The Gerontologist
Vol. 42, No. 1, 51–60
In the Public Domain
A Comparison of State Advance
Directive Documents
Gail Gunter-Hunt, MSW,1 Jane E. Mahoney, MD,1,2 and Carol E. Sieger, JD3
Purpose: Advance directive (AD) documents are based on
state-specific statutes and vary in terms of content. These
differences can create confusion and inconsistencies resulting in a possible failure to honor the health care wishes of
people who execute health care documents for one state
and receive health care in another state. The purpose of this
study was to compare similarities and differences in the
content of state AD documents. Design and Methods:
AD documents for 50 states and the District of Columbia
posted on the Partnership for Caring website were reviewed. States and regions of the country were compared
for type or types of documents used and issues included in
AD documents. Results: Three states had statutory living
will documents only; however, these states did allow for appointment of a health care agent for limited end-of-life decisions. Three states had statutory durable power of attorney
for health care documents only, 32 had both statutory living
will and durable power of attorney for health care documents, and 13 had statutory forms which combine both
types of directive in one document (advance health care directives). Of 8 identified key issues, those addressed by at
least 90% of states were designation of a proxy, personal
instructions for care, general life-sustaining measures, and
terminal illness. When document types were compared, advance health care directive documents included more of the
key issues than did living will or durable power of attorney
for health care documents ( p .001). Implications: This
variability suggests a need for national dialogue to standardize some provisions of AD documents.
wishes (i.e., capacity) to give directions for future
care in the event of incapacity. ADs have been recognized in some form by every state and the District of
Columbia. The Patient Self-Determination Act of 1990
provided congressional recognition of the right of
self-determination for patients in health care decision
making (Rich, 1998). This law requires hospitals,
health maintenance and managed care organizations,
nursing facilities, hospice programs, and home health
providers that participate in Medicare and/or Medicaid to advise patients of their rights to make health
care decisions with ADs (Haynor, 1998).
The two most common types of ADs are the living
will and the durable power of attorney for health
care. The living will is an instructional directive that
allows a person with decision-making capacity to
give instructions for medical treatment in the event
of incapacity at the end of life (typically because of
terminal illness or persistent vegetative state). The
durable power of attorney for health care is a health
care document that allows a person with capacity to
name a trusted person to act as a health care agent in
the event of incapacity. Although the statutes vary
from jurisdiction to jurisdiction, typically the agent
has broad powers for decision making when acting
in this surrogate role and is not limited to decision
making at the end of life.
Legislation in the United States regarding refusal
of life-sustaining medical treatment began in 1976
with the passage of the California Natural Death
Act. Other states followed with their own legislation
for living wills (Fade, 1994). In general, statutes for
durable power of attorney for health care were enacted later. Some states provide for only a living will
or durable power of attorney for health care, whereas
other states allow for both.
In 1993, the National Conference of Commissioners on Uniform State Laws drafted the Uniform
Health Care Decisions Act (Uniform Law Commissioners, 1994). This model Act recommended uniformity in ADs across states and replacement of existing
fragmented legislation with a single statute in each
state that would provide for one comprehensive AD
document. In accordance with this Act, some states
adopted a third type of AD, typically called an “advance health care directive.” This type of document
allows appointment of an agent to make health care
decisions and also includes a “living will directive”
Key Words: End-of-life treatment decisions, Advance
decision making, Medical ethics
Advance directives (ADs) allow adults who have
the ability to decide and communicate health care
This is Publication No. 0202 supported by the Madison VA GRECC.
We gratefully acknowledge the assistance of Kathy Kleckner, June Jacobs,
Rachel Habermann, Jessica Holt, and Brian Goodman.
Address correspondence to Gail Gunter-Hunt, William S. Middleton
Memorial Veterans Hospital, Geriatric Research, Education and Clinical
Center, 2500 Overlook Terrace, Madison, WI 53705. E-mail: gail.hunt@
med.va.gov
1
William S. Middleton Memorial Veterans Hospital, Geriatric Research, Education and Clinical Center, Madison, WI.
2
Department of Medicine, University of Wisconsin School of Medicine, Madison.
3
Partnership for Caring, Inc., New York, NY.
Vol. 42, No. 1, 2002
51
or other health care instructions section. The person
completing the document is usually provided the option of crossing out a section that he or she prefers
not to complete.
Each state has its own statutes and/or regulations
regarding ADs. Variations in state laws and types of
ADs may result in a plethora of differences in AD
documents, some of which can have important implications for the honoring of patients’ wishes. States
may differ not only in the type of document that is
explicitly authorized by state law, but also in the
extent to which a document mentions specific endof-life issues. Many state laws address the issue of
reciprocity and will honor an out-of-state directive;
however, provisions in out-of-state documents are
honored only to the extent that they conform to the
laws of the state where treatment is provided.
