Planning for medical decisions you might not be able to make yourself is one of the most important steps in protecting both your wishes and your family. The terminology around these documents can be confusing because states use different names for similar documents, and the documents themselves serve overlapping but distinct purposes.
Understanding the differences between living wills, healthcare directives, healthcare powers of attorney, and POLST forms helps you create a comprehensive plan that ensures your medical preferences are known and honored in any situation.
The Terminology Challenge
Before examining each document type, it helps to understand why the terminology creates so much confusion. States developed their own laws for advance care planning at different times, using different names for similar concepts. What California calls an Advance Health Care Directive might be called a Healthcare Proxy in Massachusetts or a Medical Power of Attorney in Texas.
Additionally, the term “advance directive” is used in two ways. Sometimes it refers to a specific document combining treatment preferences and agent designation. Other times it serves as an umbrella term covering all documents that communicate future healthcare wishes. This article uses “advance directive” as the umbrella term encompassing living wills, healthcare powers of attorney, and combined documents.
The key insight is that these documents work together as parts of a comprehensive advance care plan. Each serves a specific purpose, and most people benefit from having multiple documents in place.
Living Wills: Documenting Treatment Preferences
A living will is a written document that states your preferences for medical treatment if you become unable to communicate those preferences yourself. Despite its name, a living will has nothing to do with distributing property after death. That document is a last will and testament, which serves an entirely different purpose.
What a Living Will Covers
Living wills typically address situations where you are terminally ill, permanently unconscious, or in a condition from which recovery is not expected. The document states which life-sustaining treatments you want or do not want under these circumstances.
Common treatments addressed in living wills include cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition through feeding tubes, artificial hydration through IV fluids, dialysis, antibiotics, and other medical interventions that could prolong life without restoring health.
The document allows you to specify different preferences for different situations. You might want aggressive treatment if there is reasonable hope of recovery but prefer comfort care only if you are in a persistent vegetative state with no chance of regaining consciousness.
Limitations of Living Wills
Living wills have significant limitations that make them insufficient as standalone documents. The primary limitation is that they only take effect under specific circumstances, typically terminal illness or permanent unconsciousness. They do not cover temporary incapacity from accidents, surgeries, or reversible medical conditions.
Another limitation is that living wills cannot anticipate every medical situation. Medical decisions often involve nuances and trade-offs that a written document cannot fully address. A physician might face choices between treatments with different risk profiles, or new treatment options might emerge that did not exist when you wrote the document.
Living wills also cannot advocate for you. A document stating your preferences cannot answer questions, provide context, or push back against recommendations that conflict with your values. This is why most estate planning professionals recommend combining a living will with a healthcare power of attorney.
Healthcare Power of Attorney: Naming Your Decision-Maker
A healthcare power of attorney, also called a medical power of attorney, healthcare proxy, or healthcare surrogate depending on your state, is a document that names someone to make medical decisions on your behalf when you cannot make them yourself.
The Role of Your Healthcare Agent
The person you name is typically called your healthcare agent, healthcare proxy, healthcare surrogate, or attorney-in-fact for healthcare. This person does not need legal or medical training. What matters is that they understand your values, can handle difficult decisions under pressure, and will advocate for your wishes even when facing resistance.
Your healthcare agent’s authority typically begins when your physician determines you lack capacity to make your own medical decisions. This might happen because you are unconscious, under anesthesia, experiencing dementia, or otherwise unable to understand and communicate about your medical situation.
Once activated, your healthcare agent can consent to or refuse treatments, access your medical records, hire and fire healthcare providers, and make decisions about where you receive care. The agent should make decisions based on what you would want, not what they personally think is best.
Choosing the Right Person
Selecting your healthcare agent is one of the most important decisions in advance care planning. Consider someone who knows your values regarding quality of life, medical intervention, and end-of-life care. They should be able to have difficult conversations with medical professionals and family members.
Your agent should be willing to serve in this role. The responsibility can be emotionally challenging, particularly when making end-of-life decisions for a loved one. Have explicit conversations about your wishes so your agent understands your preferences and feels confident making decisions on your behalf.
Many people name a spouse or adult child, but you might choose a close friend, sibling, or other trusted person. Consider naming an alternate agent in case your primary choice is unavailable when needed.
Limitations of Healthcare Power of Attorney Alone
A healthcare power of attorney without accompanying guidance leaves your agent to guess your preferences. While your agent should know you well, explicitly documenting your wishes provides clarity and reduces the burden of decision-making during an already stressful time.
