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Lisa M. Fuller, FNP

“Advance directive” is a term that can refer to various types of legal documents that declare an individual’s wishes for their future medical care.

These documents vary from state to state. You can obtain your state’s basic advance directive forms from many health care providers, eldercare attorneys, state health departments, your local Area Agency on Aging or download them from:

Prepare is a free service that aims to help make medical decision-making easier for people. It can be a good resource for those who need a little help walking through the process.

When creating an advance directive, it's a good idea to consult with your loved one’s doctor, geriatric care manager, or another health care provider who's very familiar with 

When your loved one creates an advance directive, be sure they:

Follow their state’s requirements so that the advance directives will be valid.

Discuss wishes with their health care provider, loved ones, and at least one person who will be able to make decisions for them should they become incapacitated (known as a health care proxy, agent, or representative).

 discussions with the doctor through their 

Some common types of advance directives are described below.

Advance Directive

Our focus here is on helping family caregivers assist a loved one to complete the advance care planning process, but really, any adult in any stage of health should go through the process of advance care planning. After all, none of us knows when an accident or unexpected event can drastically alter life as we know it!

Unfortunately, when tragedy strikes, families are all too often left struggling to figure out what to do – and often, not everyone is on the same page. Headache and heartache abound when family members disagree about how to handle tough situations.

Advance care planning lets your loved one 

make their wishes known in the event that they can no longer speak for themselves

. It makes it much more likely that they will end up receiving the kind of care that they’d like, and it can alleviate a lot of stress and strife among members of the family.

Who is Advance Care Planning Right For?

Once advance care decisions have been made, it’s vital to document them in such a way that they'll be honored by healthcare providers and financial institutions, should the need arise. The major documents you should familiarize yourself with are included here.

How to Document Advance Care Wishes

Helping your loved one with the advance care planning process entails:

Learning about which decisions may need to be made should they become incapacitated

Making decisions about possible future care scenarios

Choosing who can manage finances, if they become incapacitated

Choosing who can make medical decisions, if they become incapacitated

Discussing these decisions and wishes with key loved ones

Documenting the decisions in a legally-binding format

Storing the original documents in a safe-yet-accessible place

Providing copies of the documents to the healthcare proxy, doctor and medical providers, and other key people.

Revisiting the documents/decisions periodically (every 10 years or so, or when there are changes in health or circumstance)

What is the Advance Care Planning Process?

) document grants a person – called an agent – authority to act on your loved one’s behalf. This could allow the agent to manage bank accounts, sell property, file taxes and handle other financial matters. POAs are sometimes limited to specific matters or to a specific period of time.

A “durable” power of attorney remains in effect even if your loved one becomes mentally incapacitated.

A durable POA won’t allow the agent to make medical decisions about your loved one’s health. They’ll need a Healthcare Power of Attorney for that.

A durable power of attorney for healthcare names the person who can make medical decisions for your loved one in the event that they become unable to do so for themselves. The person they name is called their health care proxy, representative, surrogate, or agent.

Your loved one should NOT just choose whoever happens to live closest to act as their proxy. It’s important to choose the right person for the job. The person selected should:

be willing and able to advocate for them if needed.

 is a legal document that describes which types of medical treatments your loved one would – or wouldn't – want to be used to keep them alive should they become terminally ill or permanently unconscious.

Each state has its own forms and rules regarding exactly what’s covered in a living will. Generally, they address areas such as:

Cardiopulmonary resuscitation (CPR) if the heart has stopped beating

Use of tube feeding (and for how long) if unable to eat or drink

Dialysis to remove waste from the body if kidneys aren’t able to do so

Antibiotic or antiviral medication to fight infections

 (supporting comfort as the end of life nears)

 is a document intended for individuals who are seriously ill, very frail, or near the end of their life. It is an order that must be signed by a health care provider such as a doctor or nurse practitioner. The POLST instructs other health care providers – such as paramedics or hospital staff – to refrain from life-sustaining treatment, such as CPR.

The forms vary from state to state. In some 

, such as POST, MOLST, or MOST. They aren’t yet fully available in every location. You can find out more at the National 

, or talk to your loved one’s doctor about whether a POLST is available in your area, and whether it would be appropriate in your loved one’s case.

Types of Advance Directives

There are many reasons people don’t create advanced care plans – they don’t want to think about death or dying, they’re confused about the process, or they simply don’t know about it. However, there really isn’t any reason that they shouldn’t.

Like creating a will or trust, because the unforeseen can happen at any time, starting the 

 as early as possible is strongly recommended.

