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Advance Directives for Health Care Decisions

Sometimes, people are too ill to make health care decisions for themselves. This can happen very suddenly, so it is helpful to have an advance directive. An advance directive is a written statement of how you want medical care provided if, in the future, you cannot make decisions for yourself.

The choice to create an advance directive is up to you. The St. Jude staff wants you to know your options under the law. However, you are the one who must decide the best plan for your future care.

Person signing advance health care directive

Social work can assist in completing advance directives.

Types of advance directives

Advance directive options vary by state. In Tennessee they are set by the Tennessee Health Care Decisions Act, and there are 2 types of advance directives recognized:

Appointment of health care agent – This document lets you give someone else the power to speak for you. It is also called a durable power of attorney for health care or a health care proxy. You might hear many other names for the health care agent, such as representative, proxy, attorney-in-fact, guardian, or conservator. If you cannot make your own health care decisions because of injury or illness, your agent must make those choices for you. The health care agent is usually a relative or close friend.

Most often, the Appointment of Health Care Agent only goes into effect when you are unable to speak for yourself. However, Tennessee law does allow you the option of making your appointment take effect right away, even when you still can speak for yourself. You must make this desire known on the form. If you do not choose this option, the document will take effect only when you are unable to speak for yourself.

Advance care plan – An advance care plan is sometimes called a living will, a health care directive, or a health care declaration. This document lets you state what kinds of medical care you would or would not want if any of these happen to you: 1) you are in a permanent unconscious condition; 2) you have permanent confusion; 3) you become dependent in all activities of daily living; or 4) you are in the end stage of your illness.

It often refers to medical treatments that keep you alive. These measures can include:

  • CPR (cardiopulmonary resuscitation) to restart your heart and breathing after they have stopped
  • Assisted breathing using a ventilator
  • Dialysis using a machine that does the work of your kidneys
  • Nutrition or fluids given through IV or tube feeding
  • Chemotherapy, radiation therapy, or other treatments that might prolong life
  • Blood transfusions
  • Antibiotics to fight infection

You can also make health care decisions for medical treatments to provide comfort and relieve suffering during advanced illness. Comfort care may include managing pain, anxiety, nausea, shortness of breath, or other symptoms. Your care team can help you understand decisions and care choices that you might include in advance care planning.

Completing the advance directive forms

The 2 types of advance directives can be signed as separate papers. Or sometimes, they are combined in a single form. A St. Jude social worker can give you a copy of the forms that meet the requirements of Tennessee law. If you like, your social worker can help you fill out these forms. Some states require your advance directive documents to be witnessed or have your signature notarized to make it effective. Your social worker can help you find a notary public or witnesses for a Tennessee form. Witnesses cannot be health care workers, your health care agent, or anyone who will inherit from you. Only 1 of the 2 witnesses can be a family member.

Non-written option for advance care planning

It is always best to have your advance directive choices stated in a signed, legal document. However, if you are not able to appoint a health care agent in writing, you can still tell your doctor who you would want to speak for you should the need arise. The person you choose is called your surrogate. Your doctor will write the name of the surrogate in your medical chart. In the future, if you are unable to make health care choices for yourself, the medical staff will ask this person to make decisions if that person is available and willing.  

More options to discuss

DNR order – A do not resuscitate (DNR) order is a doctor’s written order that says, “If your breathing or heart stops, do not start CPR.” A DNR order can be part of an advance directive form or a separate written statement. The DNR can be included in a form called Physician Orders for Scope of Care (POST) that includes other information and can be shared with other hospitals and care centers that you might go to.

Donating organs – Some advance directive forms let you state your wishes about donating organs and tissues. It is important to let your family and health care agent know how you feel about donating organs and tissue for transplant to another person or for research.

Share your wishes with others

Take the time to sit down with your family or health care agent and talk about your wishes. Sometimes these topics are not easy to discuss. No one wants to think about being seriously ill, having to depend on others, or dying. Everyone must face death at some point. Planning how you would like your wishes carried out can help you gain a sense of control and can reduce fear and uncertainty. It allows you and your family to make decisions that match your priorities and values.

