Complete Guide to Advance Directives for Aging Parents

No one wants to think about a time when their parent might be unable to communicate their wishes about medical care. Yet this scenario is more common than many families realize—stroke, sudden illness, dementia progression, or a serious accident can leave anyone unable to speak for themselves. Without proper planning, families are left guessing about what their loved one would want, sometimes making decisions they're never sure were right.

Advance directives solve this problem by documenting your parent's healthcare wishes while they can still express them. These legal documents ensure that medical teams know exactly what your parent wants—and doesn't want—even when they can't speak for themselves. More importantly, advance directives protect your family from the emotional burden of making life-or-death decisions without guidance.

This comprehensive guide explains everything you need to know about advance directives, including the different types, how to create them, what conversations to have, and how to ensure these documents are available when needed. Whether your parent is healthy or facing serious illness, now is the time to have these important conversations.

Key Statistics:

• Only about 37% of American adults have advance directives
• That number rises to about 70% for adults over 65
• Among those with directives, up to 70% are inaccessible during medical emergencies
• Families without advance directives are 30% more likely to experience conflict over care decisions

What Are Advance Directives?

Advance directives are legal documents that communicate a person's healthcare preferences in advance of a time when they might not be able to speak for themselves. Think of them as a voice for your parent when they temporarily or permanently lose the ability to communicate their own medical wishes.

The Main Types of Advance Directives

There are several types of advance directives, each serving a different purpose:

Living Will

A written document specifying which medical treatments a person does or doesn't want if they become terminally ill or permanently unconscious and cannot communicate. Addresses specific interventions like CPR, ventilators, feeding tubes, and dialysis.

Healthcare Proxy (Healthcare Power of Attorney)

A legal document that designates a specific person (the "agent" or "proxy") to make medical decisions when you cannot make them yourself. This person speaks for you with doctors, hospitals, and other healthcare providers.

Do Not Resuscitate (DNR) Order

A medical order that instructs healthcare providers not to perform CPR if the heart stops or breathing ceases. Must be signed by a physician to be valid. Different from a living will, which is a patient directive.

POLST (Physician Orders for Life-Sustaining Treatment)

A medical order form (also called MOLST, POST, or MOST in some states) that translates patient wishes into specific medical orders. More detailed than a DNR and addresses multiple interventions. Appropriate for seriously ill patients.

Why Multiple Documents Are Needed

Each document serves a different purpose, and together they provide comprehensive coverage:

Document	Purpose	Who Creates It
Living Will	States treatment preferences	Patient (with witnesses/notary)
Healthcare Proxy	Names decision-maker	Patient (with witnesses/notary)
DNR Order	Medical order for emergencies	Physician (with patient consent)
POLST	Detailed medical orders	Physician (with patient/proxy)

The living will and healthcare proxy work together: the living will provides guidance, while the healthcare proxy ensures someone can make decisions about situations not specifically covered in the living will. DNR and POLST forms translate these wishes into actionable medical orders that first responders and hospitals can follow immediately.

Living Will: Documenting Treatment Preferences

A living will is a written statement of your parent's preferences regarding medical treatment in situations where they cannot communicate. It typically becomes effective only when a person is terminally ill, permanently unconscious, or facing certain death without treatment.

What a Living Will Addresses

Living wills typically address preferences about the following treatments:

Cardiopulmonary Resuscitation (CPR)

Whether to attempt chest compressions, electric shocks, or breathing assistance if the heart stops. CPR success rates vary widely based on age and underlying conditions—less than 10% for most elderly patients outside hospitals.

Mechanical Ventilation

Whether to use a breathing machine if unable to breathe independently. This often requires sedation and a tube inserted into the airway. May be temporary or long-term.

Artificial Nutrition and Hydration

Whether to provide food and fluids through a feeding tube (through the nose or surgically placed in the stomach) or IV fluids if unable to eat or drink. This is often one of the most difficult decisions for families.

Dialysis

Whether to use a machine to filter blood if kidneys fail. For elderly patients, dialysis is life-extending but requires significant time commitment (typically three times weekly) and has complications.

