Advance Directives

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Plan Ahead: Document Your Personal Health Care Decisions

Cleveland Clinic is committed to providing world class care. Along with expert medical care, we strive to provide you with the most positive patient experience possible.

We believe that informing you about your right to make personal health care decisions will help you make educated choices so you can have a positive patient experience.

When you plan ahead by completing advance directives, you can feel confident knowing that you are in control of your future health care decisions.

What are advance directives?

Advance directives are legal documents that provide instructions about who should oversee your medical treatment and what your end-of-life wishes are, in case you are unable to speak for yourself. Advance directives include a Health Care Power of Attorney and a Living Will.

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What other documents can be prepared ahead of time to indicate my healthcare preferences?»

Other documents that can be prepared ahead of time to indicate your health care preferences include a Do-Not-Resuscitate (DNR) order and organ/tissue donor registration form. In addition, adult guardianship is a legal process that means a court-appointed person is assigned to make decisions about another person’s health care and other aspects of that person’s life (for example, where he or she should live).

All of these documents allow you to plan ahead by sharing your health care instructions with your medical team and your loved ones if you become unable, even temporarily, to make your own medical decisions. Advance directives help ensure your wishes are followed if you become seriously injured or unconscious.

When do advance directives come into effect?»

Advance directives only come into effect when you are unable to make your own decisions about medical treatment.

As long as you are able to make your own health care decisions, the forms will not be used.

Can I choose my own medical care based on my values, beliefs and personal choices?»

You have the right to choose your own medical care based on your values, beliefs and personal choices. You have the right to complete advance directive documents, at no charge, as long as you understand your options and can communicate them in front of witnesses OR a notary. You also have the right to wait and sign the forms when you feel confident that they accurately reflect your wishes.

Do I have to complete advance directives?»

Advance directives are not required and are always optional. You have the right to NOT complete advance directive documents. We are required to ask if you have completed these documents, but in doing so we are not trying to influence your decision to complete them. You may also choose to complete only one of the forms, and add the other documents when you are ready to make those decisions.

Advance directives are especially important if:

  • Your caregiver or health care representative is not your legal next of kin (usually relatives or people related to you);
  • You have multiple next of kin; OR
  • You have specific medical wishes due to a medical condition, religious affiliation or family situation.

What happens if I don’t complete advance directives forms? »

If you haven’t completed advance directives: Ohio law recognizes an Order of Decision Makers if you are unable to make health care decisions for yourself. If the state has appointed a guardian, this person is the first decision maker. If not, your legal next of kin have the right to make decisions for you. Ohio recognizes this order of your decision makers: legal guardian (if applicable), spouse, majority of adult children, parents, majority of adult siblings, or other nearest relative.

Completion of these forms is important for same sex couples. If the patient is unable to make his or her own health care decisions, either the next of kin or the legally appointed decision maker may act on the patient’s behalf. When a same-sex partner has not been given health care power of attorney or decision-making authority, Cleveland Clinic will seek a next-of-kin decision maker, in accord with Ohio law.

Talking about end-of-life issues is difficult. However, it is important for your family to be aware of your decisions about medical care so they can be comforted and know they are following your wishes if necessary.

What are the different types of advance directives?»

  Definition When It’s Used Who Can Complete What to Do/How to Proceed
Health Care Power of Attorney Allows you, the patient, to appoint a trusted person to make all health care decisions in the event that you:

Become terminally ill and unable to make your own health care decisions; or

Are temporarily or permanently unable to make decisions for yourself. This designee has the authority to oversee your wishes and to make other necessary decisions about health care matters.
Takes effect only when you are temporarily or permanently unable to make your own health care decisions.

If you are temporarily impaired, you become the decision maker once you can make decisions for yourself.
Any person over age 18 (who is not under current guardianship) who can make his or her own health care decisions. You may download advance directive forms for any state from the website of the National Hospice and Palliative Care Organization at www.nhpco.org. You may also request them from the Social Work or Spiritual/Pastoral Care departments or go to the links listed at the end of this document.

