On December 1, 1991 the Patient Self Determination Act (PSDA) took effect. This federal law requires all hospitals, nursing facilities, home health agencies, home health-care providers, and hospices to provide patients written information about advance directives. In general, an advance directive is a written instruction, recognized under state law, regarding the provision of medical care when an individual is incapacitated. It is made while the individual who signed it is competent.
There are two formal types of advance directives : a Living Will and a Durable Power of Attorney for Health Care (DPAHC).
Living Will
Under Title 10, Section 1044c of the US Code, a living will is a written declaration regarding the provision, withdrawal, or withholding of life-prolonging procedures, including hydration and sustenance, for the declarant whenever the declarant has a terminal physical condition or is in a persistent vegetative state. In other words, a living will tells a doctor or medical provider whether to provide, continue or withdraw any life-sustaining treatment whenever a person becomes physically incapacitated or unconscious and, therefore, unable to communicate his or her wishes, such as when in a state of coma.
Durable Power of Attorney for Health Care (DPAHC)
A DPAHC is a written authorization to an individual to make health care decisions for another person who has lost the capacity to make such decisions. This is more flexible than a living will since the treatment options are not limited by the document, but the proxy or attorney-in-fact (person given the DPAHC) must act in accordance with the conditions set forth in the document and must be a trusted person. Also, unlike a living will, the DPAHC is not only limited to end-of-life treatments. It could also include other health care related decisions.
According to the American Bar Association's online information section on Health Care Advance Directives, the combination of a living will and DPAHC is preferable because it is more comprehensive and flexible since it can include other directions, such as organ donation and the designation of the place and manner of care.
Enforceability of Advance Directives
Advance directives shall have legal effect even if they do not conform with the formalities required by state law. The PSDA deems them to have been executed in accordance with the laws of the state concerned. However, according to the final rules implementing PSDA (Federal Register: Vol. 60 No. 123, June 27, 1995, page 33294), health care providers are not required to carry out advance directives if they refuse to do so as a matter of conscience. But state law must allow such health care providers to make conscientious objections. In their book Health Care Ethics: Critical Issues for the 21st Century, John F. Monagle and David C. Thomasma say "[m]ost state directives do, in fact, include provisions for conscientious objection on religious, moral, or professional ethical grounds."
The rules require health care providers with conscientious objections to inform patients of such policy with clear and precise explanations upon admission.
Non-discrimination and Refusal of Care
Health care providers are not allowed to discriminate against a patient or refuse to provide care on the ground that such patient does or does not have an advance directive.
Do Not Resuscitate Order (DNR)
A do not resuscitate order (commonly known in medical parlance as DNR) is an instruction by a patient to his or her doctor not to administer cardiopulmonary resuscitation procedures (CPR) on him or her in the event of suffering a cardiac arrest. It is also considered as an advance directive although less formality is required to make it. It is indicated on the patient's medical chart by his or her doctor.
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