Your agent also cannot act immediately in emergencies. Emergency medical technicians responding to a 911 call will provide standard emergency care regardless of what your healthcare power of attorney says. They do not have time to locate documents or contact agents when someone is in cardiac arrest.
Combined Advance Directives
Many states now offer or recommend combined documents that include both treatment preferences (the living will component) and agent designation (the healthcare power of attorney component). These combined documents are often called advance healthcare directives, advance directives for healthcare, or simply advance directives.
Advantages of Combined Documents
Combined documents ensure that your treatment preferences and agent designation work together. Your agent has documented guidance about your wishes, and if a situation arises that your written preferences do not address, your agent can make decisions based on their knowledge of your values.
Using a single document also simplifies execution. You complete one form, arrange for witnesses or notarization once, and distribute one document to healthcare providers and family members.
State-Specific Forms
Each state has its own requirements for advance directives, and many states provide statutory forms. These are forms specifically authorized by state law that, when properly completed, must be accepted by healthcare providers in that state.
Using your state’s statutory form provides certainty that your document meets legal requirements. However, statutory forms are often written in legal language and may not encourage the kind of thoughtful reflection that leads to clear, personal preferences.
You do not necessarily have to use your state’s statutory form. Most states accept other forms that substantially comply with state requirements. However, using a non-statutory form creates some risk that providers might question its validity.
Five Wishes: A Popular Alternative Form
Five Wishes is an advance directive created by the nonprofit organization Aging with Dignity. It has become one of the most widely used advance directive forms in the United States, with over 40 million copies distributed since its introduction in 1996.
What Makes Five Wishes Different
Five Wishes combines the legal requirements of an advance directive with attention to personal, emotional, and spiritual concerns that statutory forms often overlook. The document addresses five areas.
- Wish One – designates your healthcare agent, functioning as a healthcare power of attorney.
- Two – documents your preferences for medical treatment, functioning as a living will.
- Three – addresses your comfort preferences, such as pain management and personal care.
- Four – covers how you want to be treated by caregivers, addressing dignity and respect.
- Five – provides an opportunity to share final messages with loved ones.
The document uses plain language rather than legal terminology, making it more accessible for people completing it and for healthcare providers implementing it.
Legal Validity of Five Wishes
Five Wishes meets the legal requirements for an advance directive in 46 states and the District of Columbia. The American Bar Association’s Commission on Law and Aging helped develop the document to ensure broad legal validity.
Four states have additional requirements. In New Hampshire, Kansas, Ohio, and Texas, you may need to attach state-specific forms or take additional steps. Wisconsin requires attaching a notice statement, which Five Wishes provides. Michigan and North Dakota require your agent to sign an acceptance form before acting on your behalf.
Execution Requirements
Five Wishes must be signed and witnessed according to your state’s requirements. Most states require two adult witnesses who observe your signature. The witnesses confirm that you signed voluntarily and appeared to be of sound mind.
Four states require notarization: Missouri, North Carolina, South Carolina, and West Virginia. If you live in one of these states, you must have your Five Wishes notarized in addition to having it witnessed.
Witness restrictions apply in most states. Typically, your healthcare agent cannot serve as a witness. Many states prohibit relatives, beneficiaries of your estate, or your attending physician from witnessing. The specific restrictions vary by state and should be checked before signing.
POLST: Medical Orders for Seriously Ill Patients
POLST stands for Physician Orders for Life-Sustaining Treatment, though different states use different names. You might see MOLST (Medical Orders for Life-Sustaining Treatment), COLST (Clinician Orders for Life-Sustaining Treatment), MOST (Medical Orders for Scope of Treatment), or POST (Physician Orders for Scope of Treatment) depending on your state.
How POLST Differs from Advance Directives
The fundamental difference between POLST and advance directives is that POLST is a medical order, not a legal document. Advance directives express your wishes, which healthcare providers should honor. POLST translates your wishes into actionable medical orders that providers must follow.
This distinction matters most in emergency situations. When you call 911, emergency medical technicians must provide standard emergency care. They cannot honor advance directives or healthcare powers of attorney because they are not medical orders. EMTs can honor POLST forms because POLST is a physician order that travels with you across healthcare settings.
Another key difference is the intended population. Advance directives are recommended for all adults regardless of health status. POLST is specifically designed for people who are seriously ill or frail, typically those whose physician would not be surprised if they died within a year.
What POLST Covers
POLST forms typically address four main areas. Section A – covers cardiopulmonary resuscitation, with options to attempt CPR or not attempt resuscitation (DNR). Section B – covers medical interventions, with options ranging from full treatment to comfort-focused treatment only. Section C – addresses antibiotics, with options ranging from full treatment to comfort measures only. Section D – covers artificial nutrition, with options about feeding tubes and IV nutrition.