As our society becomes more mobile, it becomes
more important to understand state differences in
AD documents. More people now travel from state
to state, and it is not uncommon for people to maintain residences in two states. Many people live in one
state and receive their health care in another state.
The purpose of this study is to evaluate, in terms of
structure and content, similarities and differences in
AD documents across the United States.
broad decision-making authority. For this analysis,
these three states were counted as living will only.
Gail Gunter-Hunt, who is a social worker, and two
social work graduate students reviewed each document to categorize the type of document and summarize issues addressed in the document. From this, eight
topics were defined as key issues in decision-making:
(a) naming of any proxy, even when limited to situations of terminal illness or persistent vegetative state;
(b) personal instructions for care; (c) general life-sustaining measures; (d) terminal illness; (e) artificial sustenance; (f) persistent vegetative state; (g) admission to
a long-term care facility; and (h) advanced illness/dementia. Documents were then reviewed twice more
by Gail Gunter-Hunt to determine document type
and inclusion of the eight key issues. Document type
was defined as living will, durable power of attorney
for health care, or advance health care directive. Appendix B provides definitions and equivalent terms
for the three document types. Appendix C provides
definitions and equivalent language for the eight key
issues. An issue was considered as included in a document if the document had wording (first column of
Appendix C), a definition (essence of definition in
second column of Appendix C) or equivalent language (third column of Appendix C) for that issue. A
specific issue was considered as mentioned in the
document if some wording was used that indicated
the issue was addressed. More specifically, an issue
could be automatically included in a document, included only by a check mark of some kind, included
unless excluded by a check mark of some kind, or
automatically excluded. None of our eight key issues
were automatically excluded. When questions arose
regarding type or content of a document, decisions
were made by consensus between Gail Gunter-Hunt
and Jane E. Mahoney, who is a geriatrician.
States and regions of the country were compared
for type or types of documents used and issues included in state documents. The 1990 census map
identifying four major regions of the country (Northeast, South, Midwest, and West) was used to divide
the fifty states plus Washington, DC, into these regions (U.S. Department of Commerce, Economics
and Statistics Administration, Bureau of the Census,
1992). Comparison was made also for frequency of
issue inclusion by type of document (living will, durable power of attorney for health care, advance health
care directive). Pearson chi-square test was used to
determine significance of differences among groups
for more than two groups, and Fisher exact test was
used for two groups. To determine the significance of
differences in mean number of issues across groups,
we used one-way analysis of variance (ANOVA) for
more than two groups and two-sample t test for two
groups. Significance level was set at p .05.
Methods
We conducted a content analysis of statutorybased AD documents of all 50 states and Washington, DC. For this purpose, we obtained all AD documents posted on the Partnership for Caring (PFC;
formerly known as Choice in Dying) website (Partnership for Caring, 2000) as of October 2000. PFC
provides state-specific ADs and updates them continually as state statutes and/or documents change.
We included all AD documents from the PFC
website that were based specifically on state statutes.
Appendix A provides a listing of citations for state
statutes as a matter of reference. For six states that
had statutes but no suggested forms, PFC drafted
documents with the counsel of local attorneys in accordance with the statutes. These states were: Massachusetts (durable power of attorney for health care),
Michigan (durable power of attorney for health
care), Indiana (durable power of attorney for health
care), New Jersey (living will and durable power of
attorney for health care), South Dakota (durable
power of attorney for health care), and Tennessee
(durable power of attorney for health care). For New
York, Massachusetts, and Michigan, PFC provided a
living will document that has been recognized by
case law rather than by statute. These three living
will documents were not included in analysis. For
three states (Pennsylvania, Louisiana, and Montana),
statutes provide for living will only. However, two of
these states (Pennsylvania and Louisiana) have durable power of attorney for finances statutes that include a check-off section for health care. In fact, lawyers in all three of these states may draft power of
attorney for health care documents providing for
Results
Types of Documents Used by States
All 50 states and the District of Columbia had at least
one statute-based AD document. Three states had a liv52
The Gerontologist
ing will only (with limited proxy) and lacked the durable power of attorney for health care (Pennsylvania,
Louisiana, and Montana; 6%). Three states had durable
power of attorney for health care only (Massachusetts,
New York, and Michigan; 6%). Thirty-two (31 states
plus Washington, DC) had both living will and durable
power of attorney for health care (63%), and 13 states
had the combination document, advance health care directive (25%). Figure 1 shows types of documents officially sanctioned by states and Washington, DC. Although not statistically significant, the South had a
larger percentage of states with advance health care directives (41%), compared with 11% of Northeastern
states, 8% of Midwestern states, and 31% of Western
states ( p .156 for comparison across regions).
