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Advance care planning is a process and a conversation.  Steps include:
  • Understand your current health situation.
  • Identify your health care agent.  Who will speak for you when you cannot speak for yourself?
  • Have a conversation with your agent, family and other loved ones to share your health care wishes and preferences.
  • Complete a health care directive document.
  • Distribute copies of your completed health care directive to your agent, your doctor(s), and others who will be involved in your care.
  • Update your health care directive when changes occur. 
Advance care planning is for every adult 18 years of age or older.
Most health care systems in the Twin Cities and other areas have classes and/or facilitators who can guide you.  Click here for contact information. 

The Honoring Choices office can also help you find a volunteer facilitator to work with you if your clinic is not listed.  Email us to learn more.
A health care directive is a legal document that records your health care agent, as well as your health care wishes and preferences.  This document is used as a communication tool when you cannot speak for yourself.  It helps guide your agent, family, loved ones, and physician in honoring your wishes. 
We suggest everyone 18 years of age or older complete a health care directive.
Yes and no.  A living will is generally more limiting because you only make decisions about life sustaining procedures, and it may not identify a person to speak on your behalf as your agent.  A durable power of attorney for health care is needed for that. 

A health care directive combines both components -- decisions about health care treatments and naming an agent -- in one document. 
Five Wishes is a very similar document to the health care directive.  Five Wishes details wishes and preferences along with naming an agent in a format that is more narrative in style.  Five Wishes is not recognized in all states, however it is approved in Minnesota.
Honoring Choices Minnesota will be happy to mail you a copy (request one by clicking here), or you can print a copy yourself from our website.  Click here to be routed to our health care directive page.  Scroll down the page to pick the language and format (PDF or Word) you prefer.
No.  A properly filled-out health care directive is a legal document, and no attorney is required to be involved.

To meet Minnesota state law as a legal document, the following must occur:

  1. The document must be in writing.
  2. It must clearly state your name and the date you are writing it.
  3. It must include either a named agent, or your treatment choices, or both.
  4. It must be signed.
  5. It must be witnessed either by a notary public, or by two adult witnesses (neither of whom are your agent, and at least one of whom is not a member of your health care team.)  Ideally witnesses are individuals who are not related to you, but someone who can attest that you are the person signing the form (friends, neighbors, etc.)
The details outlined in the health care directive provide guidance to your agent and can be specific or general depending on the individual and health situation.  Details typically covered are:

·         Primary and alternate agent (in case the primary is unavailable).
·         Goals, values, preferences about health care.
·         Medical treatment you do and do not want (CPR, breathing assistance, etc.).
·         Instructions about artificial nutrition and hydration.
·         Instructions if you are pregnant.
·         Eyes, tissue or organ donation instruction.
·         Funeral arrangements.
While there is no expiration date, itâ��s important to review your directive whenever there is a change in decade, death of a loved one, divorce, and diagnosis or health care decline.  We call these the â��5 Dâ��sâ��.
Keep a copy of your health care directive in your kitchen or easy-to-reach place.  Keep the original in a safe place, and give copies to your health care agent, family members, close friends, and your physician/health care provider.  Many people keep a copy in the glove compartment of their car or in their suitcase when traveling.
Health care directive requirements may vary from state to state.  The Honoring Choices directive is designed for Minnesota.  Other states may have different variations.  If you spend part of the year in another state (i.e. â��snowbirdsâ��) we recommend you discuss your directive with your physician in that state.  Physicians can review the directive and suggest any needed changes to fulfill local statutes.   If you travel a lot, put a copy in your purse and/or briefcase (glove compartment for automobile travel).  Many people carry their directive with them when traveling domestically or internationally to have available as a guide, though it may or may not be honored by local health care providers.
The Provider Orders for Life Sustaining Treatment (POLST) is a brightly colored form (usually yellow) that has your physicianâ��s written medical orders to honor wishes for patients who are in the last 6-12 months of life.  This form translates your wishes directly into medical orders.  Individuals in skilled nursing or other care facilities typically have a POLST - especially when someone has a serious chronic or acute disease, is very ill and in the last stages of life.  The POLST form is completed by a physician or other qualified health care providers; patients do not complete this form.  More information about POLST can be found here.
The POLST is placed in the front of the patient chart if in a care facility.  If an individual is at home, the POLST should be placed by the bedside, or in an obvious location where it can be easily seen by anyone administering care.  EMT's will often look on the front of the refrigerator if they are told a patient has a POLST.
An agent is a person you choose to represent your health care wishes if you are unable to speak for yourself.  Choose someone who is at least 18 years old, fully understands your beliefs and values about medical care, and is not easily intimidated by others.  Choose someone who will be an advocate for you, can make decisions under stress, and can cope with making difficult life and death decisions.  The term agent may also be referred to as proxy or power of attorney for health care.
If your health care agent dies, you need to begin an advance care planning conversation to identify a new agent. 

Take this opportunity to review your entire directive, and make any other updates that are needed.  After the conversation, revise your health care directive with the name and contact information of your new agent, and be sure to give new copies to everyone who has the old directive.

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Minneapolis, MN 55413
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