The specific sections and options vary by state, but all POLST forms translate patient preferences into medical orders that emergency personnel can act on immediately.
Creating a POLST
Unlike advance directives, which you can complete yourself, POLST requires a conversation with a healthcare provider. Your physician, nurse practitioner, or physician assistant discusses your medical situation, treatment options, and goals of care. Based on this conversation, you and your provider complete the POLST form together.
Both you (or your healthcare agent if you lack capacity) and your healthcare provider must sign the POLST. This dual signature requirement ensures that the form reflects an informed, shared decision rather than a unilateral choice.
POLST forms are typically printed on brightly colored paper, often pink or green depending on the state, to ensure they stand out and are easily located in emergencies. The form should be kept where it can be found quickly, such as on the refrigerator at home or at the front of a medical chart in a care facility.
POLST Availability by State
As of 2025, 43 states and Washington, D.C., have codified POLST programs into state law or have officially recognized state forms. The remaining states are in various stages of developing POLST programs.
Each state’s POLST form reflects that state’s specific requirements and may use different terminology or organize sections differently. The National POLST Collaborative provides information about state programs and access to state-specific forms.
Witness and Notarization Requirements
State requirements for executing advance directives vary significantly. Understanding your state’s requirements ensures your documents will be legally valid and honored by healthcare providers.
Witness Requirements
Most states require two adult witnesses to observe your signature on an advance directive. The witnesses must typically be at least 18 years old and appear competent to serve as witnesses.
States impose restrictions on who can serve as a witness to prevent conflicts of interest. Common restrictions include prohibiting your healthcare agent from serving as a witness, prohibiting relatives by blood, marriage, or adoption, prohibiting anyone who would inherit from you, prohibiting your attending physician, and prohibiting employees of your healthcare provider.
The specific restrictions vary by state. Some states impose all of these restrictions while others impose only some. Review your state’s requirements or the instructions on your advance directive form carefully.
Witnesses do not need to read your document or agree with your choices. They simply confirm that you appeared to be of sound mind, signed voluntarily, and are the person you claim to be.
Notarization Requirements
Some states require notarization instead of or in addition to witnesses. A notary public verifies your identity, confirms you are signing voluntarily, and adds their official signature and seal to the document.
States that require notarization for advance directives include Missouri, North Carolina, South Carolina, and West Virginia. Several other states require notarization for the healthcare power of attorney portion but not the living will portion.
Many states offer a choice between witnesses and notarization. California, for example, allows you to have your advance directive either witnessed by two adults or notarized. If you choose witnesses, at least one must be unrelated and not entitled to inherit from you.
Even when notarization is not required, it can add an extra layer of validity. Some healthcare providers feel more confident accepting notarized documents, particularly if they are unfamiliar with the specific form you used.
Special Requirements for Facility Residents
Some states impose additional requirements for people living in nursing homes, skilled nursing facilities, or other care settings. California, for example, requires that advance directives for nursing home residents be witnessed by a patient advocate or ombudsman in addition to other witnesses.
These requirements protect vulnerable populations from potential coercion or undue influence by facility staff or family members. If you complete an advance directive while residing in a care facility, verify whether additional requirements apply.
Remote Execution Options
The COVID-19 pandemic accelerated adoption of remote notarization and witnessing for many legal documents. Some states now allow advance directives to be witnessed or notarized remotely via video conference.
BlueNotary provides remote online notarization services for advance directives and other estate planning documents in states that permit remote execution. This option can be particularly valuable for people with mobility limitations or those who live far from notary services.
However, remote execution rules vary by state and may not be available for all document types. Verify your state’s current requirements before relying on remote execution.
How These Documents Work Together
Advance directives, healthcare powers of attorney, and POLST forms serve complementary purposes. Understanding how they interact helps you create a comprehensive advance care plan.
Advance Directives Provide the Foundation
Your advance directive establishes your healthcare agent and documents your general treatment preferences. This foundation applies to any medical situation where you cannot make your own decisions.
The advance directive is appropriate for healthy adults who want to plan for unexpected illness or injury. It addresses the broadest range of scenarios and provides guidance for decisions that cannot be anticipated.
POLST Addresses Immediate Medical Situations
If you develop a serious illness or become medically frail, POLST translates your general preferences into specific medical orders. POLST addresses the particular treatments most likely to arise given your current medical condition.
POLST supplements rather than replaces your advance directive. Your advance directive still designates your healthcare agent and provides guidance for decisions beyond what POLST covers. POLST provides the actionable orders that emergency personnel can follow immediately.
