s family 

for this gift of life. If the person has requested a 

DNR order but wants to donate organs, he or she 

might have to indicate that the desire to donate 

supersedes the DNR. That is because it might 

be necessary to use machines to keep the heart 

beating until the medical staff is ready to remove 

the donated organs. See For More Information

for resources about organ and tissue donation.

POLST and MOLST forms provide guidance 

about your medical care preferences in the form 

of a doctor’s orders. Typically, you create a POLST 

(Physician Orders for Life-Sustaining Treatment) 

or MOLST (Medical Orders for Life-Sustaining 

Treatment) when you are near the end of life or 

critically ill and know the specific decisions that 

might need to be made on your behalf. These 

forms serve as a medical order in addition to your 

advance directive. They make it possible for you to 

provide guidance that healthcare professionals can 

act on immediately in an emergency. 

A number of states use POLST and MOLST 

forms, which are filled out by your doctor or 

sometimes by a nurse practitioner or physician’s 

assistant. The doctor fills out a POLST or MOLST 

after discussing your wishes with you and your 

family. Once signed by your doctor, this form has 

the same authority as any other medical order. 

Check with your state department of health to 

find out if these forms are available where you live.

What About Pacemakers 

and ICDs?

Some people have pacemakers to help 

their hearts beat regularly. If you have one 

and are near death, it may not necessarily 

keep you alive. But, you might have an 

ICD (implantable cardioverter-defibrillator) 

placed under your skin to shock your heart 

back into regular beatings if the rhythm 

becomes irregular. If you decline other 

life-sustaining measures, the ICD may 

be turned off. You need to state in your 

advance directive what you want done if 

the doctor suggests it is time to turn it off.

Selecting Your Healthcare Proxy

If you decide to choose a proxy, think about people 

you know who share your views and values about 

life and medical decisions. Your proxy might be a 

family member, a friend, your lawyer, or someone 

in your social or spiritual community. It’s a good 

idea to also name an alternate proxy. It is especially 

important to have a detailed living will if you 

choose not to name a proxy.

You can decide how much authority your proxy 

has over your medical care—whether he or she 

is entitled to make a wide range of decisions or 

only a few specific ones. Try not to include guidelines that make it impossible for the proxy to 

fulfill his or her duties. For example, it’s probably 

not unusual for someone to say in conversation, 

“I don’t want to go to a nursing home,” but think 

carefully about whether you want a restriction 

like that in your advance directive. Sometimes, for 

financial or medical reasons, that may be the best 

choice for you.

Of course, check with those you choose as your 

healthcare proxy and alternate before you name 

them officially. Make sure they are comfortable 

with this responsibility.
ADVANCE CARE PLANNING

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Making It Official

Once you have talked with your doctor and have 

an idea of the types of decisions that could come 

up in the future and whom you would like as a 

proxy, if you want one at all, the next step is to fill 

out the legal forms detailing your wishes. A lawyer 

can help but is not required. If you decide to use 

a lawyer, don’t depend on him or her to help you 

understand different medical treatments. Start the 

planning process by talking with your doctor.

Many states have their own advance directive 

forms. Your local Area Agency on Aging can 

help you locate the right forms. You can find 

your area agency phone number by calling the 

Eldercare Locator toll-free at 1-800-677-1116 

or going online at www.eldercare.gov.

Some states require your advance directive 

to be witnessed; a few require your signature 

to be notarized. A notary is a person licensed 

by the state to witness signatures. You might 

find a notary at your bank, post office, or local 

library, or call your insurance agent. Some 

notaries charge a fee.

Some states have registries that can store your 

advance directive for quick access by healthcare providers, your proxy, and anyone else 

to whom you have given permission. Private 

firms also will store your advance directive. 

There may be a fee for storing your form in a 

registry. If you store your advance directive in 

a registry and later make changes, you must 

replace the original with the updated version 

in the registry. 

Some people spend a lot of time in more than 

one state—for example, visiting children and 

grandchildren. If that’s your situation, consider 

preparing an advance directive using forms 

for each state—and keeping a copy in each 

place, too.

After You Set Up Your Advance 

Directive

Give copies of your advance directive to your 

healthcare proxy and alternate proxy. Give 

your doctor a copy for your medical records. 

Tell close family members and friends where 

you keep a copy. If you have to go to the 

hospital, give staff there a copy to include in 

your records. Because you might change your 

advance directive in the future, it’s a good idea 

to keep track of who receives a copy.