After completing the form, make copies, share it with those people who may be involved in your health care decision making, and return a copy so we can honor your wishes. Include your name and date of birth on the form.
Do Not Resuscitate (DNR) Order When a medical emergency occurs, a DNR order alerts emergency personnel that a patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event that the heart or breathing stops. Only when a medical emergency occurs. State-approved DNR orders cannot be canceled by a family member without the patient’s consent. A doctor’s order is required. A DNR order is written by a physician after discussing the pros and cons of CPR with the patient or the patient’s surrogate decision maker. DNR orders can be requested by patients who have a terminal or other serious illness and feel strongly that they do not want to receive CPR. If you are considering having a DNR order written, talk to your doctor about your decision. There are three types of DNR orders available at Cleveland Clinic hospitals and your doctor can explain the differences between each one. You can find more information online at www.odh.ohio.gov.
Organ/Tissue Donor Registry Enrollment Form Supplemental to the Healthcare Power of Attorney and the Living will, the Donor Registry Enrollment Form ensures that your wishes concerning organ and tissue donation will be honored. At the time of your death, your organs can be donated as indicated. Any person over age 18 who can make his or her own decisions. This form can be completed at your local Bureau of Motor Vehicles, and directions about where to send it are provided on the form. You can also download the form online at www.lifelineofohio.org.

Think of completing advance directives like carrying an umbrella “just in case” it rains. You may not need the umbrella - or the advance directives - but they are there if you need them.

How do I complete advance directive forms?»

Any person over age 18 who can make his or her own decisions can complete an advance directive form. You do not need a lawyer to complete advance directive forms. However, the forms need to be signed by a notary or two witnesses. The witness may include anyone except your physician, family members, or the person(s) you’re naming as decision maker in the advance directives.

What if I want to make a change to my forms?»

It’s important to review your forms every year to make sure they still reflect your views.

You may cancel or stop using previous versions of the forms by completing new ones. Any changes should be written, signed and dated in accord with state law, and copies should be given to your doctor and others who have original copies.

The latest version of your form is the one that will be followed.

Where do I get advance directives forms?»

You can also request the forms from the Care Management or Spiritual/Pastoral Care departments (see the “If You Have Questions” section below for contact information).

You can download advance directive forms from the National Hospice and Palliative Care Organization website at www.nhpco.org.

Ohio Advance Directives forms (packet including health care power of attorney, living will, donor registry enrollment, and instructions)

Ohio Advance Directives forms in Spanish:

Health Care Power of Attorney

Living Will

Ohio Advance Directives forms for visually impaired
Advance Directives Forms by State

What if I live outside of Ohio?»

The laws governing advance directives vary by state, so be sure to sign the forms from your home state. If you live outside of Ohio, you can give a copy of your existing advance directives to your medical staff to keep in your Cleveland Clinic medical record. If you live out of state and do NOT already have advance directives, you can get help completing Ohio documents. When you return home, you can either keep your Ohio documents or make new documents for your home state.

What do I do with my forms after I complete them?»

After you complete the forms, talk to those people who may be involved in your healthcare decision making, and give them a copy of your forms to make sure your wishes are followed. Remember to include loved ones, family members and your healthcare providers so they know about your wishes.

We encourage you to have a copy of your advance directives placed in your medical record at Cleveland Clinic. If you have completed a living will or healthcare power of attorney and have not given us a copy, please send a copy (include your name and date of birth on the form) via fax or to the address listed below.

Return Your Forms to:
Care Management
Fax: 216.444.9050
(To confirm receipt of fax, please call the Advance Directive Coordinator at 216.444.0655)

Mail to:
Advance Directive Coordinator
Care Management
Desk P87
9500 Euclid Ave.
Cleveland, OH 44195-9905

Note: You can use this address if you are being treated at ANY Cleveland Clinic hospital, and we will make sure it is filed appropriately.

If You Have Questions

The advance directives forms are easy to complete and we are here to help you. Please talk to your social worker or a member of your hospital’s Pastoral Care or Spiritual Care Department if you need help completing the forms. We also have some cultural and religious-specific forms available that meet Ohio state laws, so please ask for more information.

