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 someone too ill to make his or her 

own healthcare decisions. Even if you are 

not sick now, making healthcare plans for 

the future is an important step toward 

making sure you get the medical care you 

would want, even when doctors and family 

members are making the decisions for you.

More than one out of four older Americans 

face questions about medical treatment 

near the end of life but are not capable of 

making those decisions. This tip sheet 

will discuss some questions you can think 

about now and describe ways to share your 

wishes with others. Write them down or at 

least talk about them with someone who 

would make the decisions for you. Knowing 

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 

about your preferences, often by putting 

them into an advance directive. An advance 

directive is 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. 

Medical Research and Advance Care Planning

Medical research plays an important role in the health of Americans of all ages. Because 

of advances in medicine and in public health, Americans are living longer and staying 

healthier as they grow older. The National Institute on Aging (NIA) supports much of 

the research around the country that looks at how people age and how to improve their 

health in their later years. NIA is part of the National Institutes of Health (NIH), the 

nation’s medical research agency. 

Some NIA-supported research focuses on advance care planning, including examining 

why people might complete advance directives and the effect of these directives on 

end-of-life care. In one study, for example, scientists funded by NIA found 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.
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It also allows you to express your values 

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

might think of an advance directive as a 

living document—one that you can adjust 

as your situation changes because of new 

information or a change in your health. 

Decisions That Could Come Up 

Near Death

Sometimes when doctors believe a cure is 

no longer possible and you are dying, 

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) or 

artificial hydration (intravenous fluids) 

• comfort care

CPR. CPR (cardiopulmonary resuscitation) 

might restore your heartbeat if your heart 

stops or is in a life-threatening abnormal 

rhythm. The heart of a young, otherwise 

healthy person might resume beating 

normally after CPR. An otherwise healthy 

older person, whose heart is beating 

erratically or not beating at all, might also 

be helped by CPR. CPR is less likely to 

work for an older person who is ill, can’t 

be successfully treated, and is already close 

to death. 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.

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 

used to keep you sedated (unconscious) 

while on a ventilator. If you can’t breathe 

on your own after a few days, 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 aren’t 

able to speak without special help because 

exhaled air goes out of the trach rather than 

past their vocal cords. 

Artificial nutrition or artificial hydration.

A feeding tube and/or intravenous (IV) 

liquids are sometimes used to provide 

nutrition when a person is not able to eat 

or drink. These measures can be helpful if 

you are recovering from an illness. However, 

if you are near death, these could actually 

make you more uncomfortable. For example, 

IV liquids, which are given through a plastic 

tube put into a vein, can increase the burden 

on failing kidneys. Or if the body is shutting 

down near death, it is not able to digest food 

properly, even when provided through a 

feeding tube. At first, the feeding tube is 

threaded through the nose down to the 

stomach. In time, if tube feeding is still 

needed, the tube is surgically inserted into 

the stomach.

Comfort care. Comfort care is anything 

that can be done to soothe you and relieve 

suffering while staying in line with your 
TIPS FROM THE NATIONAL INSTITUTE ON AGING

3

wishes. Comfort care includes managing 

shortness of breath; offering ice chips for 

dry mouth; limiting medical testing; 

providing spiritual and emotional 

counseling; and giving medication for 

pain, anxiety, nausea, or constipation. 

Often this is done through hospice, which 

may be offered in the home, in a hospice 

facility, in a skilled nursing facility, or in a 

hospital. With hospice, a team of healthcare 

providers works together to provide the 

best possible quality of life in a patient’s 

final days, weeks, or months. After death, 

the hospice team continues to offer 

support to the family.

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 present 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?

If you don’t have any medical issues now, 

your family medical history might be a 

clue to thinking about the future. Talk to 

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 to 

have the most life in your days? 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? You 

might want doctors to try CPR if your 

heart stops or to try using a ventilator 

for a short time if you’ve had trouble 

breathing, if that means that, in the future, 

you could be well enough to spend time 

with your family. Even if the emergency 

leaves you simply able to spend your 

days listening to books on tape or gazing 

out the window watching the birds and 

squirrels compete for seeds in the bird 

feeder, you might be content with that.

But, there are many other scenarios. Here 

are a few. What would you decide?

• If a stroke leaves you paralyzed 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 develop dementia, don’t 

recognize family and friends, and, in time, 

cannot feed yourself? Would you want a 

feeding tube used to give you nutrition?

What Is Hospice Care? 

What Is Palliative Care?

Hospice care is intended to provide 

comfort to you and your family during 

a life-threatening illness, rather than 

provide treatments to cure the illness. 

Palliative care is similar to comfort care 

in hospice, but it is offered along with 

any medical treatments you might be 

receiving for a life-threatening illness, 

such as chemotherapy for cancer or 

dialysis for kidney failure. The main 

goal of both hospice and palliative care 

is to keep you comfortable. In addition, 

you can always choose to move from 

hospice to palliative care if you want to 

pursue treatments to cure your illness.
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4

• What if you are permanently unconscious and then develop pneumonia? 

Would you want antibiotics and a ventilator used?

For some people, staying alive as long as 

medically possible is the most important 

thing. An advance directive can help make 

sure that happens. 

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. 

Making Your Wishes Known

There are two 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 or stand alone. You can 

choose which documents to create, depending on how you want decisions to be made. 

