An "advance directive" is a written or spoken instruction about how you would like to be treated by health care professionals when death is near and you are unable to communicate. There are several types of advance directives: a directive to physicians, an out-of-hospital do-not resuscitate order, and actions that legally authorize another person to make medical decisions on your behalf. Written forms are available to help you through your decision making and clearly specify your desires. A physician also may provide assistance in completing an advance directive.

Your advance directive will be based on your personal values, and discussing these values and wishes with family members, a chosen spokesperson and your physician in encouraged. Completing an advance directive can help prevent excessive worry, guilt, and arguments among your family members if they are asked to make important medical decisions on your behalf.

Additional Information is available at the websites listed below

Texas Department of Human Services: Website provides advance forms and information. Fees: None

Texas Hospital Association: Educational videos and information on advance directives. Fees: Yes

Texas Medical Association: Provides information on end-of-life care, do-not-resuscitate (DNR) orders, advance directives, and the American Medical Association supported physician-training program for end-of-life care (EPEC) Fees: None

The National Hospice and Palliative Care Org.: A non-profit organization that deals with end-of-life issues. Its website offers downloadable advance directives for each state

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Loss and Grieving
"If peace and dignity are what we delude ourselves to expect, most of us will die wandering what we, or our doctors, have done wrong",
Sherwin Nuland, MD, Author of How We Die

Following are some tips to help physicians discuss end-of-life issues with their patients. These tips have been endorsed by consumer organizations with respect for the physician-patient relationship and understanding that there may be variations of "tips" based on individual circumstances.

• Initiate discussions before a medical crisis.
  Have information about advance directives available to your patient. If she/he completes an advance directive, discuss your patient's wishes and make sure it is in the chart and that other members of the health care team are aware of it. Encourage the patient to discuss their end-of-life decisions with their family.


• Provide your patients, their families caregiver, or others involved in the decision-making process with the information they need to make decisions. Provide a clear overview of the diagnosis, prognosis, treatment options, risks, benefits, and outcomes. Be aware the patient and their families may ask the same questions more than once as they try to absorb the reality of the patient's circumstances


• Improve communication by involving nurses, social workers, and clergy as members of the health care team.
  Remember you are part of a team. Utilize team members and be aware of other resources such as hospital chaplains


• Respect the role of the family and especially the primary caregivers as part of the health care team.


• Patients and families do not have medical degrees help them understand what you are saying.
  Do not use euphemisms. Be gently straight forward with language such as "I believe we are approaching your final weeks, let's discuss where and how you would like to spend this time"


• Be familiar with the existing legal and ethical policies at your hospital and the state laws around end-of-life care. Issues such as withdrawal of treatment can be misunderstood. Be familiar with the designated procedure within your hospital to access your ethics committee


• Understand the local resources available to help the patient and family, such as hospice, home-care services and patient/family support groups. Work in cooperation with your health care team to initiate the appropriate referrals


• Try not to see terminal illness or death as a failure on your part.


• Be aware of the signs of depression in the patient, as well as the family and caregivers


• Work on coming to terms with your own feelings or fears about death by reading a provider oriented book about death, talking to colleagues. or taking a seminar.

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