If your loved one hasn’t yet done this, it should rank high on the list of priorities. Fortunately, there are plenty of resources to help walk you both through the process.

Why Shouldn’t My Loved One Create an Advance Care Plan?

Explore our comprehensive guide on Advance Care Planning. Learn how to prepare, document, and communicate medical wishes for your loved ones, ensuring their care preferences are respected. Ideal for family caregivers at any health stage.

Complete Guide to Advance Care Planning for Family Caregivers

Whether your loved one needs skilled medical care or just a little help in a home-like setting, there are several options when it comes to long-term care.

Introduction

If your loved one has complex medical conditions – or needs a lot of help with mobility – a nursing home (or skilled nursing facility) may be the only place that can meet their needs. It’s also easier for those who are 

 to arrange for Medicaid to cover nursing home costs than other long-term elderly care types.

Independent living can be a good choice for seniors who are mostly independent but would benefit from a friendly, supportive neighborhood and a little help with yard work and home maintenance.

Seniors who can manage fairly well on their own with a little help with meals, dressing, bathing, housekeeping, shopping, and companionship often do well in an assisted living apartment. A good option for senior living.

Residential care comes in a variety of sizes and setups, such as adult foster homes, group homes, and facility settings. They tend to emphasize a home-like environment and offer assistance with personal care, meals and housekeeping. Some homes are designated for special populations, like LGBTQ+, or those who share particular languages, cultures, or religions. This can make a big difference in your loved one’s sense of belonging.

Memory care services offers special programming for seniors with Alzheimer’s disease and other forms of dementia. They’re especially suited to seniors who are at risk for wandering. Some focus on helping your loved one function at their best despite their challenges.

Life care communities (also called continuing care retirement communities or CCRCs) typically offer independent living, assisted living, a nursing home, and sometimes memory care on the same campus so that as your loved one’s needs change they can remain part of the same community.


 can assist with senior living like personal care, housekeeping, laundry, shopping, transportation, pet care, meal preparation, and other tasks that can help them live independently with the proper support and supervision. A good option for a family member to stay at home for day care.

Home health services features licensed healthcare professionals, such as nurses and therapists, who can tend to wounds or perform other medical care in the home. Physical or occupational therapists can help modify the home for safety and independence, and help your loved one function at their best.


Palliative care services helps minimize suffering and symptoms for people who live with chronic diseases. They work to stabilize conditions such as pain, shortness of breath, and other issues that make living independently a challenge. They focus on quality of life, so if your loved one wants to stay at home, they can help identify resources to support that goal. Palliative care can be provided in a home or facility setting.

People who are expected to live less than six more months are generally eligible for hospice care services, which can be provided in the home or a facility. With hospice care services and assistance, it’s sometimes possible to remain in the home. There are also specialized hospice group homes in some areas. These can be perfect for those who need more help than they can get at home but want to remain in a peaceful, home-like environment.

Types of Senior Care Services

There’s been an influx in online do-it-yourself (DIY) estate planning services popping up over the last few years. Promising a quick, easy and inexpensive alternative to exorbitant attorney fees, it’s easy to understand their draw.

In some cases, DIY estate planning software can be a good option. For example, individuals with very simple estates – and very simple family dynamics – who wish to leave everything to their next of kin can often get by with an online will-maker service.

However, individuals who own real property, have complicated estates, dependents, or complex family systems should consult with an attorney.

Using a DIY Service as a Starting Place Can be a Smart Approach

If you decide to opt for a DIY approach to estate planning, it’s a good idea to run the completed documents by a local lawyer to ensure they’re compliant with state law and that they reflect your loved one’s wishes accurately.

Although DIY will makers typically claim that their forms are legally binding in all states, it’s not always the case. An overlooked change in law, a typo, or small detail can end up costing the estate thousands of dollars – much more than was ever saved in attorney fees in the first place.

Furthermore, a living lawyer knows which questions to ask and can offer customized guidance throughout the process, which can really impact the estate’s value (and minimize potential future headaches) when compared to an automated one-size-fits-all approach.

Starting the will online can be smart though – it can save you valuable time in the lawyer’s office, which will minimize any hourly fees.

) include a consultation with an attorney in your state as part of an estate-planning package. This can be a good compromise that minimizes risk while keeping costs down.

Legal insurance companies also tend to cover estate planning and include consultation with legal counsel, so signing up for a month of service (or a free trial) can be a financially savvy move.

DIY Estate Planning and Online Legal Documents

Considering senior care but not sure where to start? Uncover the various senior care types and make an informed decision for your family needs.

Lisa M. Fuller, FNP

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