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Steps to Create Your Advance Care Plan
Step 1
Evaluating Your Wishes, Values, and Beliefs
Advance care planning involves making yourself aware of the medical terms and choices and then thinking about your wishes, values, and beliefs.
Each person holds their own beliefs and values when it comes to what is important in life. It is important to think about these values when choosing future medical needs.
Begin by asking yourself questions about your medical and personal values. Write down what would be important to you in the event you could not speak for yourself. We are including a few questions that you may ask yourself:
• Is it important for me to breathe on my own?
• Would I want tube feedings if I could not eat or drink by mouth?
• Is it important for me to be mentally alert and able to recognize loved ones?
• Would I want to live as long as possible regardless of the stage of my illness or injury?
• Would I like to help others by donating my organs?
• Would I want to live in a nursing home if I were unable to care for myself?
• Where would I like to spend the last days of my life?
• How would I like to include my religious beliefs and traditions in my end-of-life care?
• Would I like to have a natural death, not hooked up to machines or tubes?
Of course, there are many more questions that you might ask yourself when planning for your end-of-life care. Some situations may be difficult to think about. If you have questions or need support reach out to important people in you life such as loved ones, healthcare providers, or religious leaders.
Step 2
Choosing Your Health Care Proxy (Decision-Maker)
If you are not able, the person that you choose as your health care proxy (decision-maker) will have the authority to make all health care decisions that you would make if you were able. The form also contains a space that you can include an alternate (back-up) health care proxy in the event that your first choice is unable to speak for you.
Your health care proxy will have access to all of your medical records and will discuss your treatment with your doctors. He or she may allow or refuse any tests, procedures, or treatments that are discussed and admit you to another health care facility. Your proxy is required to follow your written wishes and must honor your instructions.
There are several things to take into consideration when choosing a health care proxy. Many people choose a spouse or adult child, but you can choose anyone who is at least 18 years old and of sound mind. This might include a family member, friend, neighbor, or member of your religious organization. When choosing your alternate proxy, you might choose someone younger if your primary person is your age or older.
When considering a health care proxy, you might choose someone who: • Is willing to take responsibility to serve as your voice when needed. • Is trustworthy. • Is willing to talk to you about difficult situations. • Will speak up on your behalf when you cannot speak. • Understands your values. • Is willing to follow your instructions and honor your wishes. • Is able to make these difficult decisions in stressful situations. • Can handle conflict if there is a disagreement about your health care.
Here are examples of what your health care proxy can do on your behalf: • Talk with your healthcare team about your condition • Give permission for medical tests, medications, surgery, or other treatments • Choose where you get care • Agree or decline to donate your organs or whole body for transplant, research, or education if you have not already made the decision yourself • Decide what to do with your remains (your body) after you have died if you have not already made plans • Talk with your loved ones to help come to a decision. Your healthcare proxy will have the final say. • Your health care proxy is not responsible for your health care expenses.
Step 3
Having the Conversation
Now that you have chosen your health care proxy, it is important that you discuss your wishes. It may be difficult to start this conversation so plan ahead if possible. It might be a good idea to write down the things you would like to discuss. Choose a quiet place so that you might not be interrupted. You might also consider getting opinions from your loved ones about difficult medical decisions.
Start out by asking if he or she is comfortable taking on the role as your health care proxy. Point out the duties that would need to be carried out so that there is clear understanding of the role.
Next, share your wishes and the decisions that must be made. Share the things that you feel are important and matter to you when thinking about the last days of your life. Your health care proxy may have questions so listen carefully and try to answer to the best of your ability. Be patient and take your time. Both you and your loved one might need time to think. Do not forget to also have this conversation with your alternate proxy as well.
After sharing your wishes with your proxy, it would be a good idea to share your wishes with your family and loved ones. End-of-life situations are emotional and often stressful on family members and making your wishes known might help to alleviate conflict or disagreements.
Finally, share your wishes and your Advanced Health Care Directive form with your doctors. Your health care team will make a copy of your form to keep in your medical record. Also provide copies to your proxies and anyone that might need one.
