Advance Directive vs Living Will: What Is the Difference?

Why does the difference between these documents matter?

In February 1990, Terri Schiavo was 26 years old. Her heart stopped at her home in St. Petersburg, Florida. Doctors restarted it, but her brain was badly damaged. They later said she was in a persistent vegetative state. This means a person may seem awake at times but shows no awareness.

Terri had not written a living will. So Florida law made her husband, Michael, her decision-maker (PBS NewsHour). He said Terri had told him she would not want to be kept alive this way. Her parents, Bob and Mary Schindler, disagreed.

The court fight lasted seven years. It reached Florida lawmakers, the US Congress and President George W. Bush. Again and again, judges asked one question: what would Terri have wanted? No document could tell them. Our full story of the Terri Schiavo case follows each step.

After a judge ruled on the case, Michael Schiavo gave other families a warning on ABC's Nightline:

"Make a living will, talk about it. Death is going to happen. You need to write it down." — Michael Schiavo, quoted by the Associated Press, 20 March 2005

People listened. The same AP report said thousands of Americans were putting their wishes in writing. One nonprofit, Aging with Dignity, was sending out more than 2,000 living wills a day.

Terri's story shows two separate questions:

• What do you want, if you cannot speak?
• Who should decide for you, if you cannot decide?

A living will answers the first question. A healthcare proxy answers the second. "Advance directive" is the family name for both. Most mix-ups come from treating these three words as the same thing.

What is an advance directive?

An advance directive is any legal document that gives instructions for your medical care. It only takes effect if you cannot communicate your own wishes. That is how the US National Institute on Aging (NIA) defines it.

Think of it as a letter to the doctors who will meet you on a day you cannot speak. They do not know you. The letter tells them who you are and what you want.

The two most common advance directives are:

1. A living will: your written choices about treatment.
2. A durable power of attorney for health care: a document that names your healthcare proxy. "Durable" means it still works after you lose the ability to decide.

So every living will is an advance directive. Not every advance directive is a living will.

Most Americans have neither. A large review looked at 150 US studies from 2011 to 2016. Only 36.7% of adults had any advance directive. Only 29.3% had a living will (Yadav et al., Health Affairs, 2017). People with a chronic illness were barely more likely to have one (38.2%) than healthy adults (32.7%).

What is a living will?

A living will records the treatments you want or refuse, if you cannot decide for yourself. You can also say under which conditions each choice applies (NIA).

A living will usually covers:

• Life support: a breathing machine (mechanical ventilation) and tube feeding (artificial nutrition).
• Resuscitation: whether you want CPR if your heart stops.
• Pain and comfort: how much you want comfort to come first.
• Organ donation: whether you want to donate organs or tissue.
• Specific conditions: for example, a terminal illness or permanent unconsciousness.

A living will does not name a decision-maker. It is your voice on paper, and nothing more.

What is a healthcare proxy?

A healthcare proxy is the person you choose to make medical decisions for you. Other names are agent, surrogate or representative. You name this person in a healthcare power of attorney. That document is also a type of advance directive.

Unlike a living will, a healthcare power of attorney:

• names one specific person to decide for you;
• covers any medical situation, not only the end of life;
• can deal with events nobody planned for, such as a stroke or a car accident;
• works alongside your living will.

A living will is like written directions for a long trip. A healthcare proxy is a driver you trust, who knows where you want to go. Directions cannot help when a road is suddenly closed. A driver can choose a new road and still get you there.

The US Supreme Court saw this gap in 1990, in the Nancy Cruzan case, Cruzan v. Director, Missouri Department of Health. Justice Sandra Day O'Connor wrote:

"Few individuals provide explicit oral or written instructions regarding their intent to refuse medical treatment should they become incompetent." — Justice Sandra Day O'Connor, concurring opinion, Cruzan (1990), via Cornell Law School

In plain words: most people never say clearly what they want. O'Connor added that naming a proxy could be "an equally probative source of evidence". That means it can be just as strong as written instructions.

What if you name nobody? Then your state's law decides who speaks for you. This is usually your spouse first, then your adult children, then your parents. The exact order varies by state. If you are not married and have not named your partner, your partner could be left out (NIA). If you have no family, some states allow a close friend. Others may assign a doctor.

Ask yourself: if you could not speak tomorrow, who would the hospital call? Is that the person you would choose?

Advance directive vs living will vs proxy: what is the difference?

	Advance directive	Living will	Healthcare power of attorney
What it is	The family name for documents about future care	A written list of treatments you want or refuse	A document that names a person to decide for you
Names a person?	Yes, if it includes a proxy	No	Yes
What it covers	Depends on the documents	Mainly serious illness and end-of-life treatment	Any medical decision you cannot make yourself
When it starts	Only when you cannot communicate	When you cannot decide and a named condition applies	When you cannot make or communicate decisions

Some states combine both into one form, often called an "advance health care directive". The name on the form matters less than what it does. Check that it answers both questions: what you want, and who decides.

Where do DNR orders and POLST forms fit?

Many guides list DNR orders and POLST forms as advance directives. Strictly, they are something different. They are medical orders. A doctor or other clinician signs them, usually when you are already seriously ill.