Talking About Your Wishes

It can be helpful to have conversations with the people close to you about how you want to be 

cared for in a medical emergency or at the end of life. These talks can help you think through the 

wishes you want to put in your advance directive.

It’s especially helpful to talk about your thoughts, beliefs, and values with your healthcare proxy. 

This will help prepare him or her to make medical decisions that best reflect your values.

After you have completed your advance directive, talk about your decisions with your healthcare 

proxy, loved ones, and your doctor to explain what you have decided. This way, they are not 

surprised by your wishes if there is an emergency. 

Another way to convey your wishes is to make a video of yourself talking about them. This lets 

you express your wishes in your own words. Videos do not replace an advance directive, but they 

can be helpful for your healthcare proxy and your loved ones.
TIPS FROM THE NATIONAL INSTITUTE ON AGING

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Review your advance care planning decisions 

from time to time—for example, every 10 years, 

if not more often. You might want to revise 

your preferences for care if your situation or your 

health changes. Or, you might want to make 

adjustments if you receive a serious diagnosis; if 

you get married, separated, or divorced; if your 

spouse dies; or if something happens to your 

proxy or alternate. If your preferences change, you 

will want to make sure your doctor, proxy, and 

family know about them.

Be Prepared

What happens if you have no advance directive 

or have made no plans and you become unable to 

speak for yourself? In such cases, the state where 

you live will assign someone to make medical 

decisions on your behalf. This will probably be 

your spouse, your parents if they are available, or 

your children if they are adults. If you have no 

family members, the state will choose someone to 

represent your best interests.

Always remember: an advance directive 

is only used if you are in danger of dying 

and need certain emergency or special 

measures to keep you alive, but you are not 

able to make those decisions on your own. An 

advance directive allows you to make your 

wishes about medical treatment known.

It is difficult to predict the future with certainty. 

You may never face a medical situation where you 

are unable to speak for yourself and make your 

wishes known. But having an advance directive 

may give you and those close to you some peace 

of mind.

Advance Directive Wallet Card

You might want to make a card to carry in your wallet indicating that you have an advance 

directive and where it is kept. Here is an example of a wallet card offered by the American 

Hospital Association. You might want to make a copy or cut this one out to fill out and carry 

with you. It can also be found online at www.aha.org/2017-12-11-put-it-writing.

I have talked with my family and my doctor about the care 

I want. If I am unable to speak for myself, please contact:

Name Number

Signature

NOTIFIC A TIO N

Print name

I have a health care power of attorney I have an advance directive

(Additional names on back)

Name Number

Name Number

For more information visit:

www.aha.org/putitinwriting

Name Number

Your life.Your terms.

✃
ADVANCE CARE PLANNING

For More Information

Aging with Dignity

1-850-681-2010 

fivewishes@agingwithdignity.org

www.agingwithdignity.org

American Bar Association

1-800-285-2221 (toll-free)

aging@americanbar.org

www.americanbar.org

CaringInfo

National Hospice and Palliative Care 

Organization

1-800-658-8898 (toll-free)

caringinfo@nhpco.org

www.caringinfo.org

Center for Practical Bioethics

1-800-344-3829 (toll-free)

center@centerforbioethics.org

www.practicalbioethics.org

Donate Life America

1-804-377-3580

donatelifeamerica@donatelife.net

www.donatelife.net

The Living Bank

1-800-528-2971 (toll-free)

info@livingbank.org

www.livingbank.org

National Academy of Elder Law Attorneys

1-703-942-5711

naela@naela.org

www.naela.org

National POLST Paradigm

1-202-780-8352

info@polst.org

www.polst.org

OrganDonor.gov

Health Resources & Services Administration

www.organdonor.gov

Put It In Writing

American Hospital Association

1-800-424-4301 (toll-free)

www.aha.org/contactAHA

www.putitinwriting.org

For more information about health and aging, contact:

National Institute on Aging Information Center

1-800-222-2225 (toll-free) • 1-800-222-4225 (TTY/toll-free)

niaic@nia.nih.gov • www.nia.nih.gov

Visit www.nia.nih.gov/health to find more health and aging information from NIA and subscribe to email alerts. 

Visit https://order.nia.nih.gov to order free print publications.

JANUARY 2018

NIH PUBLICATION NO. 18-AG-8039