5 Steps to Advance Care Planning

Completing Advance Care Planning is easier than you think.  Following these 5 simple steps.

1. A CONVERSATION

It starts with a conversation, talking about what you want at the end of your life.  These are the conversations you have with yourself, your family or your close friends, often after you’ve heard about or witnessed another person’s end-of-life experience.  Before you do anything else, have conversations to help you better understand what it is you want.  

2. DECISIONS

The first decision is, who will be your Healthcare Agent. This is the person you want to make healthcare decisions for you if you’re ever not able to make them for yourself. Next is a group of decisions around the kind of care you want when your end of life is near.  Caring Conversations, Five Wishes and Prepare for your care are helpful tools.

3. LEGAL DOCUMENTS

The primary document that needs to be completed includes:  

  • Durable Power of Attorney for Healthcare – in this document you name your Healthcare Agent.
  • Healthcare Directive – in this document you indicate what kinds of medical care you do and don’t want at the end of your life. 

This document requires nonrelative witnesses, and it needs to be notarized.

  • HIPAA Authorization – allows your doctor to share information with designated people.
  • Outside the Hospital DNR, TPOPP, POLST – for terminally ill patients, this document requires a doctor’s signature.
  • Body Disposition – designates the person who can make decisions about a person’s remains after death.

Financial Documents

  • Durable Power of Attorney for Finances
  • Will or Trust

4. COMMUNICATION

Once the legal documents are complete, the next step is to communicate that they exist and what’s in them to the people who matter most. Share copies of these documents with your family, physicians, lawyer, and other people who should know your wishes.

5. LIFE CIRCUMSTANCES CHANGE

Since we are all growing older and life happens, there may be several times that we change how we feel about the kind of care we want.  When this happens, it’s time to review your choices and see if they still reflect your wishes. At the very least, review your documents and refresh those conversations routinely.

Advance Care Planning Resources

The Conversation Project Starter Kit theconversationproject.org/get-started

Common Practice commonpractice.com/hello 

Caring Conversations practicalbioethics.org/resources/caring-conversations

Five Wishes fivewishes.org/five-wishes/individuals-families/individuals-and-families

Prepare for your care prepareforyourcare.org/welcome

Missouri Bar Durable Power of Attorney for Healthcare and Healthcare Directive missourilawyershelp.org/wp-content/uploads/2020/02/final-dpa-forms-fillable-2.pdf 

Missouri HIPAA Authorization missourilawyershelp.org/wp-content/uploads/2020/02/final-hipaa-fillable-revised-mary.pdf 

Gateway End-of-Life Coalition gatewayeol.org/

The Language of Advance Care Planning

Advance Care Planning The process of planning for your future care.

Advance Care Planning Legal Documents that describe your wishes include:

  • Durable Power of Attorney (DPOA) for Healthcare or Healthcare Agent
  • Healthcare Directive or Living Will
  • HIPAA Authorization
  • Outside the Hospital DNR or POLST or TPOPP
  • Body Disposition 
  • Durable Power of Attorney for Finances
  • Will, Trust

Healthcare Durable Power of Attorney Identifies your health care agent (or proxy), the person you trust to act on your behalf if you are unable to make healthcare decisions or communicate your wishes.  This is the most important document.  Make sure you choose the person who will follow your wishes and advocate for you.

Healthcare Directive or Living Will Specifies which medical treatments you want or don’t want at the end of your life, or if you are no longer able to make decisions on your own (e.g. in a coma)

Do Not Resuscitate (DNR), or no code or allow natural death, is a legal order written either in the hospital or on a legal form to withhold cardiopulmonary resuscitation CPR. It only applies in the hospital.

Outside the Hospital DNR This document states that even outside the hospital CPR cannot be used if your heart and/or breathing stops.  It must be signed by your physician. This is for people who are not expected to live a year due to a terminal illness. It’s also known as Practitioner Orders for Life-Sustaining Treatment (POLST) and Transportable Physician Orders for Patient Preferences (TPOPP).