If you have questions or need help completing the forms, please call the number listed below for your hospital:

Ashtabula County Medical Center, Care Management 440.997.6633
or Pastoral Care: 440.997.6628
Cleveland Clinic Main Campus, Advance Directive Coordinator 216.444.0655
or Care Management: 216.444.6552
Euclid Hospital, Care Management 216.692.8800
Fairview Hospital, Care Management 216.476.7070
Hillcrest Hospital, Care Management 440.312.4662
Lakewood Hospital, Care Management 216.529.7193
Lutheran Hospital, Care Management 216.363.2030
Marymount Hospital, Chaplain’s Office 216.587.8140
Medina Hospital, Spiritual Care 330.721.5189
South Pointe Hospital, Care Management 216.491.7263

I’m a physician, how will I know if a patient has an Advance Directive?»

Cleveland Clinic policy and procedures include asking the patient or family upon admission about the existence of Advance Directives. This is documented in the Demographic Sheet on the chart. Copies of Advance Directives should be placed on the chart in the tabbed section for Advance Directives. Also, health professionals should document the content of discussions about the patient's end of life desires or any expression of treatment preferences.

Where can I find more information about Advance Directives?»

What is healthcare ethics? »

Healthcare ethics refers to difficult decisions about medical treatments that involve moral principles, religious beliefs or professional guidelines. Healthcare ethics is a thoughtful exploration of how to act well and make morally good choices, based on beliefs and values about life, health, suffering and death.

What are common ethical questions relating to healthcare? »

Generally, ethics questions arise when the right thing to do is not clear or when people disagree about what is best for a person who is ill. Examples include:

  • When should life-sustaining treatments like breathing machines or feeding tubes be started, continued or stopped?
  • What should family members and healthcare professionals do if a patient refuses treatment that promises to be medically helpful?
  • Who should make healthcare decisions for patients when they are unable to communicate or decide for themselves?
  • What should patients do when they do not understand what professionals are saying and feel they are not offered the opportunity to participate in their own healthcare decisions?

 

Who can help me make ethical healthcare decisions? »

The Ethics Consultation Service is staffed by clinical bioethicists who are members of the Bioethics Department. Typically, the Ethics Consultation Service is able to respond quickly to requests for assistance.

The Ethics Consultation Service is primarily intended as a resource when patients, family members or health professionals may feel that they have reached the limits of their own personal or professional ability to address ethical questions.

The Cleveland Clinic Foundation offers this advisory service free to patients, family members and healthcare providers. The patient and anyone involved in caring for that patient can request an Ethics Consultation without fear of intimidation or reprisal. All discussions are confidential.

Some questions or issues necessitate the use of an ad hoc sub-committee of the CCF Ethics Committee. This sub-committee is convened for any of the following reasons:

  • The Chairman of the Ethics Committee (or designee) believes that the issues are sufficiently complex that a team composed of members of the Ethics Committee would be beneficial to advise about the issue.
  • The person requesting the Ethics Consultation believes that the issues are sufficiently complex that advice by members of the Ethics Committee would be beneficial.
  • Ethics Committee or CCF policy requires involvement of members of the Ethics Consultation.
  • External agencies request a formal analysis of or recommendation about a case.

What is an ethics consultation?»

An Ethics Consultation is a process by which either trained consultants or an Ethics Consultation Sub-Committee of the Ethics Committee responds to requests for help to resolve ethical conflicts, issues, or questions involving patient care. An Ethics Consultation is advisory. Patients, family members, and healthcare providers remain responsible for their own decisions. Clarification of the ethically accepted course of action can help the healthcare providers and patients navigate difficult clinical circumstances.

When should an ethics consultation be requested? »

An Ethics Consultation may be requested when an ethical problem or question involving patient care is not being satisfactorily addressed or resolved for all concerned. The Ethics Consultation is designed to support, not to replace normal lines of communication about ethically troubling situations.

