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The importance of communicating your last wishes

Created date

July 20th, 2015
filling out form
filling out form

Because of increasing awareness, the number of seniors who have advance directives in place has risen somewhat over the past two decades. Despite the increase, about half of people over 60 still haven’t put their end-of-life wishes into writing.

“Having advance directives can give you peace of mind,” says Ellen L. Csikai, L.C.S.W., M.P.H., Ph.D., spokesperson for the National Association of Social Workers and professor at the University of Alabama’s School of Social Work in Tuscaloosa, Ala. “It’s always better for families and loved ones if they know your preferences before an illness strikes.”

But when the time comes, how can you be sure that your advance directives will be honored? “Unfortunately, there is never a guarantee that your wishes will be carried out,” Csikai says. “You can, however, take some steps to help ensure things go as smoothly as possible.”

Don’t wait until the last minute

People entering the hospital are stressed or ill, and filling out forms is usually the last thing on their minds. Nevertheless, most hospitals will give you the opportunity to do so. The Patient Self-Determination Act (PSDA), which Congress passed in 1991, specifies that health facilities receiving federal funding must inform patients of their rights to accept or refuse treatment and to prepare advance directives. 

But it’s still best to be ahead of the game. A study from the National Institute on Aging found that while in the hospital, about half of an estimated 13 million seniors needed someone else to make important health decisions about topics such as medical procedures, life-sustaining measures, and post-hospital care. Surprisingly, most of these seniors were being treated on regular medical units, not critical care areas. 

Have the proper forms in place

“Some people hesitate to write a living will because it seems like a complicated process,” says Myla Carpenter, M.D., medical director at

You name a health care proxy by filling out a health care power of attorney form. This person will make decisions for you if you are incapacitated. “Some people give their proxy complete authority and flexibility with decision-making in any medical situation,” Carpenter says. “You can also decide exactly what kinds of decisions your proxy can make for you.”

People in certain states may have forms in place called MOLST (Medical Orders for Life-Sustaining Treatment) or POLST (Physician Orders for Life-Sustaining Treatment)—different names for the same type of document.

“A MOLST or POLST is a document completed and signed by a physician after discussion with the patient,” says Dan Morhaim, M.D., Maryland state legislator and author of the book The Better End (Johns Hopkins University Press, 2011). “They are doctor’s orders that must be adhered to as part of the medical record.” Examples of issues specified on a MOLST include transfusions, dialysis, and cardiopulmonary resuscitation. 

These documents are not the same as advance directives, however. “MOLST forms are intended primarily for people with serious chronic illnesses,” Csikai says. “They can minimize confusion about what level of care is desired by a patient when in a facility for medical care and who might move between facilities, such as a hospital and long-term-care facility, as most forms are transportable.”  These forms can be utilized whether or not there was a previously formulated advance directive.  

Keep it current

“When faced with difficult, emotionally charged decisions, families can feel guilty about a range of issues that have occurred over a lifetime,” Csikai says. “It may be very difficult to carry out a loved one’s wishes, especially if it involves withdrawing treatment.

“Research shows that it’s easier for families when advance directives are in place,” Csikai continues. “People need to keep in mind that they are not making a decision to withdraw or withhold treatment; rather, they are acting as the voice of their loved one who has already made the decision.”

Sometimes, there may be conflict among family members about what is best. “Doctors may be able to help by explaining more about a patient’s status or about the treatments that are in place,” Carpenter says. “There are other professionals, such as social workers and counselors, who can also assist in resolving conflicts.”

Your preferences could change for any reason, so advance directives should be reviewed and updated every year, but Morhaim says you can modify and update your forms at any time. If your health status changes significantly or you are admitted to a facility such as a hospital or long-term care, you should also review all of your documents.

Make several copies. “Your forms need to be easily retrieved by all essential people, such as your health care proxy and doctor,” Csikai says. “You should have your own copy handy and give copies to your doctor, your health care proxy, a trusted family member, and/or a friend should keep the others.” And because each state differs with regard to advance directives laws, prepare forms for other states where you spend a significant amount of time.

The best insurance: Communication

A report from the Agency for Healthcare Research and Quality found that almost 75% of physicians whose patients had an advance directive were not aware the documents existed. “This statistic reinforces the absolute necessity of communication,” Csikai says. “People are afraid to talk about death. But research shows that it’s less stressful on families and loved ones if they know what treatment is desired and that plans are in place. You need to have that conversation.”