Antibiotics and Other Treatments

Whether to treat infections aggressively or allow natural death to occur. Some people want antibiotics for comfort (treating painful infections) but not to extend life artificially.

Comfort Care and Pain Management

Preferences about pain medication, even if it might hasten death. Most people want maximum comfort measures regardless of other choices. This is always appropriate and legal.

Limitations of Living Wills

While essential, living wills have important limitations to understand:

• They can't cover every scenario: Medical situations are complex and unpredictable. A living will provides guidance but can't anticipate every possibility.
• Interpretation challenges: Terms like "terminal" or "reasonable hope of recovery" may be interpreted differently by different doctors.
• They only apply in specific circumstances: Most living wills only become effective when a person is terminally ill or permanently unconscious—not during temporary incapacity.
• They may not be immediately available: In emergencies, medical staff may not have access to the document.

Why You Also Need a Healthcare Proxy:

Because living wills can't cover every situation, having a healthcare proxy who knows your parent's values and can interpret their wishes is crucial. The proxy can make decisions about situations not specifically addressed in the living will.

Healthcare Proxy: Choosing a Decision-Maker

A healthcare proxy (also called healthcare power of attorney, healthcare agent, or medical power of attorney) is perhaps the most important advance directive document. It designates a trusted person to make medical decisions when your parent cannot make them themselves.

What a Healthcare Proxy Can Do

The healthcare proxy has significant authority when activated:

Make treatment decisions: Consent to or refuse any medical treatment, procedure, or test
Choose healthcare providers: Select or remove doctors, specialists, and care facilities
Access medical records: Review all health information protected by HIPAA
Interpret wishes: Apply the patient's known values to situations not covered in a living will
Decide about clinical trials: Consent to experimental treatments or research participation
Make end-of-life decisions: Decide about life support, palliative care, and hospice
Authorize autopsy and organ donation: Make decisions about what happens after death

Choosing the Right Healthcare Proxy

This decision requires careful thought. The best healthcare proxy:

Knows Your Parent's Values

Understands what matters most to your parent—quality of life, length of life, independence, spiritual beliefs. Has had explicit conversations about end-of-life preferences.

Can Handle Difficult Decisions

Able to make hard choices under pressure without being paralyzed by emotion. Can follow your parent's wishes even if personally uncomfortable with the decision.

Will Advocate Effectively

Comfortable pushing back against medical staff if necessary. Able to ask questions, request second opinions, and ensure your parent's wishes are respected.

Is Available and Accessible

Geographically nearby or able to travel quickly. Reachable by phone at any time. Not frequently traveling or difficult to contact.

Willing to Serve

Has explicitly agreed to take on this responsibility. Understands what it entails and feels capable of fulfilling the role.

Common Questions About Healthcare Proxies

Can I name more than one person?

You can name alternate agents who serve if the primary agent is unavailable, but most states don't allow co-agents who must agree. Joint decision-making can cause dangerous delays in emergencies.

Should I choose my oldest child?

Birth order shouldn't determine selection. Choose based on the qualities above, not family hierarchy. The oldest child may not be the best advocate or most emotionally equipped for the role.

Can my spouse and children override the proxy?

No, the legally designated healthcare proxy has authority over other family members. This is one reason clear documentation is so important—it prevents family conflicts.

When does the proxy's authority begin?

Typically when a physician determines the patient lacks decision-making capacity. Some documents allow the proxy to act immediately; others only when incapacitated.

Important Distinction:

A healthcare proxy is different from financial power of attorney. The healthcare proxy only makes medical decisions. Financial power of attorney handles money, property, and legal matters. Your parent may want the same person for both, or different people based on their strengths.

Understanding DNR Orders

A Do Not Resuscitate (DNR) order is a medical order that tells healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops beating or they stop breathing. Unlike a living will (which is a patient directive), a DNR is a physician's order that must be signed by a doctor to be valid.