Requests for help from the Ethics Consultation Service are encouraged in the following situations:

  • A patient, a family member or healthcare provider wants to "talk through" important ethical dimensions of the patients care.
  • Efforts by the patient, family and professional staff to resolve a problem have reached an impasse.
  • There is serious ethical disagreement among healthcare providers or within the patient/family relationship.
  • The case is ethically unusual, unprecedented or very complex.
  • In decisions about life-sustaining medical treatment for patients unable to decide for themselves.
  • In situations when communication or cooperation with the patients surrogate decision maker is compromised.
  • A patient, family member or healthcare provider needs help in facing an ethically significant decision.

What are some common ethical problems? »

In general, an ethical problem exists when it is not clear what is the ethically sound action or course of action or when people disagree about what is best for a patient.

The following are some examples of ethical problems that can arise in the hospital:

  • What should a patient or surrogate do when he/she cannot understand what caregivers are saying, but tests and treatments continue anyway?
  • Who should make healthcare decisions when patients are unable to communicate or decide for themselves?
  • What should family members or caregivers do when they strongly disagree or are very uncertain about what is best for the patient?
  • When should life-prolonging treatments be started, continued or stopped?
  • What should family members and caregivers do when a patient refuses treatment that promises to be medically beneficial?
These and other ethical questions and concerns may develop to the point where conflict and serious disagreement results. Healthcare providers should rely on their education, experience and good judgment to prevent such escalation of disagreement. Discussing such situations with the Ethics Consultation Service might prove helpful before a true impasse is reached.

 

How is an ethics consultation requested? »

Patients and family members can directly request an Ethics Consultation by calling the hospital operator and asking for the Ethics Consultation Service. They can also tell their nurse or healthcare provider that they want an Ethics Consultation.

Staff made aware of a patient or family desire for an Ethics Consultation shall convey the request to the Ethics Consultation Service.

During work hours, the Ethics Consultation Service can be reached by calling the Bioethics Department at 216.444.8720 or 4-8270. All other times use pager 2-2512.

Physicians or House staff may convey their request for an Ethics Consultation personally by telephone or by written orders in a patient's medical record, which shall be conveyed by the Nursing staff to the Ethics Consultation Service.

Nursing staff or other employees may request an Ethics Consultation directly or through their supervisor or manager who will initiate the consultation request.

The Ethics Consultant will notify the Attending Physician or their designee of the request for an Ethics Consultation.

Will my consultation with ethics professionals be confidential? »

Yes. The deliberations and the proceedings of the Ethics Committee and the Department of Bioethics staff are strictly confidential.

Is the advice from an ethics consultation legally binding? »

No. All recommendations from the Ethics Committee and the Department of Bioethics are advisory. An ethics consultation does not provide legally binding decisions for patients, families or professionals.

Is there a charge for an ethics consultation? »

There are no fees for an ethics consultation, and you will not be billed for any ethics advice. Cleveland Clinic provides ethics consultations and other ethics resources as a service to patients, families and Cleveland Clinic professionals.

Which departments regularly review ethics issues?»

The department provides Ethics Liaison Services to selected critical care units at Cleveland Clinic.

Surgical Intensive Care Unit

Weekly interdisciplinary team rounds are conducted to review ethical problems or issues arising in the care of patients.

Medical Intensive Care Unit

Patient care rounds are conducted with an interdisciplinary team led by Pulmonary Critical Care Fellows weekly to assist in the ethical management of patients with complex medical care needs and in communication with their families.

Monthly sessions are held with clinical-bedside nurses to address ethical issues and moral distress arising in the care of patients.

Neuro Intensive Care Unit

Patient care rounds are conducted with an interdisciplinary team led by a Neuro Intensivist or Fellow once a week to assist in the ethical management of patients with complex medical care needs and in communication with their families.

Cardio-Thoracic Intensive Care Unit

Weekly interdisciplinary team rounds are conducted to review ethical problems or issues arising in the care of patients.

Need help with Advance Directives?

Assistance for patients in completing Advance Directives is available from either:

Spiritual Care Department
216.444.2518

Social Work Department
216.444.6552.

If you have questions about the applicability of Advance Directives, conflicts in their interpretation or implementation or about the withholding and withdrawing of life-sustaining treatment, contact:

Bioethics Department
216.444.8720, Pager #22512.


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