What Is an Advance Directive (Living Will)?

Detailed Explanation

An advance directive answers a question that neither a will nor a set of funeral wishes can: what should happen to your medical care if you're alive but can't speak for yourself? It lets you set that out in advance, while you're well enough to think it through, so the people around you aren't left guessing in a hospital corridor.

The term covers a family of documents rather than one form. Depending on the country, and often the state, it might be called a living will, an advance care directive, an advance health directive, or an advance decision to refuse treatment. The idea underneath is the same everywhere. For how it fits with the other planning documents, see the End-of-Life Planning hub.

The two jobs an advance directive can do

Most advance directive systems cover two separate things, sometimes in one document and sometimes in two:

• Your instructions. The treatments you would refuse or accept in particular circumstances, such as resuscitation (CPR), breathing machines, tube feeding or dialysis, plus the values you'd want decisions to be based on. This part is what people usually mean by a "living will."
• Your decision-maker. A person you trust to make health decisions for you when you can't. The name for this person changes from place to place: a substitute decision-maker or enduring guardian in Australia, an attorney under a health and welfare lasting power of attorney in England and Wales, and a health care agent or proxy in the US.

Written instructions can only cover the situations you thought of. A named person can deal with the ones you didn't, and can speak up for you in real time. That's why the two work best together.

When it applies, and when it doesn't

An advance directive only comes into play once you've lost the capacity to make or communicate a particular decision. As long as you can decide for yourself, you decide, and you can change your mind at any time.

It also has limits. It can refuse treatment, but it can't force doctors to give treatment they don't think is clinically appropriate. It can't be used to ask for assisted dying, which, where it's legal at all, has its own separate process. And it has no authority over your money or your estate: financial decisions while you're alive belong to a power of attorney, and your assets after death belong to your will.

How the Rules Differ Between Countries

Advance directives are recognised in many countries, but the law behind them is local. Three examples show how much the details can vary.

England and Wales. The NHS describes an advance decision to refuse treatment (sometimes called a living will) as legally binding if it complies with the Mental Capacity Act 2005, is valid, and applies to the situation. You must be 18 or over and have capacity when you make it. If it refuses life-sustaining treatment, it must be written down, signed by you and by a witness, and state clearly that it applies even if your life is at risk. An advance statement, which records wider wishes about your care, is a separate document. Naming a decision-maker is done through a health and welfare lasting power of attorney. Scotland and Northern Ireland have their own arrangements, so check NHS inform or nidirect there.

United States. The two common documents are a living will, which records the treatments you'd want or refuse, and a health care power of attorney, which names a health care agent or proxy. Each state has its own law and usually its own form, including its own witnessing or notary requirements. A do-not-resuscitate (DNR) order is a different thing again: it's a medical order made with your doctor, telling providers not to attempt CPR.

Australia. Every state and territory has its own legislation and form. Some call it an advance care directive, others an advance health directive, and some states combine your instructions and your substitute decision-maker in one document while others keep them separate. Australian health guidance says a directive is legally binding if you signed it with decision-making capacity, and that you don't need a lawyer.

Beyond these three, many other countries recognise some form of advance directive, but how binding it is, and the formalities it needs, differ. If you live in one country and spend long periods in another, don't assume a document made in one will be followed in the other.

How it works where you are

• In Australia: What is an advance care directive, and how do you make one in Australia? covers the state and territory forms, witnessing rules, and substitute decision-makers.
• In the UK and the US: there's no separate page on this yet. Planning ahead with no family in the UK and planning ahead with no family in the US both explain the local documents, including lasting powers of attorney and health care proxies.

Making One: The General Steps

The exact process depends on where you live, but it usually looks like this:

1. Get the official form or guidance for where you live. Health departments and official advance care planning services publish free versions. A generic template from another country or state may not meet local rules.
2. Think it through first. Talk to your doctor about what particular treatments involve and what your health conditions may mean. The most useful directives come from an honest conversation, not from ticking boxes quickly.
3. Choose your decision-maker, if you're naming one. Pick someone who knows your values, is willing to take it on, and can hold firm under pressure. It doesn't have to be a relative; see how do you plan ahead if you have no family or next of kin.
4. Sign and witness it correctly. Witnessing rules vary, and some documents also need registering or a doctor's involvement.
5. Share copies. Your doctor, your decision-maker and close family should all know it exists and where to find it.
6. Review it. Look at it again after a major diagnosis, a move, or a change in what matters to you.

Things to Consider

• Talk to the people who may be in the room. A document helps most when your family already knows what you want and why. How do you talk to your family about funeral wishes has ideas that work just as well for medical wishes.
• Be specific enough to act on. "I don't want to be kept alive on machines" is a start, but naming the treatments and the circumstances gives doctors and your decision-maker something they can actually follow.
• Moving changes things. If you move to another country or state, check whether your existing directive is recognised or needs remaking on the local form.
• It sits alongside your other plans. A will, a power of attorney and a record of your funeral wishes each cover a different moment. None of them replaces the others.

Common Mistakes

• Confusing it with a will. A will has no power over medical treatment while you're alive, and an advance directive has none over your estate.
• Writing it and telling no one. A directive locked in a drawer during an emergency can't guide anyone.
• Using the wrong form. A document written for one country or state may not meet the requirements where it needs to be used.
• Leaving it unchanged for decades. Health, relationships and values change. An old directive may no longer say what you'd want, or may name a decision-maker who is no longer the right person.
• Relying on family to "just know." Even close relatives can disagree under stress. Written wishes and a named decision-maker take that weight off them.