Figure 2. Percentage of states (including Washington, DC)
addressing key issues.
Issues Included in State Documents
We evaluated the extent to which eight identified key
issues were covered by state documents. All states allowed naming of a proxy in at least one document. In
three states (Pennsylvania, Louisiana, and Montana),
the proxy was limited to circumstances of terminal illness and/or persistent vegetative state. In the other 47
states and the District of Columbia, a broad proxy
could be named. For the other issues, the extent to
which issues were mentioned in state documents varied
depending on the issue. As shown in Figure 2, almost
all states addressed personal instructions for care, general life-sustaining measures, and terminal illness. Most
states addressed artificial sustenance and persistent vegetative state. In contrast, admission to a long-term care
facility and advanced illness/dementia were specifically
mentioned by less than one fourth of the states.
ment. Thirty-five states had living wills based on
statutes. By definition, the living will included issues
related to general life-sustaining measures and terminal illness 100% of the time. However, one third of
living will directives made no specific mention of persistent vegetative state or artificial sustenance. A little more than one fourth of living will documents allowed for naming a proxy (limited to end-of-life
care); fewer mentioned admission to a long-term care
facility or advanced illness/dementia.
Thirty-five states had durable power of attorney
for health care documents. By definition, this type of
document always appointed a broad proxy (i.e., not
limited to terminal illness or persistent vegetative
state). Regarding specific mention of other key issues,
in general, these documents did less well than either
the living will or the advance health care directive.
The 13 advance health care directive documents
were the most comprehensive documents, including
Issue Inclusion by Type of Document
As shown in Table 1, there were substantial differences in issue inclusion according to type of docu-
Figure 1. Documents officially sanctioned by states and Washington, DC. DPAHC durable power of attorney for health care; LW living will, AHCD advance health care directive.
Vol. 42, No. 1, 2002
53
Table 1. Frequency of Issue Inclusion by Document Type
Table 2. Frequency of Issue Coverage Comparing States With
and Without Advance Health Care Directive (AHCD) Documents
Type of document
Issue
Any proxya
Personal
instructions
General lifesustaining
measures
Terminal illness
Artificial
sustenance
Persistent
vegetative state
Long-term care
facility
Advanced illness/
dementia
LW
(n 35)
10 (29%)
DPAHC
(n 35)
AHCD
(n 13)
35 (100%) 13 (100%)
States
With
AHCD
Documents
(n 13)
p value
of 2
.001
35 (100%) 21 (60%)
13 (100%)
.001
35 (100%) 26 (74%)
35 (100%) 5 (14%)
13 (100%)
13 (100%)
.001
.001
23 (66%)
17 (49%)
13 (100%)
.004
23 (66%)
8 (23%)
11 (92%)
.001
0 (0%)
8 (23%)
3 (23%)
.010
4 (11%)
2 (6%)
2 (15%)
.538
Note: LW living will; DPAHC durable power of attorney
for health care; AHCD advance health care directive.
a
Limited proxy for living will, broad proxy for DPAHC and
AHCD.
Statesa
Without
AHCD
Documents
(n 38)
Issue
n
%
n
%
p value
for Fisher
Exact Test
Any proxy
Personal instructions
General life-sustaining
measures
Terminal illness
Artificial sustenance
Persistent vegetative
state
Long-term care facility
Advanced illness/
dementia
13
13
100
100
38
37
100
97
1.000
.745
13
13
13
100
100
100
36
35
28
95
92
74
.551
.405
.037
12
3
92
23
26
8
68
21
.085
.579
2
15
6
16
.666
a
Includes District of Columbia.
Regional Differences
Table 3 shows the frequency of inclusion of key issues in state documents according to region of the
country. There were significant differences across regions regarding the inclusion of general life-sustaining measures and admission to a long-term care
facility. Northeastern states mentioned general lifesustaining measures significantly less often than did
states in other regions ( p .021). Regarding admission to a long-term care facility, no Northeastern or
Western states mentioned the issue in their documents; in contrast, 42% of Midwestern and 35% of
Southern states included it ( p .013). The average
number of issues included in state documents did not
differ by region (M 5.3, SD 1.7 issues included
per state for Northeastern states; M 6.2, SD 1.0
for Southern states; M 5.6, SD 1.4 for Midwestern states; and M 5.8, SD 0.8 for Western
states; p .349, ANOVA).
each of the eight issues more frequently or at least as
frequently as either of the other document types. A
broad proxy could be named in 100% of documents.