Resolving Conflicts
If your POLST and advance directive conflict, healthcare providers generally follow the more recent document, assuming it represents your current preferences. However, this can create confusion and delay.
The best practice is to update all documents together when your preferences change. If you complete a POLST, review your advance directive to ensure consistency. If your advance directive preferences change, discuss whether your POLST should be updated as well.
Your healthcare agent can also clarify your wishes if documents appear to conflict. This is one reason why naming a healthcare agent who truly understands your values is so important.
Ensuring Healthcare Providers Honor Your Documents
Creating advance care documents accomplishes nothing if healthcare providers do not know about them or do not follow them. Taking specific steps to ensure your documents are accessible and honored is essential.
Make Documents Accessible
Keep your original advance directive in a location where it can be found if needed. A desk drawer or file cabinet in your home works well. Do not store the original in a safety deposit box, which may be inaccessible in emergencies.
Give copies to your healthcare agent, your primary care physician, and any specialists who provide ongoing care. If you have a POLST, ensure it is prominently displayed at home, such as on the refrigerator, and that care facilities have copies.
Consider carrying a wallet card that identifies your healthcare agent and indicates where your advance directive is located. Many advance directive forms include wallet cards for this purpose.
Discuss Your Wishes
Documents alone are not enough. Have conversations with your healthcare agent, family members, and physicians about your values and preferences. These conversations help everyone understand not just what treatments you want but why you want them.
When your healthcare team understands your values, they can make better decisions in situations your documents do not specifically address. They can also advocate more effectively for your preferences with other providers or family members who might disagree.
Provide Documents to Hospitals
When you are admitted to a hospital or other healthcare facility, provide a copy of your advance directive. Most facilities ask about advance directives during admission and will include your documents in your medical record.
If you have a POLST, provide it at every admission. The POLST should be placed at the front of your medical chart so it is immediately available if an emergency arises.
Register Your Documents
Some states maintain registries where you can file advance directives for easy access by healthcare providers. Arizona, California, Idaho, Louisiana, Maryland, Montana, Nevada, North Carolina, Oregon, Vermont, Virginia, Washington, and West Virginia all maintain some form of advance directive registry.
Registration is typically voluntary and may involve a small fee. The advantage is that healthcare providers can access your documents even if you are unable to provide them, such as if you are found unconscious away from home.
Understand Provider Obligations
Healthcare providers are generally required to honor valid advance directives. Federal law requires hospitals receiving Medicare or Medicaid funding to inform patients about advance directives and to document whether patients have them.
However, providers may decline to follow advance directives in limited circumstances. A provider who has moral or religious objections may transfer your care to another provider. A provider may decline to follow instructions that conflict with accepted medical practice or that the provider believes are based on outdated or incorrect medical information.
If a provider refuses to follow your advance directive, they should inform you or your healthcare agent and facilitate transfer to a provider who will honor your wishes.
Address Religious Hospital Policies
If you receive care at a religiously affiliated hospital, be aware that institutional policies may limit certain treatments. Catholic hospitals, for example, follow the Ethical and Religious Directives for Catholic Health Care Services, which prohibit certain procedures.
Discuss potential conflicts with your physician before an emergency arises. If your preferences might conflict with a hospital’s policies, consider whether you should seek care at a different facility for planned procedures.
State-Specific Considerations
While advance care planning principles apply nationwide, execution requirements and available forms vary by state. Consider these state-specific factors when creating your documents.
Using Out-of-State Documents
If you spend time in multiple states, such as retirees who winter in a different state, your advance directive from one state may or may not be honored in another.
Most states recognize advance directives from other states if the document meets either the requirements of the state where it was executed or the requirements of the state where it is being used. However, some states have limited or unclear provisions for out-of-state documents.
The safest approach is to execute advance directives that comply with the requirements of each state where you spend significant time. At minimum, if you relocate permanently, execute new documents that comply with your new state’s requirements.
Updating After Major Life Changes
Review and update your advance care documents when you experience major life changes. Marriage, divorce, serious illness, relocation to a new state, or changes in family relationships may all warrant updates.
If your healthcare agent is no longer appropriate, such as after a divorce from a spouse who was named as agent, execute a new document naming a different agent. Simply destroying the old document may leave you without a valid advance directive.
Working with an Attorney
You do not need an attorney to create advance directives. State statutory forms and tools like Five Wishes allow you to complete documents yourself. However, consulting an estate planning attorney can be valuable if your situation is complex, if you want to ensure your documents integrate properly with your overall estate plan, or if you have questions about your state’s specific requirements.
