Nearing the End of Life

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Advance directives

It might not be enough to just tell your family what your wishes are for your medical care. You can choose the kind of treatment you get and refuse any treatment that you do not want, but only if you plan ahead. If you have not already made a decision about your care at the end of your life, now is the time to do it.

An advance directive puts your decisions about your future health care in writing. Advance directives are legal documents. One type of directive clearly states your wishes about who you want to make your medical decisions. Another type can give specific details about how you would like to die. Your doctors will generally follow instructions in your advance directive if you become unable to express your desires as your illness progresses, but only if they know about those wishes and have copies of your directive. Having an advanced directive helps take the burden off your family members and healthcare team. It also helps to ensure that you will get what you want up until the very end of your life. The main types of advance directives are briefly described below:

Durable power of attorney for health care

A durable power of attorney for health care (or DPOA) can also be called a medical power of attorney, a health care proxy, or an appointment of a health care agent.

A DPOA for health care is a written legal document. In it, you name someone who will make medical decisions for you if you become too ill to make decisions yourself. This person will talk to the doctors and health care team on your behalf and make decisions for you if you become unable to do so. In a DPOA for health care, you can also note the specific kinds of treatment or procedures you do or do not want.

If your wishes are not known, the person you appoint will make those decisions for you based on what they think you would want. So, you need to let that person know what you have in mind, and what you do and don’t want. Make sure that the person you choose understands your wishes, and that you feel certain that they can carry them out. Also be sure that your family members know who you have appointed as your decision-maker.

Living will

The other main type of advance directive is a living will. A living will gives you power to state your wishes if you can’t make decisions for yourself. The living will gives directions about the use of certain medical treatments at the very end of life. For example, you may state that you do not want a feeding tube or intravenous (IV) fluids at the end of your life. You may also decide you do not want CPR (cardiopulmonary resuscitation) if your heart stops or to be put on a breathing machine (called a ventilator) if you stop breathing on your own. This is something you should discuss with your family and healthcare team ahead of time, but it’s even better to have it written down, too. Having these issues clearly resolved to your satisfaction can give you and your family peace of mind.

Do Not Resuscitate and Do Not Attempt Resuscitation orders

If you are in the hospital, you can ask your doctor to add a Do Not Resuscitate (DNR) or an Allow Natural Death (AND) order to your medical record to keep staff from trying to revive you if you stop breathing. But an in-patient DNR or AND order is only good while you are in the hospital, and some hospitals may require a new form be signed each time you are admitted – even to the same hospital. There are other special orders that can be used in hospitals, such as “Do Not Intubate” (so that CPR would be tried but you wouldn’t be put on a breathing machine). Talk with your doctor about your options while you are in the hospital, and make sure your wishes are noted in writing.

Some states have a special Do Not Attempt Resuscitation (DNAR) order for use outside the hospital. The non-hospital DNR is intended for emergency medical service (EMS) teams, who answer 911 calls. In most cases, EMS must do everything they can to try and keep you alive. Even though families expecting a death are advised to call other sources for help when the patient gets worse, a moment of uncertainty sometimes results in a 911 call and unwanted measures that prolong death. The non-hospital DNR or DNAR order is a way for patients to refuse full resuscitation efforts even if the EMS is called. It must be signed by both the patient and the doctor.

Making sure your plans are followed

Once you’ve decided on your plan, it’s important that you share it with others who might be involved in your care. Your partner, adult children, and even your parents will need to know. Often older people assume that their adult children know what they want, but when asked, their children really don’t feel at all certain. This kind of misunderstanding leads to conflict, fear of making the wrong decision, or even avoiding making decisions when the time comes to do so.

Keep in mind that, without a written advance directive in hand, your doctor may ask your closest family members – spouse, parents, adult children – to make decisions when you can’t. In some states, there’s a legal sequence of who makes decisions when a family member can’t. States have very different laws, for example, requiring doctors to confer with next of kin, or calling for court-appointed guardians. A written advance directive helps to ensure things are handled the way you want them to be, but only if your doctor has a copy and your family knows about it. Even then, family members can sometimes challenge your directive if you can’t speak for yourself.

When called upon to make decisions about your health care, your family must feel sure about what you want in order to feel comfortable enough to voice these decisions. Even if you have it in writing, it helps prevent anxiety and conflict among your immediate family if they’re all very clear on what you want. It makes a difference when they hear it from you – it often means much more than hearing it from another family member or even seeing it in writing.

If your family is estranged, or if they are likely to feel uncomfortable and disagree over difficult emotional decisions, it’s even more important to have these things in writing and be sure everyone close to you knows about it.

More information on advance directives

  • Advance directives can only be used for decisions about medical care.
  • Other people cannot use them to control your property or money.
  • Advance directives take effect only when you are unable to make your own decisions.

Make copies of your advance directives and give copies to all of your health care providers. Talk to your family about your wishes so they know what you want. Be sure your closest family members can quickly and easily find a copy of your advance directive.

You can get more information in our document, Advance Directives. It can be ordered from our toll-free number or read on our website.

Organ and tissue donation

Some people are interested in donating organs. Even though you have cancer, you still may have the options of donating either your corneas (from your eyes) or your entire body for medical research. If you would like your body to benefit someone or some cause after your death ask your doctor about these options.

Organ and tissue donation instructions can be included in your advance directive. Many states also have organ donor cards or add notations to your driver’s license. Be sure that your family and those close to you know your wishes about this too. See our document, Can I Donate My Organs If I’ve Had Cancer? to learn more.

Letter of instructions

Although this is not a legal document, it can be very helpful. This letter can be a guide for your family to help them make decisions at the end of your life and after you are gone.

In the instructions, you can name who you want to look after or take in your children or pets. This is useful if the guardian you have named in your will lives out of state. You may also list names and phone numbers of those who should be contacted right after your death. This could include relatives, your lawyer, your financial adviser, the human resources manager at your former job, your insurance agent, or whomever else might need or want to be involved at this time.

You should list the location of important papers and bank and investment accounts. Note also the person who should contact these organizations. You may also want to leave instructions about the kind of funeral or memorial service you would like.

Copies of instructions should be given to the executor of your will, trusted family members, and/or other loved ones. Be sure to talk with the people who will need to carry out these instructions. Be sure they are willing to follow your requests and see if they have any questions about your wishes.

All of these documents should be kept in a safe place in your home. You can store originals in a safe deposit box if you want, but copies should be given to close family members, members of your health care team, and your lawyer. It’s important to make sure more than one person knows where these documents are and can get to them quickly if you aren’t there to let them into your home. It’s also important to tell your health care team what the documents say when and if the need arises. If your wishes have changed since you last set up such a document, be sure that old copies are destroyed and that your loved ones know where your new documents are.

Life insurance

If you have life insurance through your job and you leave your job, take your life insurance policy with you. You may be able convert it to an individual permanent policy with no proof of insurability, but you usually must do it within a month of leaving the job. You will have to pay the premiums out of pocket, but some employers have a policy with a feature called a “waiver of premium rider.” This means that you keep your group life insurance policy but you don’t have to pay the premiums if you are totally disabled. They are paid by the insurance company instead.

If you have your own individual life insurance policy, keep it active by paying the premiums on time. Find out if the policy has a waiver of premium rider. If it does, this could save you money and keep your policy in effect.

You may also want to double-check the beneficiary or beneficiaries you’ve named on your life insurance policy. Be sure the money is going to those you want to get it.

Last Medical Review: 01/14/2014
Last Revised: 02/06/2014