Personal instructions, general life-sustaining measures, terminal illness, and artificial sustenance each
were mentioned in 100% of documents, with persistent vegetative state mentioned in more than 90% of
documents. Advance health care directive documents
were significantly more likely to mention admission
to a long-term care facility than were living will documents. Overall, the advance health care directive included a significantly greater number of the eight key
issues, with a mean of 6.3 (SD 0.6) issues per advance health care directive, compared with 3.5 (SD 1.6) per durable power of attorney for health care
and 4.7 (SD 1.0) per living will ( p .001,
ANOVA).
Discussion
Issue Inclusion Comparing States With Advance
Health Care Directives Versus States With
Other Documents
A recent study (Steinhauser et al., 2000) found in
a survey of seriously ill patients, recently bereaved
family members, physicians, and other care providers
that there was strong agreement in all four groups
regarding the importance of having treatment preferences in writing and naming someone to make decisions in the event of incapacity. Despite the perception of importance among the public and health
care professionals, the published literature contains
limited data examining the type and content of AD
documents used by each of the 50 states and the
District of Columbia. We found substantial variability across the country both in the types of documents used by states and in the content of documents.
Regarding types of AD documents, most states
had statutes providing for both a living will and a
We compared states that used the advance health
care directive document (n 13) with states that
used other types of documents (n 38). Table 2
shows frequency of inclusion of issues in states with
advance health care directive documents versus states
without this document. The only significant difference was for artificial sustenance. All states with advance health care directive documents included artificial sustenance in their documents, compared with
74% of states without. Overall, states with advance
health care directives included a greater number of
the eight issues, with a mean of 6.3 (SD 0.6) issues
included in these state documents, compared with
5.6 (SD 1.3) issues included in the other state documents ( p .019, two-sample t test).
54
The Gerontologist
Table 3. Inclusion of Key Issues in States’ Documents According to Region of the Country
Region of Country
Northeast
(n 9)
South
(n 17)
Midwest
(n 12)
West
(n 13)
Issuea
n
%
n
%
n
%
n
%
p value
of 2
Any proxy
Personal instructions
General life-sustaining measures
Terminal illness
Artificial sustenance
Persistent vegetative state
Long-term care facility
Advanced illness/dementia
9
9
7
7
8
6
0
2
100
100
78
78
89
75
0
0
17
17
17
17
13
14
6
4
100
100
100
100
76
82
35
24
12
11
12
11
9
7
5
0
100
92
100
92
75
58
42
0
13
13
13
13
11
11
0
2
100
100
100
100
85
85
0
15
1.000
.346
.021
.096
.814
.363
.013
.346
a
Issue counted as included by a state if in one or more of its documents.
durable power of attorney for health care, but some
provided for only one or the other. Only a minority
of states had a combination advance health care directive document providing for both types of directives in one document. Besides varying in type of
document, states also varied considerably in the extent to which key issues were included in their documents. States with advance health care directive documents included significantly greater numbers of the
key issues in their documents compared with states
with other types of documents.
In 1989, Emanuel and Emanuel proposed a single
“medical directive” that included both treatment
preferences and designation of a proxy (Emanuel &
Emanuel, 1989). The Uniform Health Care Decisions
Act (Uniform Law Commissioners, 1994), which
was recommended to all states in 1993 and approved
by the American Bar Association in 1994 (Galambos, 1998), called for a single comprehensive directive in each state to replace existing fragmented directives. Despite this, most states continue to maintain
separate documents and directives.
We agree with Emanuel and Emanuel (1989) and
the Uniform Law Commissioners (1994) that consolidation of ADs into one document may be important.
In states that have both a living will and a durable
power of attorney for health care, the possibility exists that a person may choose to complete only one
type of document. If two documents are available, it
is unclear to what extent people fill out both or if
they preferentially complete one rather than another.
In one Illinois teaching hospital, 64% of all medical
ADs were durable powers of attorney for health care,
suggesting this type of directive may be preferred
(Gross, 1998). Other recent studies lend support to
this finding. In the SUPPORT study involving five
teaching hospitals in Massachusetts, North Carolina,
Ohio, Wisconsin, and California, 66% of the 688 ADs
from 569 patients were durable powers of attorney
(Teno, Licks, et al., 1997). Likewise, Hammes and
Rooney (1998) found that 65% of the ADs used by
540 decedents in a western Wisconsin community
were for durable power of attorney for health care.
Placing both types of directives together in one docuVol. 42, No. 1, 2002
ment may increase the likelihood of completion of
both. Use of one comprehensive directive simplifies
completion, as it only needs to be signed and witnessed once. In addition, individuals may not understand the difference between the living will and the
durable power of attorney for health care and, when
documents are separate, individuals may give inconsistent directions. Having the two directives combined may facilitate understanding of each and provide consistency of provisions between documents.
