Are advance directives the same in every state?

One state's advance directive doesn't always work in another state. Some states do respect another state's advance directives; others will respect other states' advance directives as long as they are similar to the state's own law; and some states don't have an answer to this question. If you regularly spend time in more than one state, it's smart to consider whether a living will, advance directive, or power of attorney for health care issued in your home state will also be valid in the second state. Most states accept health care directives from other states as long as the documents are legally valid in the state in which they were made, but this is not always the case.

Living wills, health care powers of attorney, and advance directives have different names in different states. Below is a chart describing how your state handles these documents. The two most common types of AD are the living will and the durable power of attorney for health care. The living will is an instructional directive that allows a person with decision-making ability to give instructions for medical treatment in case of disability at the end of life (usually due to a terminal illness or persistent vegetative state).

Permanent Power of Attorney for Health Care is a health care document that allows a person with the ability to appoint a trusted person to act as a health care agent in the event of disability. Although statutes vary from jurisdiction to jurisdiction, the agent usually has broad decision-making powers when acting in this substitute role and is not limited to end-of-life decision-making. Legislation in the United States concerning the denial of life-sustaining medical treatment began in 1976 with the passage of the California Natural Deaths Act. Other states continued their own legislation for living wills (Fade 199).

In general, statutes for a durable power of attorney for health care were enacted later. Some states only provide a living will or durable power of attorney for health care, while other states allow both. In 1993, the National Conference of Commissioners on Uniform State Laws drafted the Uniform Health Care Decisions Act (Uniform Law Commissioners 199). This model law recommended uniformity in ADs in all states and replacement of existing fragmented legislation with a single statute in each state that would provide to obtain a complete AD document.

Under this Act, some states adopted a third type of AD, usually called an advance health care directive. This type of document allows the appointment of an agent to make health care decisions and also includes a living will directive or other section of health care instructions. The person completing the document usually has the option of striking out a section they prefer not to complete. As our society becomes more mobile, it is more important to understand the differences in status in AD documents.

Now, more people travel from one state to another, and it's not uncommon for people to maintain residences in two states. Many people live in one state and receive medical care in another state. The purpose of this study is to evaluate, in terms of structure and content, the similarities and differences in AD documents in the United States. All 50 states and the District of Columbia had at least one statutory-based AD document.

Three states had a living will only (with limited power of attorney) and lacked permanent power of attorney for health care (Pennsylvania, Louisiana, and Montana; 6%). Three states had permanent power of attorney for health care only (Massachusetts, New York, and Michigan; 6%). Thirty-two (31 states plus Washington, DC) had a living will and permanent power of attorney for health care (63%), and 13 states had the combined document, the advance health care directive (25%). Although not statistically significant, the South had a higher percentage of states with advance health care directives (41%), compared to 11% for Northeastern states, 8% for Midwestern states, and 31% for Western states (p%3D).

Thirty-five states had a permanent power of attorney for health care documents. By definition, this type of document always designated a broad proxy (i.e. With regard to the specific mention of other key issues, these documents generally performed less well than the living will or the advance health care directive. We compared states that used the advance health care directives document (n %3D) 1 with states that used other types of documents (n %3D) 3.Table 2 shows the frequency of inclusion of issues in states with advance health care directive documents versus states without this document.

The only significant difference was for artificial sustenance. All states with advance health care directive documents included artificial sustenance in their documents, compared to 74% of states that did not. Overall, states with advance health care directives included a greater number of the eight issues, with an average of 6.3 (SD %3D 0), issues included in these state documents, compared to 5.6 (SD %3D 1), issues included in the other state documents (p %3D). Table 3 shows the frequency of inclusion of key issues in state documents by region of the country.

There were significant differences between regions with regard to the inclusion of general life-sustaining measures and admission to a long-term care facility. Northeastern states mentioned general life-support measures much less frequently than states in other regions (p %3D). With regard to admission to a long-term care facility, no state in the Northeast or West mentioned the issue in their documents; however, 42% of Midwestern states and 35% of Southern states included it (p%3D). The average number of issues included in state documents did not differ by region (M %3D 5.3, SD %3D 1.7 included emissions by state for Northeastern states; M %3D 6.2, SD %3D 1.0 for Southern states; M %3D 5.6, SD %3D 1.4 for Midwest states; and M %3D 5.8, SD %3D 0.8 for Western states; P %3D.

A recent study (Steinhauser et al. Despite the perception of importance among the public and health professionals, the published literature contains limited data examining the type and content of AD documents used by each of the 50 states and the District of Columbia. We found substantial variability across the country, both in the types of documents used by states and in the content of the documents. With respect to AD document types, most states had statutes that established both a living will and a durable power of attorney for health care, but some established only one or the other.

Only a minority of states had a combined advance health care directive document that provided both types of directives in one document. In addition to varying the type of document, states also varied considerably in the extent to which key issues were included in their documents. States with advance health care directives documents included significantly more of the key issues in their documents compared to states with other types of documents. In 1989, Emanuel and Emanuel proposed a single medical directive that included both treatment preferences and the appointment of a proxy (Emanuel and Emanuel 198).

The Uniform Health Care Decisions Act (Uniform Law Commissioners 199), which was recommended to all states in 1993 and passed by the United States Bar Association. Association in 1994 (Galambos 199), called for a single comprehensive directive in each state to replace existing fragmented directives. Despite this, most states still maintain separate documents and directives. We agree with Emanuel and Emanuel (1989) and the Uniform Law Commissioners (1994) that consolidating announcements into a single document can be important.