An attorney can also help if you want to include provisions beyond what statutory forms address, such as specific instructions about experimental treatments, religious considerations, or preferences about organ donation.
Common Mistakes to Avoid
Certain mistakes commonly undermine advance care planning. Avoiding these pitfalls helps ensure your documents work as intended.
Failing to Complete Any Documents
The most common mistake is simply not creating advance directives. Many people intend to complete these documents but never get around to it. Unexpected accidents and illnesses happen at any age, making advance planning important for all adults.
Completing Documents but Not Sharing Them
Documents locked away where no one can find them cannot guide healthcare decisions. Ensure your healthcare agent, family members, and physicians all have copies and know where to find the originals.
Naming an Inappropriate Healthcare Agent
Naming someone who does not know your wishes, who cannot handle difficult decisions, or who will be unavailable when needed undermines your planning. Have explicit conversations with your chosen agent and ensure they are willing and able to serve.
Using Outdated Documents
Preferences often change over time, particularly after health changes. Review your documents periodically and update them to reflect your current wishes. Destroy old versions to prevent confusion.
Assuming One Document Covers Everything
Different documents serve different purposes. A living will alone does not name a decision-maker. A healthcare power of attorney alone does not document your preferences. POLST alone does not apply to non-emergency situations. Comprehensive planning typically requires multiple documents.
Failing to Update POLST After Health Changes
POLST reflects your preferences given your current medical condition. If your condition changes significantly, review your POLST with your healthcare provider to ensure it still reflects appropriate choices.
Frequently Asked Questions
What is the difference between a living will and a regular will?
A living will addresses medical treatment decisions while you are alive but unable to communicate. A regular will, or last will and testament, addresses distribution of your property after death. Despite sharing the word “will,” these documents serve completely different purposes.
Do I need both an advance directive and a POLST?
If you are healthy, an advance directive is sufficient. POLST is designed for people who are seriously ill or medically frail. If you develop a serious illness, your physician may recommend completing a POLST in addition to your existing advance directive.
Can I write my own advance directive?
Yes. Most states allow you to use statutory forms or other forms that meet state requirements. You do not need an attorney, though consulting one can be helpful for complex situations. You do need to follow your state’s requirements for witnesses or notarization.
What if my family disagrees with my advance directive?
Your validly executed advance directive should be followed even if family members disagree. Your healthcare agent speaks for you and should advocate for your documented wishes. This is why having conversations with family about your values is important, even though their agreement is not legally required.
Can emergency medical technicians honor my advance directive?
No. EMTs cannot honor advance directives because these documents are not medical orders. EMTs can honor POLST forms because POLST is a medical order. If you want emergency personnel to follow specific instructions, such as not attempting resuscitation, you need a POLST or similar medical order.
How often should I update my advance directive?
Review your advance directive at least every few years and after major life changes such as marriage, divorce, serious illness, or changes in your healthcare agent’s availability. You can revoke or update your advance directive at any time as long as you have mental capacity to do so.
Do advance directives work across state lines?
Most states honor advance directives from other states if they meet either the state of execution’s requirements or the state of use’s requirements. However, to ensure your documents are honored, consider executing documents that comply with every state where you spend significant time.
What if I change my mind while hospitalized?
You can revoke or change your advance directive at any time while you have capacity to do so. Simply telling your physician that you have changed your mind is effective to revoke previous instructions, though documenting the change in writing is preferable.
Conclusion:
Advance care planning involves multiple documents that work together to ensure your medical preferences are known and honored. Living wills document treatment preferences for end-of-life situations. Healthcare powers of attorney name a trusted person to make decisions on your behalf. Combined advance directives address both elements in a single document. POLST forms translate preferences into medical orders for seriously ill patients.
Understanding which documents you need, how to execute them properly, and how to ensure healthcare providers can access and honor them is essential for effective planning. Most adults benefit from having a combined advance directive that names a healthcare agent and documents treatment preferences. Those with serious illness should also discuss POLST with their healthcare provider.
The execution requirements vary by state. Most states require witnesses, some require notarization, and some offer a choice. Following your state’s specific requirements ensures your documents will be legally valid and accepted by healthcare providers.
Creating the documents is only the first step. Sharing copies with your healthcare agent, family members, and physicians, having conversations about your values, and updating documents when circumstances change are equally important for ensuring your wishes are ultimately honored.
Taking time now to complete advance care planning relieves your family of difficult decisions during crisis moments and gives you confidence that your medical care will reflect your own values and preferences regardless of what the future holds.