The Uniform Health Care Decisions Act (Uniform
Law Commissioners, 1994) also called for basic
standards in advance directive documents to provide consistency across states. Our research demonstrates that lack of uniformity is prevalent, particularly regarding the issues of admission to a long-term
care facility and advanced illness/dementia. We agree
with the Uniform Law Commissioners that uniformity of basic provisions in documents across states
may be important. Ethical and treatment dilemmas
may arise for individuals who become incapacitated
in a state other than the state in which their AD document was completed. Some states may mandate
that certain provisions for care be specifically mentioned for the agent to make a decision. Standardization of state documents to minimally include certain
issues may increase the likelihood that an individual’s wishes will be honored regardless of where
treatment is received. The availability of standardized documents would provide individuals with baseline provisions that address issues that could arise in
any state.
Although it is unclear if the mention of specific issues in ADs actually influences end-of-life care, we
suggest that it may be important to include specific
issues in AD documents. The literature suggests that
inclusion of issues in a document may improve a
proxy’s knowledge of the patient’s wishes. Weinberg
and Brod (1995) have shown that although individuals may designate a proxy, their health care wishes
may not be known to the proxy. Other authors have
confirmed that discordance between an individual’s
wishes and the proxy’s perception of those wishes is
common (Gerety, Chiodo, Kanten, Tuley, & Cor55
nell, 1993; Marbella, Desbiens, Mueller-Rizner, &
Layde, 1998; Mattimore et al., 1997; Sulmasy et al.,
1998; Zweibel & Cassel, 1989). Data suggest that
preferences are expressed, however, when specific
options about an issue are provided in an AD document (Gross, 1998; Teno, Licks, et al., 1997). Furthermore, Sulmasy and colleagues (1998) have shown
that surrogate accuracy improves when the patient
has previously expressed preferences to the surrogate.
Thus, an important reason to include issues in AD
documents is to enhance the discussion between the
principal in the specific document and the proxy.
When specific issues are mentioned in a document,
the opportunity is provided for the person completing the document to make sure his or her agent understands preferences for care. If the person has
never thought about these issues, reference to them
in the document may encourage an exploration of
the specifics of the issue and some decision making.
A discussion prompted by having specific issues mentioned in a document may actually be more important than the actual completion of the document.
Emanuel (2000) has suggested that the best discussions and plans for care may not be documented in
the directive. The use of a comprehensive AD that
mentions specific issues may serve as a vehicle to promote discussion between the patient, family, proxy,
and provider regarding the patient’s values and
thoughts on quality of life. Orentlicher (1990) suggested that this type of comprehensive document
would increase the proxy’s understanding of the patient’s wishes regarding medical care.
Surprisingly, we found that only a minority of
state AD documents mentioned issues of admission
to a long-term care facility and advanced illness/dementia. With the aging of the United States population and the expanding prevalence of dementia (Report to the Secretary of Health and Human Services,
1998), anticipatory planning regarding long-term
care becomes increasingly important. Specific mention of the issues of admission to a long-term care facility and advanced illness/dementia may facilitate
anticipatory planning discussions with family and
health care providers regarding preferences for care.
The person’s values and goals for care can also be explored in the context and can guide the discussion.
There are several limitations to this analysis. First,
we examined a select number of issues; other issues
such as pain relief and organ donation are also important. Second, a few states did not have statutory
documents. Consequently, variations exist within those
states as to how AD documents are completed.
Third, even for states that do have statutory documents, individuals may use AD forms other than the
statutory forms. However, it is likely that forms are
drafted that closely resemble statutory forms. A 1998
study found that in one hospital in Illinois, 84 of 86
living wills and 206 of 210 durable powers of attorney for health care directives were standard state
forms (Gross, 1998). Fourth, we did not examine
specific state statutes; some issues may be addressed
in statutes but not mentioned on suggested forms.
We felt that it was more relevant to evaluate the
forms rather than the statutes, as communication
about a specific issue may be neglected when it is not
included on the form. Fifth, we did not examine differences in definitions, either in the documents themselves or in accompanying instructions. States may
differ substantially in definitions of issues, including
definitions of incapacity, terminal illness, and lifesustaining measures, or specific definitions may be
lacking. They may also differ in how the choice
about an issue is presented. This is an important area
for future study.