Step 4
Fill out an Advance Directive for Health Care
How to Complete Your Advance Directive Form
Part I: Living Will The first part of your Oklahoma Advance Directives for Health Care form contains a Living Will. This is the portion that you will make your choices for health care in the event you are unable to speak for yourself. This section is divided into three medical situations called 1) Terminal Condition, 2) Persistent Unconsciousness, and 3) End-Stage Condition. These conditions were listed in the glossary and here we will walk you through each step so that you can better understand your choices.
1. Terminal Condition is caused by a disease or injury. It is not curable and the condition will not improve. Two doctors must agree that the patient has a terminal condition, meaning that even if all medical treatment was performed, death will most likely occur within six months.
2. Persistent Unconsciousness means that the patient may have open eyes but has very little brain activity. Unlike patients that are in a coma, these patients will never “wake up” and do not feel pain, hunger, or thirst.
3. End-Stage Condition is a medical illness or injury that is in an advanced stage. The patient may experience loss of mental and physical abilities such as talking, walking, swallowing, or recognizing loved ones. A patient with an end-stage condition has a very low chance of recovering or improving with or without medical treatment.
With each of the conditions above, you can choose one of three actions and initial beside your choice. These choices are:
• Receive all life-sustaining treatment
• Receive no life-sustaining treatment EXCEPT artificial nutrition and hydration
• Receive no life-sustaining treatment
What is life-sustaining treatment? This means that you wish to have any recommended medical treatment that would keep you alive. This might include a ventilator (breathing machine), feeding tubes, dialysis, chemotherapy, antibiotics, or surgery. You would initial by this choice if you wish for all of these treatments in any of the conditions above.
What if I choose to receive life-sustaining treatment including artificial nutrition and hydration? If you make the choice to receive all life-sustaining treatment, this means that you wish to receive any of the medical treatments listed above to keep you alive. This includes tube feedings if you are unable to eat or drink by mouth. However, there are cases in which a doctor might not recommend a treatment because it will not help your condition or will cause you further harm.
What if I choose no life-sustaining treatment including artificial nutrition and hydration? If you make this choice, this means that if doctors determine that you will not recover, you wish to refuse treatment so that you may have a natural death. However, even if you make this choice, you will be kept as comfortable as possible with treatment such as pain medication.
What if I choose NOT to have life-sustaining treatment but YES to artificial nutrition and hydration if needed? If you make this choice, this means that you do not want any of the treatments defined above in order to keep you alive but you would like to have tube feedings if you are unable to eat or drink by mouth.
What about the part to initial for more specific instructions? This is optional. There is a space to initial after each of the conditions if you would like to be more specific about your care. If you are unable to speak for yourself, you can write further instructions about your wishes in the space provided on the form. Notice that there is a place to initial after the optional instructions and it is required if you choose to write out instructions.
Now that we have discussed the Living Will portion of your Advance Directive for Health Care form, please look over the next few pages for an example. We have included arrows indicating where you would initial for each choice. Please remember that you should only initial by one choice in sections one, two, and three. Section four is optional and is where you would write out any further instructions.
What is artificially administered nutrition and hydration? This is also known as tube feedings. If you are still able to eat or drink by mouth safely, this does not apply. However, if a patient is unable to eat or drink anything by mouth, these feedings can be used to give nutrition and hydration for a short amount of time. These feedings are provided through an IV (into a vein) or a tube inserted into your nose, stomach, or intestine (gut). This will allow a patient to heal but can have some side effects such as discomfort, bloating, and risk of infection. It is possible that a tube can be dislodged so sometimes a patient will need to be physically restrained so that the tube will not be pulled out. If you have any questions or concerns about end-of-life tube feedings, speak with your doctor.
Your Advance Directive will only be used if your attending physician and another physician determine that you are unable to make medical decisions.
(1) Choose whether you would want life-sustaining treatment and/or tube feeding if you have a terminal illness that even with treatment, will likely result in death within 6 months.
Initial here if you DO NOT want life-sustaining treatment, but you DO want tube feeding.
Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.
Initial here if you DO want BOTH life-sustaining treatment and tube feeding.