What CPR Actually Involves

Understanding what resuscitation entails helps inform the decision:

• Chest compressions: Forceful, repeated pushing on the chest (can break ribs, especially in elderly patients)
• Defibrillation: Electric shocks to restart the heart
• Intubation: A tube inserted into the airway for mechanical breathing
• Medications: Drugs injected to stimulate heart function
• ICU admission: Typically followed by intensive care if resuscitation succeeds

CPR Success Rates

Television shows depict CPR as usually successful, but reality is different:

Real-World CPR Outcomes:

• In-hospital cardiac arrest: About 25% survive to hospital discharge
• Out-of-hospital cardiac arrest: About 10% survive to discharge
• Nursing home residents: Less than 5% survive to discharge
• Patients with multiple chronic conditions: Survival rates even lower
• Of survivors: Many experience brain damage or diminished function

These statistics don't mean CPR is never appropriate—for some patients, it's absolutely the right choice. But understanding the realistic outcomes helps families make informed decisions rather than choosing based on unrealistic TV portrayals.

Types of DNR Orders

In-Hospital DNR

Placed in the medical chart during a hospital stay. Only applies while the patient is in that facility. Nursing home DNRs work similarly.

Out-of-Hospital DNR (also called Prehospital DNR)

A portable order that travels with the patient and is honored by emergency medical services (EMS) in the community. Different states have different forms and requirements. Often requires a special bracelet or form posted in the home.

DNR Does NOT Mean:

• "Do not treat" — patients with DNR orders still receive all appropriate medical care
• "Comfort care only" — unless specifically requested, other treatments continue
• "Give up" — it's a specific decision about one intervention, not overall care
• Less attention from medical staff — DNR patients receive the same quality of care

How to Obtain a DNR Order

Discuss with your parent's physician whether a DNR aligns with their wishes and medical situation
The physician writes the order and signs it
For out-of-hospital DNR, obtain the appropriate state form
Some states require a DNR bracelet or form posted in the home
Ensure all caregivers and facilities have copies

POLST: Turning Wishes Into Medical Orders

POLST (Physician Orders for Life-Sustaining Treatment) takes advance care planning further than a DNR by creating comprehensive medical orders covering multiple treatment decisions. Known by different names in different states (MOLST, POST, COLST, MOST), POLST forms are brightly colored (usually pink or green) medical orders that travel with patients across care settings.

Who Should Have a POLST

POLST is not for everyone. It's appropriate when:

• The person has a serious illness or advanced frailty
• A clinician wouldn't be surprised if they died within 1-2 years
• They're in a nursing home or have frequent hospitalizations
• They've decided to limit some interventions
• A living will exists but needs to be translated into medical orders

Healthy adults should have living wills and healthcare proxies but typically don't need POLST until they develop serious illness.

What POLST Covers

A typical POLST form addresses:

Section A: Resuscitation

Whether to attempt CPR if heart stops or breathing ceases. Options typically include "Attempt Resuscitation" or "Do Not Attempt Resuscitation (DNR)."

Section B: Medical Interventions

Level of treatment desired: Full Treatment (all interventions including ICU), Selective Treatment (hospital care but avoid ICU/intubation if possible), or Comfort-Focused Treatment (relieve symptoms, stay in current location).

Section C: Artificially Administered Nutrition

Whether to provide nutrition through a feeding tube if unable to eat. Options include long-term tube feeding, trial period, or no artificial nutrition.

Additional Information

Healthcare proxy information, patient signature (or proxy signature if patient lacks capacity), and physician signature. Some forms include space for additional orders.

POLST vs. Living Will

Aspect	Living Will	POLST
Type of Document	Patient directive	Medical order
Who Signs	Patient only	Patient and physician
Who Needs It	All adults	Seriously ill patients
Actionable	Guides decisions	Immediate medical orders
Honored by EMS	May not be recognized	Yes, required to follow

Find Your State's POLST Program:

Visit polst.org to find information about your state's program, including the official form, how to complete it, and local resources for discussion.

Having the Conversation About End-of-Life Wishes

The documents themselves matter less than the conversations that inform them. Many families complete advance directive forms without truly understanding what their parent wants—or why. Taking time to explore values and preferences leads to better decisions and greater peace for everyone.