We also did not compare state documents with the
Five Wishes AD (Commission on Aging with Dignity, 2000). The Five Wishes was developed by the
Florida Commission on Aging with Dignity in response to what has been perceived to be the overly
legal nature of many state AD documents. The document is considered by many to be unique because it is
a statement of the patient’s values, as opposed to just
a statement about specific medical interventions or
who the person wants to act as agent. It speaks to all
of a person’s needs: medical, personal, emotional,
and spiritual. Differences in state statutes have led to
state-by-state variation in acceptance of this document.
Finally, we are unable to determine how these real
or perceived legal standards affect clinical care. Application of the law is likely to vary depending on the
provider, attorney, health care setting, or degree of
advocacy for a particular patient. Specific providers
may fail to understand the law or decide to ignore it.
The practice setting (home, hospital, nursing home)
could also have an impact on whether the standards
are correctly applied, as legal oversight might be
greater in one setting than another. Data from the
SUPPORT study suggest that although family members feel ADs aid them in end-of-life decision making, there is no evidence that ADs affect physician
management (Teno, Lynn, et al., 1997).
In summary, this study demonstrated that there
are substantial differences in types of AD documents
used across the United States. Only a minority of
states uses a document combining living will and durable power of attorney for health care. Whereas
some end-of-life issues are included in almost all
state documents, issues of admission to a long-term
care facility and advanced illness/dementia, which
are particularly relevant to an aging population, are
mentioned only infrequently. Advances in medical
technology along with the clinical realities of a
longer life span, an increase in the incidence of dementia in the general population, and a more mobile
society are all factors that drive the need for comprehensive documents that reflect the complexities of
medical decision making today.
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Received February 21, 2001
Accepted September 18, 2001
Decision Editor: Laurence G. Branch, PhD
Appendix A
State Statute Citations
Alabama
Natural Death Act, Ala. Code §§ 22-8A-1 to 22-8A-10
Durable Power of Attorney Act, Ala. Code § 26-1-2
Alaska
Rights of Terminally Ill Act, Alaska Stat. §§ 18.12.010 to 18.12.100
Statutory Form Power of Attorney Act, Alaska Sta. §§ 13.26.332 to 13.26.358
Arizona
Living Wills and Health Care Directives Act, Ariz. Rev. Stat. Ann. §§ 36-3201 to 36-3262
Arkansas
Rights of the Terminally Ill or Permanently Unconscious Act, Ark. Code Ann. §§ 20-17-201 to 20-17-217
Durable Power of Attorney for Health Care Act, Ark. Code Ann. § 20-13-104
California
California Health Care Decisions Law, Cal. Prob. Code §§ 4600 to 4805
Colorado
Medical Treatment Decision Act, Colo. Rev. Stat. §§ 15-18-101 to 15-18-113
Patient Autonomy Act, Colo. Rev. Stat §§ 15-14-501 to 15-14-509
Connecticut
Removal of Life Support Systems Act, Conn. Gen. Stat. Ann. §§ 19a-570 to 19a-580c
Statutory Short Form Durable Power of Attorney, Conn. Gen. Stat. Ann. §§ 1-42 to 1-54a
Delaware
Health-Care Decisions Act, Del. Code Ann. tit. 16, §§ 2501 to 2518
District of Columbia
Natural Death Act, D.C. Code Ann. §§ 6-2421 to 6-2430
Health-Care Decisions Act, D.C. Code Ann. §§ 21-2201 to 21-2213
Florida
Health Care Advance Directives Act, Fla. Stat. Ann. §§ 765.101 to 765.404
Georgia
Living Wills Act, Ga. Code Ann. §§ 31-32-1 to 31-32-12
Durable Power of Attorney for Health Care Act, Ga. Code Ann. §§ 31-36-1 to 31-36-13
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Vol. 42, No. 1, 2002
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Appendix A
State Statute Citations (Continued)
Hawaii
Uniform Health-Care Decisions Act, Haw. Rev. Stat. §§ 327E-1 to 327E-16
