The American Approach: Understanding Healthcare Directives in the US System

The United States has developed a distinctive approach to advance care planning that reflects both its healthcare system's complexity and its strong cultural emphasis on individual autonomy. As an advance care planning specialist who has worked extensively with the American system, I've observed how its unique features create both opportunities and challenges for individuals documenting their healthcare wishes.

The Legal Foundation of US Advance Directives

Unlike many countries with nationalised healthcare systems, the US approach to advance care planning operates under a dual framework of federal and state laws. The federal Patient Self-Determination Act of 1990 established the nationwide recognition of advance directives, requiring healthcare facilities receiving Medicare or Medicaid funding to:

• Inform patients of their right to create advance directives
• Ask whether patients have existing advance directives
• Document and honour these directives in medical records
• Provide education for staff and community about advance directives

However, the specific requirements for creating legally valid advance directives are determined by state law, creating significant variations across the country. The American Bar Association maintains resources tracking these state-by-state differences.

Key Components of the American Approach

The US system typically divides advance care planning into two primary documents:

Living Will

The living will specifies which medical treatments you would accept or refuse in specific situations, particularly regarding end-of-life care. These documents typically address interventions such as:

• Cardiopulmonary resuscitation (CPR)
• Mechanical ventilation
• Artificial nutrition and hydration
• Dialysis
• Comfort care preferences

Research published in the New England Journal of Medicine demonstrates that clearly documented living wills significantly increase the likelihood that end-of-life care will align with patient preferences.

Healthcare Proxy (Durable Power of Attorney for Healthcare)

This document appoints a person to make healthcare decisions on your behalf when you cannot communicate or lack decision-making capacity. Different states use varying terminology for this role—healthcare proxy, healthcare agent, medical power of attorney, or surrogate decision-maker—but the function remains similar.

The healthcare proxy has authority to interpret your living will, consent to or refuse treatment, and make decisions in situations not explicitly covered by your written directives. Studies have shown that having a designated healthcare proxy significantly improves adherence to patient preferences.

State-Specific Variations in US Advance Directives

Understanding state variations becomes crucial when creating advance directives in the American system:

Witnessing Requirements

Most states require two witnesses for advance directives, but specific restrictions vary widely:

• Some states prohibit healthcare providers or facility employees from serving as witnesses
• Many states restrict family members or beneficiaries of your estate from witnessing
• A few states require notarization instead of or in addition to witnesses

Conclusion:

For guidance tailored to your needs, explore trusted dementia help sites, resources on family legacy preservation, online wills and estate planning platforms, and dedicated advance care directive resources. You’ll also find expert guidance and secure Evaheld Legacy Vault services, along with valuable information for nurses supporting end-of-life planning and values-based advance care planning. Evaheld is here to ensure your future planning is secure, meaningful, and deeply personal — with family legacy preservation resources designed to support your advance care planning, and those closest to you: families, carers, and communities.