When to Have These Conversations

The best time is before there's an urgent need:

• Ideally: While your parent is healthy and not facing any immediate health crisis
• Natural opportunities: After a health scare, when completing other legal documents, when a friend or relative faces illness
• Milestone moments: Retirement, significant birthdays, when grandchildren are born
• Media prompts: After watching a movie or TV show dealing with end-of-life issues

Starting the Conversation

Opening this discussion feels awkward for most families. Try these approaches:

Lead with Your Own Plans

"I've been thinking about my own advance directives. Would you help me think through some of the decisions? I'd also love to know what you would want."

Reference Someone Else's Experience

"When [friend/relative] was sick, the family had to make so many difficult decisions. It made me realize we should talk about what you would want if something happened."

Ask About Values, Not Just Procedures

"What's most important to you about how you live? What would make life not worth living for you?" These questions get at underlying values that inform specific decisions.

Frame It as a Gift

"I want to honor your wishes if I ever need to make decisions for you. Help me understand what you would want so I can be confident I'm doing right by you."

Essential Questions to Explore

Go beyond "do you want CPR?" to understand the deeper values:

Questions About Quality of Life:

• What activities make your life meaningful?
• What would be worse than death for you?
• How important is independence to you?
• What would you not want to live without?
• How would you feel about living in a nursing home?

Questions About Medical Care:

• How much are you willing to go through for a chance at more time?
• Is there a point where you'd want us to stop aggressive treatment?
• How do you feel about being on a ventilator or feeding tube?
• Would you want to be kept alive if you couldn't recognize family?
• What matters more: length of life or quality of life?

Questions About Death and Dying:

• Where would you want to spend your final days?
• Who do you want with you?
• Are there any religious or spiritual practices that are important?
• How do you feel about organ donation?
• What kind of memorial or funeral would you want?

Helpful Resources for Conversations

These tools can guide deeper discussions:

• Five Wishes: A popular advance directive document written in everyday language that addresses medical, personal, emotional, and spiritual wishes
• The Conversation Project: Free starter kit with guided questions for families
• Go Wish Cards: A game-like format for exploring end-of-life values
• Prepare for Your Care: Online program that guides users through advance care planning

Creating the Documents: Step-by-Step

After having conversations about wishes and values, it's time to formalize those preferences in legally valid documents. The process is simpler than most people expect.

Step 1: Choose Your Approach

You have several options for creating advance directives:

State-Specific Forms (Free)

Most states provide official advance directive forms through their health departments or attorney general offices. These forms are specifically designed to meet state legal requirements.

Search: "[Your state] advance directive form" or visit CaringInfo.org for state-specific forms

Five Wishes ($5)

A widely-used document written in everyday language that meets legal requirements in most states. Addresses not just medical decisions but also personal comfort, how to be treated, and what you want loved ones to know.

Available at FiveWishes.org or through many hospitals and hospices

Attorney-Prepared Documents (Variable Cost)

An elder law attorney can prepare customized documents that address complex situations. Recommended if there are family conflicts, significant assets, or complicated medical situations.

Cost typically $200-500 for advance directives alone, or included in comprehensive estate planning

Hospital or Doctor's Office

Many hospitals and medical practices provide free advance directive forms and can help complete them. Some have patient advocates or social workers who guide the process.

Step 2: Complete the Forms

When filling out the documents:

Be specific but not too rigid: Provide clear guidance while allowing flexibility for unforeseen situations
Use your own words: Add personal statements explaining your values and reasoning
Name alternates: Designate backup healthcare proxies in case the primary is unavailable
Consider scenarios: Think about temporary incapacity vs. permanent, treatable illness vs. terminal diagnosis
Don't assume: Spell out wishes even for things that seem obvious to you

Step 3: Execute the Documents Properly

Legal requirements vary by state, but typically include:

Common Requirements:

• Witnesses: Most states require two adult witnesses who are not beneficiaries of the estate
• Notarization: Some states require notarization instead of or in addition to witnesses
• Signature: The person creating the directive must sign (or make their mark) while mentally competent
• Dating: All documents should be dated

Mental Capacity Is Required:

Your parent must be mentally competent when signing advance directives. If there are any concerns about capacity (such as early dementia), consider having a physician document that your parent understands what they're signing. This can prevent later challenges to the document's validity.