Durable Power of Attorney for Health Care Decisions Act, Haw. Rev. Stat. §§ 551D-1 to 551D-7
Idaho
Natural Death Act, Idaho Code §§ 39-4501 to 39-4509
Illinois
Living Will Act, Ill. Comp. Stat. Ann. ch. 755, §§ 35/1 to 35/10
Powers of Attorney for Health Care Act, Ill. Comp. Stat. Ann. ch. 755, §§ 45/4-1 to 45/4-12
Health Care Surrogate Act, Ill. Comp. Stat. Ann. ch. 755, §§ 40/1 to 40/55
Indiana
Living Wills and Life-Prolonging Procedures Act, Ind. Code Ann. §§ 16-36-4-1 to 16-36-4-21
Powers of Attorney Act, Ind. Code Ann. §§ 30-5-1-1 to 30-5-10-4
Iowa
Life-sustaining Procedures Act, Iowa Code Ann. §§ 144A.1 to 144A.12
Power of Attorney Act, Iowa Code Ann. §§ 144B.1 to 144B.12
Kansas
Natural Death Act, Kan. Stat. Ann. §§ 65-28,101 to 65-28,109
Durable Power of Attorney for Health Care Decisions Act, Kan. Stat. Ann. §§ 58-625 to 58-632
Kentucky
Living Will Directives Act, Ky. Rev. Stat. Ann. §§ 311.621 to 311.644
Louisiana
Natural Death Act, La. Rev. Stat. Ann. §§ 40:1299.58.1 to 40:1299.58.10
Power of Attorney Act, La. Civ. Code Ann. art. 2997
Maine
Uniform Health-Care Decisions Act, Me. Rev. Stat. Ann. tit. 18-A, §§ 5-801 to 5-817
Powers of Attorney Act, Me. Rev. Stat. Ann. tit. 18-A §§ 5-501 to 5-506
Maryland
Health Care Decisions Act, Md. Code Ann., Health-Gen. I §§ 5-601 to 5-618
Massachusetts
Health Care Proxies by Individuals Act, Mass. Ann. Laws ch. 201D
Michigan
Power of Attorney for Health Care Act, Mich. Comp. Laws Ann., § 700.496
Minnesota
Living Will Act, Minn. Stat. Ann. §§ 145B.01 to 145B.17
Durable Power of Attorney for Health Care Act, Minn. Stat. Ann. §§ 145C.01 to 145C.16
Mississippi
Uniform Health-Care Decisions Act, Miss. Code Ann. §§ 41-41-201 to 41-41-229
Missouri
Life Support Declarations Act, Mo. Ann. Stat. §§ 459.010 to 459.055
Durable Power of Attorney for Health Care, Mo. Ann. Stat. §§ 404.800 to 404.872
Montana
Rights of the Terminally Ill Act, Mont. Code Ann. §§ 50-9-101 to 50-9-11, 50-9-201 to 50-9-206
Durable Power of Attorney Act, Mont. Code Ann. §§ 72-5-501 to 75-5-502
Nebraska
Rights of the Terminally Ill Act, Neb. Rev. Stat. §§ 20-401 to 20-416
Power of Attorney for Health Care Act, Neb. Rev. Stat. §§ 30-3401 to 30-3432
Nevada
Uniform Act on the Rights of the Terminally Ill, Nev. Rev. Stat. Ann. §§ 449.535 to 449.690
Durable Power of Attorney for Health Care Act, Nev. Rev. Stat. Ann. §§ 449.800 to 449.860
New Hampshire
Living Wills Act, N.H. Rev. Stat. Ann. §§ 137-H:1 to 137-H:16
Durable Power of Attorney for Health Care, N.H. Rev. Stat. Ann. §§ 137-J:1 to 137-J:16
New Jersey
Advance Directives for Health Care Act, N.J. Stat. Ann. §§ 26:2H-53 to 26:2H-78
New Mexico
Uniform Health-Care Decisions Act, N.M. Stat. Ann. §§ 24-7A1 to 24-7A-18
Durable Power of Attorney Act, N.M. Stat. Ann. §§ 45-5-501 to 45-5-502
New York
Health-Care Proxy Act, N.Y. Pub. Health Law §§ 2980 to 2994
North Carolina
Rights of the Natural Death Act, N.C. Gen. Stat. §§ 90-320 to 90-322
Health Care Power of Attorney Act, N.C. Gen. Stat. §§ 32A-15 to 32A-26
North Dakota
Uniform Rights of the Terminally Ill Act, N.D. Cent. Code §§ 23-06.4-01 to 23-06.4-14
Durable Powers of Attorney for Health Care Act, N.D. Cent. Code §§ 23.06.5-01 to 23-06.5-18
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The Gerontologist
Appendix A
State Statute Citations (Continued)
Ohio
Modified Uniform Rights of the Terminally Ill Act, Ohio Rev. Code Ann. §§ 2133.01 to 2133.15
Power of Attorney for Health Care Act, Ohio Rev. Code Ann. §§ 1337.11 to 1337.17
Oklahoma
Rights of the Terminally Ill or Persistently Unconscious Act, Okla. Stat. Ann. tit. 63, §§ 3101.1 to 3101.16
Hydration & Nutrition for Incompetent Patients Act, Okla. Stat. Ann. tit. 63, §§ 3080.1 to 3080.5
Oregon
Health Care Decisions Act, Or. Rev. Stat. §§ 127.505 to 127.640
Pennsylvania
Advance Directive for Health Care Act, Pa. Stat. Ann, tit. 20 §§ 5401 to 5416
Durable Powers of Attorney Act, Pa. Stat. Ann. tit. 20 §§ 5601 to 5607
Rhode Island
Rights of the Terminally Ill Act, R.I. Gen. Laws §§ 23-4.11-1 to 23-4.11-14