Initial here only if you have written instructions regarding treatment or tube feeding in the event of a terminal illness.
(2) Choose whether you would want life-sustaining treatment and/or tube feeding if you become persistently unconscious.
Initial here if you DO NOT want life-sustaining treatment, but you DO want tube feeding.
Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.
Initial here if you DO want BOTH life-sustaining treatment and tube feeding.
Initial here only if you have written instructions regarding treatment or tube feeding in the event you become persistently unconscious. If I am incapable of making an informed decision regarding my health care, I, ________________, direct my health care providers to follow my instructions below.
I. Living Will
If my attending physician and another physician determine that I am no longer able to make decisions regarding my health care, I direct my attending physician and other health care providers, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below:
(1) If I have a terminal condition, that is, an incurable and irreversible condition that even with the administration of life-sustaining treatment will, in the opinion of the attending physician and another physician, result in death within six (6) months:
(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
(Initial only if applicable)
_____ See my more specific instructions in paragraph (4) below.
(2) If I am persistently unconscious, that is, I have an irreversible condition, as determined by the attending physician and another physician, in which thought and awareness of self and environment are absent:
(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
(Initial only if applicable)
(3) Choose whether you would want life-sustaining treatment and/or tube feeding if you have an incurable condition causing you to be incompetent and completely dependent.
Initial here if you DO NOT want life-sustaining treatment, but you DO want tube feeding.
Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.
Initial here if you DO want BOTH life-sustaining treatment and tube feeding.
Initial here only if you have written instructions regarding treatment or tube feeding in the event you have an end-state condition.
(4) This is an optional section where you can give more specific instructions about your wishes. 3) If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, which results in severe and permanent deterioration indicated by incompetency and complete physical dependency for which treatment of the irreversible condition would be medically ineffective:
(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration.
(Initial only if applicable)
_____ See my more specific instructions in paragraph (4) below.
(4) OTHER. Here you may:
(a) describe other conditions in which you would want life-sustaining treatment or artificially administered nutrition and hydration provided, withheld, or with drawn,
(b) give more specific instructions about your wishes concerning life-sustaining treatment or artificially administered nutrition and hydration if you have a ter minal condition, are persistently unconscious, or have an end-stage condition, or
(c) do both of these:
If you choose to, write your specific instructions here.
Initial here only if you have written specific instructions. _________ Initial
This second part of your Oklahoma Advance Directive for Health Careform concerns the health care proxy that we discussed earlier in this guide. Remember this person will serve as your representative to make health care choices if you are unable to do so. This person can legally have access to your medical information as well as make health care decisions, talk with your doctors, agree to or refuse treatments, or admit you to another facility or to hospice. When making these decisions, your health care proxy is legally bound to follow the instructions you chose in the Living Will section of the Advance Directive for Health Care. Oklahoma’s Advance Directive form allows you to choose one health care proxy and an alternate health care proxy in the event your first choice is unable to do so. If your first choice is your age or older, you may want to choose someone younger as your alternate.
Your health care proxy must be at least 18-years old and of sound mind. This should be someone that you can share your wishes with and trust that they will honor these wishes. Usually a spouse or adult child is chosen as the proxy but sometimes they may feel like they cannot make difficult decisions. In this case, you can choose another family member or a trusted friend. Once you have chosen your proxies, make sure that you discuss your wishes and that there is a clear understanding about what treatment you prefer. It would also be helpful to discuss your wishes with your family and loved ones. This will help to prevent any disputes among your loved ones.
Below is an example of part two of your form.
In this section, you can name a trusted person and an alternate person to make health care decisions for you if you are unable to do so.
Write the first and last name of your health care proxy.
Write the first and last name of your alternate proxy.
You will also have a space to put the address and phone number for your proxies. II. My Appointment of My Health Care Proxy
If my attending physician and another physician determine that I am no longer able to make decisions regarding my health care, I direct my attending physician and other health care providers pursuant to the Oklahoma Advance Directive Act to follow the instructions of ______________________________, whom I appoint as my health care proxy.