Step 4: Obtain Medical Orders

If appropriate, work with your parent's physician to create:

• DNR order (if desired)
• POLST form (if seriously ill)
• Out-of-hospital DNR (if applicable in your state)

These require a physician's signature and translate the patient's wishes into actionable medical orders.

Storing and Sharing Advance Directives

An advance directive that can't be found when needed is as useless as not having one at all. Studies show that 70% of advance directives are not available when needed. Proper storage and sharing is crucial.

Who Should Have Copies

Distribute copies to everyone who might need them:

Healthcare proxy: The designated decision-maker must have a copy
Alternate proxies: Backup decision-makers should also have copies
Primary care physician: Should be in your parent's medical record
Specialists: Any doctors who provide regular care
Local hospital: Can often store documents in their system
Family members: Key relatives should know where documents are, even if they don't have copies
Nursing home or assisted living: If applicable, facility should have copies on file
Attorney: If an attorney prepared the documents

Storage Options

Electronic Storage

Many states now have advance directive registries. Some hospitals and health systems also maintain electronic records. Your parent's patient portal may allow uploading documents.

Physical Storage at Home

Keep original documents in an easily accessible location—not a safe deposit box, which may not be accessible in emergencies. A fireproof home safe or a clearly labeled folder works well.

Emergency Access

For POLST and out-of-hospital DNR, post on refrigerator or in another standard location that EMS knows to check. Some people keep a card in their wallet indicating that advance directives exist and who to contact.

Travel Copies

If your parent travels frequently, consider keeping copies in their luggage or uploaded to a secure cloud service accessible from anywhere.

Create a "Document Emergency Kit":

Prepare a folder or binder containing copies of all important documents: advance directives, healthcare proxy form, insurance cards, medication list, emergency contacts, and primary care physician information. Keep this where it can be grabbed quickly if needed.

When to Review and Update Advance Directives

Advance directives aren't "set it and forget it" documents. They should be reviewed periodically and updated when circumstances change.

Regular Review Schedule

Even without major changes, review documents:

• Annually: Quick review to confirm everything still reflects current wishes
• Every five years: More thorough review and potential re-execution
• After major health changes: New diagnosis, hospitalization, or significant decline

Events That Trigger Updates

Review and potentially update advance directives after:

Changes in Health

New serious diagnosis, significant decline, or recovery from serious illness may change perspectives on treatment.

Changes in Relationships

Death of spouse or healthcare proxy, divorce, estrangement from designated proxy, or new trusted person entering life.

Moving to a New State

Laws vary by state. Documents valid in one state may need updating to meet another state's requirements.

Change in Values or Beliefs

Religious conversion, philosophical shifts, or changed perspective on quality of life.

Experience with Others' End-of-Life Care

Witnessing a loved one's death may clarify or change preferences.

How to Update Documents

Create entirely new documents (don't just cross things out)
Execute new documents with proper witnesses/notarization
Destroy all copies of old documents
Distribute new documents to everyone who had copies of the old ones
Update any electronic registries
Notify healthcare proxy of any changes to their authority or instructions

Important:

The most recent, properly executed document takes precedence. To avoid confusion, always date documents clearly and destroy old versions when creating new ones.

Frequently Asked Questions

What is the difference between a living will and a healthcare proxy?

A living will is a written document that specifies which medical treatments you do or don't want if you become incapacitated and cannot communicate. It provides specific guidance about interventions like CPR, ventilators, and feeding tubes. A healthcare proxy (also called healthcare power of attorney) designates a specific person to make medical decisions on your behalf when you cannot make them yourself. Most experts recommend having both: the living will provides guidance about specific wishes and values, while the healthcare proxy appoints someone to interpret those wishes and make decisions about situations not explicitly covered in the living will. Together, they provide comprehensive protection.