Health Care Power of Attorney Act, R.I. Gen. Laws §§ 23-4.10-1 to 23-4.10-12
South Carolina
Death with Dignity Act, S.C. Code Ann. §§ 44-77-10 to 44-77-160
Power of Attorney Act, S.C. Code Ann. §§ 62-5-501 to 62-5-505
South Dakota
Living Wills Act, S.D. Codified Laws §§ 34-12D-1 to 34-12D-22
Durable Powers of Attorney Act, S.D. Codified Laws §§ 59-7-2.1 to 59-7-2.8, 59-7-8
Tennessee
Right to Natural Dealth Act, Tenn. Code Ann. §§ 32-11-101 to 32-11-112
Durable Power of Attorney for Health Care Act, Tenn. Code. Ann. §§ 34-6-201 to 34-6-214
Texas
Advance Directive Act, Tex. Health & Safety Code Ann. §§ 166.001 to 166.166
Utah
Personal Choice and Living Will Act, Utah Code Ann. §§ 75-2-1101 to 75-2-1119
Vermont
Terminal Care Document Act, Vt. Stat. Ann. tit. 18, §§ 5251 to 5262 and tit. 13, § 1801
Durable Powers of Attorney for Health Care Act, Vt. Stat. Ann. tit. 14, §§ 3451 to 3467
Virginia
Health Care Decisions Act, Va. Code Ann. §§ 54.1-2981 to 54.1-2993
Washington
Natural Death Act, Wash. Rev. Code Ann. §§ 70.122.010 to 70.122.920
Durable Power of Attorney Act, Wash. Rev. Code Ann. § 11.94.010
West Virginia
Health Care Decisions Act, W. Va. Code §§ 16-30-1 to 16-30-24
Wisconsin
Declaration to Physicians and Do-Not-Resuscitate Orders Act, Wis. Stat. Ann. §§ 154.01 to 154.29
Power of Attorney for Health Care Act, Wis. Stat. Ann. §§ 155.01 to 155.80
Wyoming
Living Will Act, Wyo. Stat. Ann. §§ 35-22-101 to 35-22-109
Durable Power of Attorney for Health Care Act, Wyo. Stat. Ann. §§ 3-5-201 to 3-5-213
Appendix B
Definitions and Other Accepted Names for Document Types
Document
Working definition
Living Will
Document that allows competent adult to give directions for future care
in the event of incapacity due to terminal illness or impending death.
Declaration to Physicians
Directive to Physicians
Durable Power of
Attorney for Health Care
Health care proxy document that allows a person to name a trusted
person to act as agent with broad powers to make health care
decisions in the event of incapacity.
Appointment of a Health
Care Representative
Health Care Proxy
Advance Health Care Directive
Document that combines the appointment of an agent and the provision
of a treatment directive; based on Uniform Health Care Decision Act.
Advance Directive
Health Care Directive
Vol. 42, No. 1, 2002
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Other names for document
Appendix C
Definitions and Equivalent Language Examples for Key Issues
Issue
Working Definition
Proxy
Person designated to make surrogate decisions. Designation
of proxy may be for limited or broad purposes.
Personal representative
Agent
Surrogate
Personal Instructions
Designation of any specific desires about treatment,
provisions for care or limitations on medical care.
Other wishes
Special provisions
General Life Sustaining
Treatment without which the patient will die, excluding
artificial nutrition and hydration.
Life prolonging
Death delaying treatment
Mechanical respiration
Terminal Illness
Incurable condition from which there is no recovery, to a
reasonable degree of medical certainty, and death is
likely to occur within a relatively short time.
Incurable or terminal condition
Artificial Sustenance
Provision of food and water through a tube or intravenous line.
Artificial nourishment and hydration
Tube feeding
Persistent Vegetative State
Condition expected to last permanently, without
improvement, and in which thought, sensation, purposeful
action, social interaction, and awareness of self are absent.
Permanently unconscious
Comatose with no reasonable
expectation of regaining consciousness
Admission to a Long-Term
Care Facility
Authorization for admission to a facility providing extended
skilled and/or intermediate nursing care.
Nursing home
Nursing care facility
Health care facility
Place where person gets care
Advanced Illness/Dementia
Irreversible end-stage condition characterized by severe and
permanent deterioration and dependency.
Severe dementia
End-stage condition
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The Gerontologist