In states that have both a living will and a durable power of attorney for health care, there is a possibility that a person may choose to complete only one type of document. If there are two documents available, it is not clear to what extent people complete both or whether they preferably complete one over the other. At one university hospital in Illinois, 64% of all medical ADs were durable powers of attorney for health care, suggesting that this type of directive is preferred (Gross 199) .Other recent studies support this finding. In the SUPPORT study involving five teaching hospitals in Massachusetts, North Carolina, Ohio, Wisconsin and California, 66% of the 688 DAs of 569 patients were permanent powers of attorney (Teno, Licks, et al.

Similarly, Hammes and Rooney (1998) found that 65% of the ADs used by 540 deceased in a western Wisconsin community were to obtain a durable power of attorney for health care. Including both types of directives together in a single document may increase the likelihood of completing both. Using a comprehensive policy simplifies its completion, since it only needs to be signed and witnessed once. In addition, people may not understand the difference between living will and permanent power of attorney for health care, and when documents are separate, people may give inconsistent instructions.

The combination of the two directives can make each one easier to understand and provide consistency of provisions between documents. Although it is not clear whether the mention of specific problems in AD really influences end-of-life care, we suggest that it may be important to include specific topics in AD documents. The literature suggests that including problems in a document may improve a representative's knowledge of the patient's wishes. Weinberg and Brod 1995 have shown that although individuals can appoint a proxy, the agent may not know their wishes for health care.

Other authors have confirmed that there is a common mismatch between a person's wishes and the representative's perception of those desires (Gerety, Chiodo, Kanten, Tuley and Cornell 1993; Marbella, Desbiens, Mueller-Rizner and Layde 1998; Mattimore et al. However, the data suggest that preferences are expressed when subject-specific options are provided in an AD document (Gross 1998; Teno, Licks, et al. In addition, Sulmasy and colleagues (1998) have shown that surrogate accuracy improves when the patient has previously expressed preferences for the surrogate. Therefore, an important reason for including problems in AD documents is to improve the discussion between the principal in the specific document and the proxy.

When specific problems are mentioned in a document, the person completing the document is given the opportunity to ensure that their agent understands the care preferences. If the person has never thought about these topics, referring to them in the document may encourage exploration of the details of the topic and decision-making. A debate driven by the mention of specific issues in a document may be more important than the actual completion of the document. Emanuel 2000 has suggested that the best discussions and plans of care may not be documented in the directive.

The use of a comprehensive DA that mentions specific issues can serve as a vehicle to promote discussion among the patient, family, proxy, and provider regarding the patient's values and thoughts on quality of life. Orentlicher (1990) suggested that this type of comprehensive document would increase the representative's understanding of the patient's wishes regarding medical care. There are several limitations to this analysis. First, we examined a select number of issues; other issues, such as pain relief and organ donation, are also important.

Second, some states did not have legal documents. As a result, there are variations within these states in how AD documents are completed. Third, even for states that do have legal documents, people can use AD forms other than legal forms. However, it is likely that forms will be written that closely resemble legal forms.

A 1998 study found that in an Illinois hospital, 84 of 86 living wills and 206 of 210 durable powers of attorney for health care directives were standard state forms (Gross 199). Fourth, we do not examine specific state statutes; some issues may be addressed in statutes but not mentioned in forms. We considered that it was more relevant to evaluate forms than statutes, since communication on a specific topic may be neglected when it is not included in the form. Fifthly, we did not examine differences in definitions, either in the documents themselves or in the accompanying instructions.

States may differ substantially in the definitions of problems, including definitions of disability, terminal illness and life-sustaining measures, or specific definitions may be lacking. They may also differ in the way the choice on a topic is presented. This is an important area for future studies. Frequency of issue Inclusion by document type Limited power of attorney for living will, broad power of attorney for DPAHC and AHCD.

Frequency coverage Comparison of states with and without Advance Health Care Directive (AHCD) documents Inclusion of key issues in state documents by region of country The issue counted as included by a state if it is on one or more of its documents. Definitions and Other Accepted Names for Document Types Definitions and Equivalent Language Examples for Key Issues Documents Officially Approved by States and Washington, DC. DPAHC %3D Durable Power of Attorney for Health Care; LW%3D Living Will, AHCD %3D Advance Health Care Directive. Percentage of states (including Washington, DC) addressing key issues.

Thanks for the attendance of Kathy Kleckner, June Jacobs, Rachel Habermann, Jessica Holt and Brian Goodman. Desbiens. Department of Commerce Administration, Economics and Statistics, Census Bureau Oxford University Press is a department of Oxford University. Promotes the University's goal of excellence in research, scholarships and education through worldwide publication.

This PDF is available only to subscribers For full access to this PDF, log in to an existing account or purchase an annual subscription. Advance directives must be in writing. Each state has different forms and requirements for creating legal documents. Depending on where you live, a witness may need to sign a form or be notarized.

You can ask an attorney to help you with the process, but it's usually not necessary. A power of attorney for health care or health care is a type of advance directive in which you name a person to make decisions for you when you are unable to do so. You should discuss the changes with your primary care physician and ensure that a new directive replaces an old directive in your medical record. A comparison was also made for the frequency of inclusion of issues by document type (living will, durable power of attorney for medical care, advance medical care directive).

Every adult should have an advance directive explaining the type of medical care they want or don't want when they can't make their own decisions. In some states, advance care planning includes a document called medical orders for life-sustaining treatment (POLST). There are several possible non-statutory modes of communication that can function as an advance directive. Frequency of coverage issuance comparing states with and without Advance Health Care Directive (AHCD) documents.

Other states have no specific restrictions or rules on whether or not they will accept advance directives from other states. In addition, make sure that your home state specifications for advance directives also cover the requirements of the second state. . .

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