Advanced directive may be one of the most important and underutilized tools in estate planning and health planning. This is partially due to the stigma that people have about advanced directives, as if, by planning how to deal with health issues, they are somehow going to cause health problems. However, the reality is that most people will encounter at least one medical emergency during their lifetime. In the event that the health event renders a person unable to communicate his or her wishes, the advanced directive is a method of ensuring that the patient is still able to communicate his or her wishes. This is specifically relevant in scenarios where third parties may have to make decisions about whether to provide or withhold life-saving treatments. There are a number of different documents that fall under the rubric of advanced directives. The term encompasses all legally binding written documents that describe an individual's choices for health care, or name a proxy for decision-making purposes, if the individual becomes unable to make health decisions. The three most common advanced directives are the living will, the durable power of attorney for health care (POA), and the do not resuscitate order (DNR) (AHA, 2012). A living will is a "written, legal document spells out the types of medical treatments and life-sustaining measures you want and don't want, such as mechanical breathing (respiration and ventilation), tube feeding or resuscitation. In some states, living wills may be called health care declarations or health care directives" (Mayo Clinic Staff, 2011). The living will does not requires a third party designee to be effective, but an individual has to make sure that someone is aware of the living will and can and will convey it to health professionals. In contrast, the medical POA does require the intervention of a third party; it "is a legal document that designates an individual -- referred to as your health care agent or proxy -- to make medical decisions for you in the event that you're unable to do so" (Mayo Clinic Staff, 2011). The DNR is less comprehensive than a living will and can be included in other documents, or stand-alone; it can even be included in a patient's medical charts. All that a DNR states is that the patient is not to be resuscitated in the event that the patient's heart stops or if the patient stops breathing (Mayo Clinic Staff, 2011).

While advanced directives can come in multiple formats, it is important for individuals to follow applicable state and federal laws when drafting an advanced directive. At this point in time, no court has ever invalidated the idea of the advanced directive and the Patient Self-Determination Act of 1990 goes so far as to require hospitals to inform patients about advance directives (AHA, 2012). Moreover, in many circumstances, it is important for a person to have more than one of these documents, because a living will may not be able to predict all possible health care situations.

Many people tend to ignore the importance of advance directives, not because they do not feel strongly about what they want done in the event of a medical emergency, but because they feel so strongly about what they want done that they assume others will feel the same way or will respect wishes that they may have expressed in passing. This position is naive. The reality is that reasonable people can and do disagree about what type of medical interventions are appropriate in different scenarios. The best person to make medical decisions for an individual is that individual. Moreover, the best time to make those decisions is when a person is healthy and is able to make calm and rational decisions about what type of healthcare interventions would be desirable. However, it is equally important for individuals to review those decisions from time to time. A healthy young adult may not have any need for a DNR, while the same person 50 years later or struggling with a chronic illness may have different medical needs.

In fact, advanced care planning plays a critical role in health care for the aging population. "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" (National Institute on Aging, 2013). Advanced care planning encourages people to investigate individual health circumstances and decide what care would be desired in specific situations, based upon the individual's own health. It is critical to realize that advance care planning does not deprive the patient of individual decision-making...

Furthermore, advance directives are revocable and can also be of limited duration, such as a patient having a DNR in effect while in treatment for a specific medical problem. They are critical because, without advanced directives, an incapacitated patient's wishes will not necessarily be respected. "If there is no advance directive by the patient, the decision is left to the patient's family, physician, and hospital, and ultimately a judge.
Usually the family, physician, and hospital can reach an agreement without resorting to the courts, often with the help of a hospital ethics committee. However, many times the individual who has the authority to make the decision is not the person the patient would have chosen" (Mayo Clinic Staff, 2012).

There are several myths about advanced directives that make them appear to be more difficult than they truly are. For example, some people believe that advance directives are only used to deny treatment, but they can actually be used to outline the type of treatment that a patient would like to receive (ABA, Unk.). In fact, advanced directives are as important for the person who wants the doctors to use any and all available life-saving strategies as for the person who wants a DNR. Others believe that naming a health care proxy deprives the person of decision-making ability, but, as is described above, proxies only have power if a person is incapacitated (ABA, Unk). Perhaps the most critical mistake that people make is thinking that the advance directive, alone, is sufficient to ensure that the patient's wishes are respected. Patients need to discuss their wishes with family, friends, and their healthcare professionals, to ensure that they are knowledgeable about what the patient wants done.

As in other areas of healthcare, culture can have a significant impact on whether a patient is likely to seek an advanced directive, and, if not, if the family will be likely to carry out the patient's wishes. For example, Hispanics do not think that seriously ill patients should be fully informed about their illness, but, instead, that the family is obligated to take over in those scenarios (Lobar et al., 2006). African-Americans are more mistrusting of advanced directives in particular, and the health care system, in general, which can make them reluctant to engage in advanced care planning (Lobar et al., 2006). Furthermore, both African-American and Mexican-Americans are more likely to prefer family decision-making, which can complicate issues when family members do not agree about which treatment is appropriate (Lobar et al., 2006).

In fact, while there are a number of famous cases where the families of non-responsive patients fought for their right to die, including Karen Ann Quinlan and Nancy Cruzan, the more relevant cases involve patients who have become incapacitated, but have families that do not agree on the appropriate course of treatment for the patient. Perhaps the most famous of all such cases was the case of Terri Schiavo, where the husband and parents of a woman with a traumatic brain injury differed greatly on her medical outcome. Her biological family wanted her to be on life support indefinitely, but her husband wanted life support withdrawn so that she would be allowed to die. However, a recent case demonstrates how even loving family members who are in agreement can work to prevent a patient's wishes. Cancer patient SungEun Grace Lee had repeatedly expressed her desire to be removed from life support to her doctors at North Shore University Hospital in Manhasset, New York (Hartocollis, 2012). Her family argued that due to medication and depression about her illness, Lee was not competent to make decisions that would impact her life. Her doctors disagreed, stating that Lee was competent. Because of the dispute, and the fact that there was no advanced directive, the case went before a court to determine whether or not Lee was competent to make her own medical decisions. Lee won the right to make her own legal decisions, and then decided that she wanted to continue life support, which makes the case a morally difficult one. Because Lee had no advance directive and had a terminal condition, her family may have been correct that depression was altering her decision-making. However, whether such depression impacts competency is a different question, and the fact that Lee changed her mind about her decision does not mean her initial decision was any less…