• DNR (do not resuscitate) order: tells staff not to attempt CPR if your heart and breathing stop. The NIA says it still helps to have one, even if your living will refuses CPR. Without it, staff will make every effort to restart your heart. An out-of-hospital DNR tells ambulance crews the same thing.
• POLST form: a portable medical order for people who are seriously ill or very frail. The letters once stood for "Physician Orders for Life-Sustaining Treatment". Today the national POLST group says it simply means "portable medical orders". It goes with you between home, hospital and care home, and covers more than CPR. Some states call it MOLST, POST or MOST.

Your advance directive is your voice. A DNR or POLST turns it into an order that emergency staff can follow at once. If you are seriously ill, ask your doctor if you need one.

Do I need both a living will and a healthcare proxy?

Most people are better protected with both. A living will on its own has limits:

• It cannot predict every medical situation.
• Different doctors may read the same words in different ways.
• It cannot change as your situation changes.

Even a living will may not stop a family fight. A Florida lawyer told the AP that, even with a written directive, Terri's family "might still be arguing" (AP).

A proxy on its own has limits too. Without written guidance, your proxy may have to guess. People are often wrong. In one study cited by the NIA, people got nearly 1 in 3 end-of-life choices for a loved one wrong.

Together, they give your proxy your written wishes plus the power to act on them. Add a real conversation, and your proxy is not guessing. Terri Schiavo's family never had all three.

What makes an advance directive legal in your state?

Each US state has its own rules. Common requirements are:

• Witnesses. In most states, two adult witnesses are enough (ASPE). Your named proxy and your own doctor are often not allowed to be witnesses.
• A notary. Some states require one, or let you use one instead of witnesses.
• Specific forms or wording. Many states have their own free form.
• Registries. Some states keep a database of directives, so doctors can find yours fast.

You can get free forms from your State Attorney General's office or your local Area Agency on Aging. To find your agency, call the Eldercare Locator on 800-677-1116. AARP, the American Bar Association and the National Hospice and Palliative Care Organization also offer state forms. Veterans can use a VA form (NIA).

Four more facts are worth knowing:

1. Hospitals must tell you. Under the Patient Self-Determination Act of 1990, providers paid by Medicare or Medicaid must give adult patients written information about this right. They must also note if you have one (ASPE). That is why a hospital may ask you about it on admission.
2. Medicare pays for the talk. Advance care planning is covered in the Medicare annual wellness visit (NIA).
3. Your directive is respected, but not a guarantee. The NIA says an advance directive is "legally recognized but not legally binding". A provider may refuse on grounds of conscience or hospital policy. If so, they must tell your proxy at once and consider moving your care to someone else.
4. Moving states. Most state laws accept a directive signed in another state. But it will likely be read under the new state's rules (ASPE). If you spend a lot of time in two states, the NIA suggests filling in each state's form.

What if I live outside the US?

The words change from country to country. In England and Wales, for example:

• An advance decision to refuse treatment (ADRT) is the NHS version of a living will. Unlike in the US, a valid ADRT that fits the situation is legally binding. To refuse life-sustaining treatment, it must be in writing and signed by you and a witness. It must also say it applies even if your life is at risk.
• A lasting power of attorney for health and welfare names the people who decide for you. You register it with the Office of the Public Guardian. It costs £92 and takes 8 to 10 weeks if there are no mistakes (GOV.UK). It only works in England and Wales. Scotland and Northern Ireland have their own systems.

In other countries, ask your doctor or a local lawyer which documents your law recognises.

Is a living will the same as asking for assisted dying?

No. A living will lets you refuse treatment, such as CPR or a breathing machine. It does not ask anyone to end your life. The NHS makes the same point: refusing treatment is not the same as asking someone to help end your life.

Assisted dying is a separate legal process, and only in some places. In Oregon, the person must be "capable of making and communicating health care decisions" (Oregon Health Authority). So a living will or a proxy cannot make that request for you.

Assisted dying is a regulated medical process for assessed, eligible patients in some places. It is not a response to suicidal feelings.

What can you do this week?

You do not need a lawyer to start. You need one person, one conversation and one form. To see what you already have in place, take the free end-of-life readiness check.

1. Choose your person. Pick someone who will follow your wishes, even under pressure from others. Ask them if they agree.
2. Talk about what matters. Tell them what a good day looks like for you. Tell them what you would not want.
3. Get your state's form. Fill in both parts: your treatment wishes and your proxy.
4. Sign it the right way. Use the witnesses or notary your state requires.
5. Share copies. Give them to your proxy, your doctor and close family. Do not lock the only copy in a safe deposit box.
6. Review it every year. The NIA suggests a yearly check. Also review it after a big change, such as retirement, a move or a new diagnosis. Date each new version.

Before you close this page, sit with three questions. Who would you trust to speak for you? Does that person know what you want? And if doctors asked them tomorrow, would they know for sure?

Terri Schiavo's family spent seven years in court asking what she wanted. One page and one conversation can spare yours that question. Writing it down is not planning to die. It makes sure your own voice still counts on a day you cannot speak.