The more your health care agent, your doctor, and your family know about your wishes, the better able they will be able to make decisions for you if the need occurs.

Common questions

  1. How will decisions be made for me if I do not have an advance directive?

    If you become too ill to speak for yourself, treatment decisions will be made by your doctor and family based on your expressed wishes, if known, or if not, what they believe you would want, or what is best for you. However, without an advance directive you face 2 risks:

    Your family members and health care team may disagree about what actions to take.

    The doctor or your family may choose a course of treatment that you would not have wanted.

  2. Do I need a lawyer to create an advance directive?

    No. You can complete the legal form to create a Tennessee advance directive.  Your social worker can give you the form. They are easy to fill out. Some people may prefer to use a lawyer, but it is not required.

  3. Can I change my mind after I sign an advance directive?

    Yes. You may change or cancel your advance directive at any time. All you have to do is tell your doctor or give the doctor a copy of the new form. The doctor will make note of the change in your medical record. Also, make sure your family and health care agent know about the change.

  4. Who should know about my advance directive(s)?

    You decide who has access to your health care information, including your advance directive. However, you should inform your doctor and give the doctor a copy for your medical record. Most people also give a copy to the person they name as health care agent. Many people also give copies to their other health care providers and to close family members. Be sure to keep a copy with your important personal papers. The more your health care agent, your doctor, and your family know about your advance directive, the better able they will be able to carry out your wishes.

  5. Will my health care team honor my wishes as stated in my advance care plan?

    Almost always, the answer is yes. But, in some cases a health care provider may choose not to comply based on personal morals or ethics. For example, a provider may choose not to take part in certain aspects of patient care or treatment for cultural, religious, or ethical reasons, according to the St. Jude policy called Staff Rights: Refusal to Treat. Also, if an attending doctor feels that your request is medically inappropriate, the health care team might not comply with the wishes in your advance care plan. For reasons of conscience, an attending doctor can decline to comply with a patient’s or health care agent’s request to provide treatment, according to the St. Jude Policy on Withholding or Withdrawing Life-Prolonging Treatment. An example is when the health care team is asked to use all possible efforts to resuscitate a patient when the doctor does not consider it to be in the best interest of the patient. Many other hospitals have policies similar to these St. Jude policies.

  6. What are examples of care staff might not want to take part in?

    The list below includes types of care that some staff members might choose not to take part in. This is not a complete list, and employees may request not to take part for reasons not included in the list below.

    • Giving blood or blood products
    • Continuing treatment at the end of life
    • Stopping medical treatment needed to keep a patient alive
    • Stopping food and nutrition support

  7. What will happen if the staff decide not to take part?

    If the provider decides not to take part, that provider must try to transfer your care to another provider who can follow through with your wishes as stated in your advance care plan.

    Talk to your medical team about what will happen if your advance care plan cannot be honored, based upon St. Jude policy. Ask your medical team any questions about your advance care plan and what will happen if your advance care plan cannot or will not be followed.

  8. Will I need different advance directives for inpatient and outpatient visits?

    No. After you have completed an advance directive, it will be part of your medical record. Health care providers in both settings will have access to this document in your medical chart. You can bring a copy with you to other hospitals and doctor’s offices.

  9. Does my religion have anything to say about advance directives or the kinds of treatment I should choose?

    Most faiths approve of people making their own choices when it comes to health care, especially those that concern life-sustaining measures. If you have religious questions about making an advance directive, talk to your priest, minister, rabbi, other spiritual adviser, or the hospital chaplain.

  10. If 911 is called, will the paramedics follow my advance care plan?

    When someone calls 911, the emergency medical workers who come to your rescue will not change their response based on an advance care plan. They are not doctors. If they are called to a home or the scene of an accident, their job is to stabilize you and transport you to a hospital. The hospital is where treatment decisions will be made. However, some states do authorize 911 workers to follow a doctor’s written DNR order.

  11. Questions?

    To learn more about advance directives, talk to your social worker at St. Jude. If you are in the local area, call 901-595-3670. If you are outside the Memphis area, dial toll-free 1-866-2STJUDE (1-866-278-5833), extension 3670.

    You can also get information on the Tennessee Department of Health website.

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Reviewed: August 2022