These documents include:

• living will

• durable power of attorney for health care

• other documents discussing DNR (do 

not resuscitate) orders, organ and tissue 

donation, dialysis, and blood transfusions

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 

decisions about emergency treatment. In a 

living will, you can say which of the procedures described on page 2 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 might 

not be able to do so. Your proxy, also 

known as a 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.

A durable power of attorney for health care 

enables you to be more specific about your 

medical treatment than a living will.

Some people are reluctant to put specific 

health decisions in writing. For them, 

naming a healthcare agent might be a 

good approach, especially if there is someone they feel comfortable talking with 

about their values and preferences.

Other advance care planning documents. You might also want to prepare 

separate 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 lifesustaining 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.
TIPS FROM THE NATIONAL INSTITUTE ON AGING

5

Two medical issues that might arise at the 

end of life are DNR orders and organ and 

tissue donation.

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 unevenly. 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 the normal 

rhythm of your heart. A non-hospital DNR

will alert emergency medical personnel 

to your wishes regarding CPR and other 

measures to restore your heartbeat if you 

are not in the hospital. A similar document 

that is less familiar is called a DNI (do not 

intubate) order. A DNI tells medical staff 

in a hospital or nursing facility that you do 

not want to be put on a breathing machine.

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, 

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 

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. See For More 

Information for resources about organ and 

tissue donation.

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 

with whom you worship. 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. 

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 other life-sustaining measures are not used, the ICD may also 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.
ADVANCE CARE PLANNING

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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. 

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. That’s why you 

should 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 want your advance directive 

to be witnessed; some want your signature 

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 people spend a lot of time in more 

than one state—for example, visiting 

children and grandchildren. If that’s 

your situation also, you might consider 

preparing an advance directive using 

forms for each state—and keep a copy 

in each place, too.

After You Set Up Your Advance 

Directive

There are key people who should be told 

that you have an advance directive. Give 

copies to your healthcare proxy and 

alternate proxy. Give your doctor a copy 

for your medical records. Tell key 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.

Review your advance care planning decisions from time to time—for example, every 

10 years, if not more often. You might 

Future Directions

A number of states are developing 

or starting to use an advance care 

planning form known as POLST 

(Physician Orders for Life-Sustaining 

Treatment) or MOLST (Medical Orders 

for Life-Sustaining Treatment). These 

forms serve in addition to your advance 

directive. They make it possible for you 

to provide more detailed guidance about 

your medical care preferences. Your 

doctor will talk with you and/or your 

family for guidance, but the form is 

filled out by the doctor or, sometimes, 

a nurse practitioner or physician’s 

assistant. Once signed by your doctor, 

this form has the force of any other 

medical order. These forms are often 

printed on brightly colored paper so 

they are easily found in a medical or 

hospital file. Check with your state 

department of health to find out if this 

form is available where you live.
TIPS FROM THE NATIONAL INSTITUTE ON AGING

7

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 are not 

able to make those decisions on your 

own. An advance directive allows you 

to continue to make your wishes about 

medical treatment known.

Looking Toward the Future

Nobody can predict the future. 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.

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.

Still Not Sure?

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 

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 a slightly revised example of the wallet 

card offered by the Office of the Attorney General in Maryland. It uses the phrase 

“healthcare agent” instead of “healthcare proxy.” 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.oag.state.

md.us/Healthpol/adDir_cards.pdf. ✃
ADVANCE CARE PLANNING

For More Information

Other federal and non-federal resources 

with information about advance directives 

include:

Caring Connections 

National Hospice and Palliative 

Care Organization

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

1-877-658-8896 (toll-free/multilingual)

www.caringinfo.org

Caring Conversations 

Center for Practical Bioethics

Harzfeld Building

1111 Main Street, Suite 500

Kansas City, MO 64105-2116

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

www.practicalbioethics.org

American Bar Association

321 North Clark Street

Chicago, IL 60654

1-800-285-2221

www.americanbar.org 

(search for “Consumer’s Tool Kit for 

Health Care Advance Planning”)

Donate Life America

701 East Byrd Street, 16th floor

Richmond, VA 23219

1-804-377-3580

www.donatelife.net

National Legal Resource Center

www.nlrc.aoa.gov

OrganDonor.gov 

Health Resources and Services 

Administration

1-888-275-4772 (toll-free)

www.organdonor.gov

POLST (Physician Orders for 

Life-Sustaining Treatment)

www.polst.org

Put It In Writing

American Hospital Association

155 North Wacker Drive

Chicago, IL 60606

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

www.putitinwriting.org

The Living Bank

P.O. Box 6725

Houston, TX 77265

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

www.livingbank.org

To order free publications (in English or Spanish) or sign up for email alerts, go to:

www.nia.nih.gov/health

Visit www.nihseniorhealth.gov, a senior-friendly website from the National Institute on Aging 

and the National Library of Medicine. This website has health and wellness information for older adults. 

Special features make it simple to use. For example, you can click on a button to make the type larger.

For more information about health and aging, contact:

National Institute on Aging Information Center

P.O. Box 8057 • Gaithersburg, MD 20898-8057

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

www.nia.nih.gov • www.nia.nih.gov/espanol

FEBRUARY 2012

REPRINTED MARCH 2014