What is Advance Care Planning?

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It may also help relieve family members and physicians of their concerns in making difficult decisions during challenging moments. It should be a routine part of standard medical care. It may include advance directive documents such as a living will, power of attorney for healthcare decisions or healthcare agent.

Why is it Important?

An advance directive allows a person to document or verbally state to healthcare professionals and family in advance what their wishes are before that individual is unable to make decisions at the end of life.

Advance Directive Resources

Many materials exist on the topic of advance care planning for patients. Understanding it all can be a challenge. Yet they all have some key points in common. These include deciding who can speak for you when you cannot speak for yourself and identifying what your wishes for care would be.

We chose a few materials to help you start thinking and planning. Some of these are forms and some of them are more detailed guides. We placed them in three buckets:

  • First are the items that simply outline what advance care planning requires.
  • The second bucket contains materials that provide more guidance.
  • The third bucket is more like a workbook to walk you through the decisions you have to make.

Please review the instructions of each form/workbook, as it may not be necessary to complete every single item. These forms will be living documents as they can be updated as often as you would like.

Absent of medical power of attorney as recommended by Inova, a surrogate is an adult authorized by Virginia statute to make medical decisions for a decisionally incapacitated patient when there is no applicable advance directive or appointed agent.

A Power of Attorney for Healthcare (PoA) is an adult legally appointed by the individual in an advance directive to make healthcare decisions in the event of the individual's decisional incapacity. The PoA is also known as medical power of attorney, agent, or healthcare agent.

If there is no such directive or appointed Medical PoA and the patient has been determined to lack decisional capacity, then a physician may provide, continue, withhold or withdraw healthcare upon the authorization of any of the following persons, in the specified order of priority, if the physician is not aware of any available, willing and capable person in a higher class. Surrogate decision-makers are appointed per 54.1-2986 Code of Virginia.

A booklet of frequently asked questions on making decisions about your medical care and completing an advance directive. It is available through Inova in English, Spanish, Amharic, Arabic, Farsi, Korean, Urdu, and Vietnamese. This can be used as a companion guide to any Advance Care Planning document, including VA Advance Directive forms.

An advance care planning form that enables you to name your healthcare decision maker if you are unable to make your own decisions and list your choices for health care including instructions about the care you wish to receive or not receive, and your wishes regarding organ donation. You can choose to complete the whole document or only the sections you wish to complete.

Caring Conversations workbook can guide a person through thinking about future health care. It includes a form that may be used to name your health care decision maker if you are unable to make your own decisions and a form to list your choices for health care. It is free and available in English and Spanish.

Five Wishes is an advance care planning tool that supports your decision making. Available in 29 languages and Braille, Five Wishes encourages conversation and allows you to document a series of decisions related to your future care in a narrative-based format. Five Wishes is ideal for patients who are looking for a more detailed and structured guide for completing their advance directive.

Notes for Virginia Patients

Virginia patients with a mental health treatment history should complete the general Advance Directive form above AND a Mental Health supplement form.

Virginia patients who may be pregnant at the time of their treatment may wish to complete an advance directive form that includes an optional “life prolonging procedures during pregnancy” provision. This form is available on the Virginia Hospital and Healthcare Association website.

Inova Health System accepts all valid ACP documents, even if they are created in another state – as long as the document is valid in the state where it was created. This website does not provide every possible valid ACP document type.

Planning for Future Health Care Decisions - Testimonials

"My sister and I were in charge of my mother’s care through 10 years of Alzheimer’s. She did not have a Health Care Directive of any sort. I think it is very important for the patient to define quality of life in their own words and make that part of Advanced Planning.
"My parents (one now passed and one 90+ year old) had one and it was very helpful as they aged, and we couldn't have conversations about [their] choices anymore. It was helpful that I was able to have conversations with my mom before she was affected by Alzheimer's -- and documented them -- as my father then became confused as he got older and wasn't sure about what she wanted, so having the document was helpful to remind him. Just overall good to have the hard conversation and then document it so people who have to make decisions for you know what YOU want. It is a heavy burden for others to make decisions for you, so giving them some help to know they are making decisions consistent with your wishes/beliefs."
"I have had an advance directive for over 10 years as I believe it is so important for ME to make these decisions ahead of any crisis situation so my loved ones do NOT have to try and project what I may have wanted."
"I want to be prepared for anything that might happen in the future - I want any decisions to be made by me/on my behalf. I want to be in control of any health decisions even if I am unable."