If my health care proxy is unable or unwilling to serve, I appoint ________________________ as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatever health care decisions I could make if I were able, except that decisions regarding life-sustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as I have indicated in the foregoing sections.
If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.
The third section of your Advance Directive form allows you to choose if you wish to donate your entire body or body parts for research or transplantation.
Organ and tissue donation will NOT affect the medical care that you receive when you are alive and will only occur after death.
There are many people waiting for organ transplants due to illness or injury. You are never too old to be an organ or tissue donor, and it will NOT affect the medical care that you receive. An organ donor can still have an open casket at a funeral and be buried.
Medical schools and research organizations study bodies to understand disease and better educate students. In most cases, you cannot donate your body for research if you choose to be an organ donor for transplant. Bodies donated for research will eventually be creamated, and you may request that your ashes be returned to your family. If you choose to donate your body, you should contact the organization in advance to make arrangements.
Below is an example of part three of your form.
Optional Section: Anatomical Gifts
Initial next to transplantation if you want to be an organ donor. Initial next to therapy if you want to donate for therapy.
Initial next to advancement of medical science and/or dental science if you want to donate your body or body parts for research or education.
Initial here if you want to donate your whole body.
Initial here if you want to choose specific parts of your body to donate and then initial next to each part that you would like to donate. III. Anatomical Gifts
Pursuant to the provisions of the Uniform Anatomical Gift Act, I direct that at the time of my death my entire body or designated body organs or body parts be donated for purposes of:
(Initial all that apply)
_____ Transplantation
_____ Therapy
_____ Advancement of medical science, research, or education
_____ Advancement of dental science, research, or education
Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. If I initial the “yes” line below, I specifically donate:
_____ My entire body
Or
_____ The following body organs or parts: (parts are listed on the form with a space beside them to initial)
The fourth section of your Advance Directive for Health Care form gives you information about your choices and filling out your form. Please read this information and ask a member of your health care team if you have any questions.
Part V: Execution
The last section of your Advance Directive for Health Care is where you sign your form and where two witnesses must sign with you. Your form does NOT need to be notarized. However, you must sign the form in front of your two witnesses for the form to be valid. Your two witnesses must be at least 18 years old and should not be related to you or inherit from you upon your death. If you do not have two people to witness you sign, you can bring the completed form with you to your doctor visit and members of our health care team can serve as your witnesses.
Step 5
Share your Advance Directive
Once you have completed your Oklahoma Advance Directive for Health Care form, it is important to take a few more steps:
• Make several copies of your completed form. You should keep one for yourself where it can be easily found. Provide a form to each of your health care proxies. Take a copy to your doctor and your hospital so that it may be placed in your medical record. If you live in a nursing home or assisted living facility, give a copy to staff so that it can be a part of your medical file.
• Discuss your wishes with your loved ones who will be involved if you are injured or have a serious illness. Answer questions and explain your values so that they may understand your wishes. Let them know the names of your health care proxies as well.
Always keep this information in an easy-to-find location, in case of an emergency.
Step 6
Review and Update Your Advance Care Plan
It is a good idea to review your form at least once a year or when you have a major life event. Remember the Five D’s: • Decade: You should review your form as you begin a new decade in life. • Death: You should review when a loved one dies, especially if that person is your Health Care
Proxy or alternate. • Divorce: You should review if you go through a divorce or other life change. • Diagnosis: You should review if you or your health care proxies is diagnosed with a serious medical condition. • Decline: You should review if your health condition declines (gets worse), especially if you are unable to live by yourself. This applies to your health care proxies as well.
Making Changes to Your Form You can change your mind and make changes to your Advance Directive for Health Care form at any time. This includes voiding the entire document or making changes by crossing out portions and making changes. If you want to void the entire form, you should write “I Revoke” on each page and keep it for your records. You should also let your health care proxies and doctors know that you have decided to void the form.
The best way to make changes is to complete a new form. When this form is completed, it automatically voids your first directive. Tear up the old forms and make sure to give your new form to your health care proxies and doctor.
Tell your health care proxy about any changes to your Advance Care Plan.