Does my parent need a lawyer to create advance directives?

In most cases, no lawyer is required to create valid advance directives. State-specific forms are often available free online from state health departments, bar associations, hospitals, or organizations like Five Wishes. However, legal requirements vary by state—some require notarization, others require witnesses, and rules about who can serve as a witness differ. If your parent has a complex medical situation, significant assets, potential for family conflict, or concerns about capacity, consulting an elder law attorney can help ensure documents are properly executed and legally sound. An attorney can also customize documents to address specific situations not covered by standard forms.

What is a POLST form and who needs one?

POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form that translates advance directive wishes into specific, actionable medical instructions. Unlike living wills, which are patient directives that guide decisions, POLST forms are actual medical orders signed by a physician that must be followed by healthcare providers. POLST is appropriate for people with serious illness, advanced frailty, or limited life expectancy—typically when death within 1-2 years wouldn't be surprising. POLST forms are brightly colored (usually pink or green) so they're easily recognizable and travel with the patient across care settings. Healthy adults generally don't need POLST; a living will and healthcare proxy are sufficient until serious illness develops.

Can advance directives be changed or revoked?

Yes, advance directives can be changed or revoked at any time as long as the person is mentally competent to make that decision. To update documents, create entirely new versions following your state's legal requirements, destroy all copies of old documents, and distribute new copies to everyone who had the previous version. Notify your healthcare proxy, doctors, hospitals, and any facilities holding copies about the changes. It's recommended to review advance directives annually, after major health changes, after significant life events (like becoming widowed), or after moving to a new state. Many people update their documents every five years regardless of changes, just to ensure they still reflect current wishes and to re-engage with the conversation.

What happens if someone doesn't have advance directives?

Without advance directives, state law determines who makes medical decisions for an incapacitated person, typically following a hierarchy: spouse first, then adult children, parents, siblings, and so on. This can lead to several problems: family conflicts when relatives disagree about treatment, court involvement if no appropriate decision-maker exists or family members are in conflict, delays in care while decision-makers are identified, and most importantly, decisions that may not align with what the person would have wanted. Doctors may provide aggressive treatment by default since they don't know the patient's wishes. Creating advance directives ensures your parent's specific wishes are known and followed, dramatically reduces the burden on family members, and prevents potential legal battles over care decisions.

Are advance directives from one state valid in another?

Most states recognize advance directives from other states, but this isn't universal and some states have specific requirements. If your parent spends significant time in multiple states (such as snowbirds who split time between states), consider having documents that comply with both states' requirements or executing separate documents for each state. If your parent moves permanently to a new state, it's wise to execute new documents following that state's specific requirements to avoid any potential issues. The National POLST organization notes that POLST forms should generally be honored across state lines, but a new POLST may be needed when transferring care to a new state's healthcare system.

Can my parent with dementia still create advance directives?

It depends on the stage of dementia. A person must have mental capacity to create valid advance directives—meaning they understand what the document is, what choices they're making, and the consequences of those choices. In early dementia, many people retain this capacity. If there's any question about capacity, have the conversation and complete documents as soon as possible. A physician can assess and document that the person has capacity at the time of signing. If dementia has progressed to where capacity is in question, consult with an elder law attorney about whether documents can still be validly executed. If your parent already lacks capacity, a guardian may need to be appointed by a court to make decisions, or state law's default hierarchy will apply.

What if family members disagree with my parent's advance directive wishes?

Legally, a properly executed advance directive represents your parent's wishes and should be followed, regardless of family members' personal preferences. The healthcare proxy has legal authority to make decisions, and other family members cannot override them. To minimize conflicts: involve family members in conversations about wishes while your parent can still participate, have your parent explain their reasoning directly to family, document wishes clearly and specifically, and choose a healthcare proxy who can handle family pressure while honoring the patient's wishes. If conflicts arise during a crisis, hospital ethics committees and social workers can help mediate. In extreme cases, family members have sought court intervention, but courts generally uphold valid advance directives and appointed healthcare proxies.