Patient Rights and End-of-Life Planning: Advance Directives, DNR and Proxies

On 25 July 1973, Dax Cowart was 25 years old. He was an Air Force pilot who had flown to Vietnam, and a rodeo champion from Texas. That day, he and his father went to look at some land. A pipeline nearby was leaking gas. When they started the car, the gas caught fire. His father died. Dax was burned over most of his body (Wikipedia).

From the first minutes, Dax said he did not want treatment. He kept saying it for 14 months. His doctors treated him anyway. His mother signed the consent papers. She feared for his soul, and she could not let him go (Orlando Sentinel, 1989).

He lost both hands and both eyes. But Dax was awake, clear and able to reason. Two films, Please Let Me Die (1974) and Dax's Case (1984), made him famous in medical ethics. Years later he said:

"I was completely astonished that, in this country, I could be forced to undergo treatment." — Dax Cowart, Orlando Sentinel, 1989

Dax lived. He earned a law degree in 1986, married, and spent decades teaching doctors about patient choice. He died of cancer in 2019, aged 71 (Bioethics Today). He never said his doctors had been right. We will come back to why.

His story asks the question at the heart of this page. When you are seriously ill, who decides what happens to your body?

Today, in most countries, the answer is: you do, if you can. You have the right to:

• Information about your diagnosis, your options and their risks.
• Say yes or no to any treatment, even one that keeps you alive.
• Plan ahead in writing, with an advance directive.
• Name a person to speak for you if you cannot.
• See your medical records, ask for a second opinion and keep your information private.
• Good pain and symptom care, whatever you decide about other treatment.

These rights differ by country and by setting. This page explains where each one came from, what the research says, and where people still disagree. It informs. It does not tell you what to choose.

For most of history, doctors decided and patients obeyed. That began to change in a New York court in 1914.

Mary Schloendorff had agreed to an examination under anaesthesia. She had refused surgery. The surgeons operated anyway. Judge Benjamin Cardozo wrote a sentence that medical schools still quote (Wikipedia):

"Every human being of adult years and sound mind has a right to determine what shall be done with his own body." — Judge Benjamin Cardozo, Schloendorff v. Society of New York Hospital, 1914

Think of your body as your home. A doctor is a skilled guest. They can give advice, but they need your permission to come in. That permission is called consent.

Three later US cases turned this idea into end-of-life law:

1. Karen Ann Quinlan (1976). In 1975, Karen, aged 21, fell into a coma and needed a breathing machine. Her parents asked for it to be removed. On 31 March 1976, the New Jersey Supreme Court agreed. Her case led many hospitals to set up ethics committees, groups that help families and doctors with hard decisions (Wikipedia).
2. Nancy Cruzan (1990). Nancy was badly hurt in a car crash in 1983. Her parents asked to stop her tube feeding. On 25 June 1990, the US Supreme Court ruled 5 to 4. It said that "a competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment" (Cornell LII). But it also let Missouri demand "clear and convincing evidence" of what Nancy would have wanted. She had left nothing in writing.
3. Terri Schiavo (1990 to 2005). Terri had no living will either. Her husband and her parents fought in court for seven years about her care. Read her story in Advance Directive vs Living Will. France had a similar fight over Vincent Lambert, whose wife and parents went to court for years about his tube feeding.

The lesson from Cruzan was simple: write it down. Congress passed the Patient Self-Determination Act in 1990. Since 1 December 1991, US hospitals and nursing homes paid by Medicare or Medicaid must tell patients about their right to make an advance directive. They must also ask if patients already have one (Wikipedia).

Did it work? Not on its own. The SUPPORT study followed 9,105 seriously ill adults in five US teaching hospitals in the early 1990s (JAMA, 1995). It found that:

• only 47% of doctors knew when their patient did not want CPR;
• 46% of do-not-resuscitate orders were written within two days of death;
• 38% of patients who died spent at least 10 days in intensive care;
• for half of conscious patients who died in hospital, families reported moderate to severe pain at least half the time.

Then the researchers tested a fix. Specially trained nurses talked with patients, families and doctors. Nothing improved. Rights on paper were not the same as rights respected. That gap still shapes the debate today.

Yes. In most countries, an adult with mental capacity can refuse any treatment, even if refusing may lead to death. This includes a breathing machine (ventilator), tube feeding, dialysis, surgery and CPR.

The law often treats this as the strongest patient right of all. Two UK cases show it clearly:

• Ms B (England, 2002). Bleeding in her spine left Ms B paralysed from the neck down. She asked doctors to turn off her ventilator. They refused for months. On 22 March 2002, Dame Elizabeth Butler-Sloss ruled that Ms B was competent to decide. The hospital had been treating her unlawfully (Wikipedia).
• Montgomery (UK, 2015). The UK Supreme Court said doctors must tell patients about any risk a reasonable person in their position would care about. What other doctors usually say is no longer the test (Wikipedia). In simple words: real consent needs real information.

Is refusing treatment the same as assisted dying? Most laws say no. In Vacco v. Quill (1997), all nine US Supreme Court justices agreed that New York could ban assisted suicide while still letting patients refuse treatment. The main opinion called the line between the two "both important and logical" (Cornell LII). Its reasoning: when you refuse treatment, the illness causes death, not the doctor.

Not everyone accepts this line. In 1975, the philosopher James Rachels argued in the New England Journal of Medicine that the difference between killing and letting die "itself has no moral importance" (Rachels, NEJM 1975). Supporters of assisted dying often use his argument. Opponents answer that intention matters. A doctor who stops a burdensome treatment does not aim at death. This links to the doctrine of double effect, an old rule in ethics. It says an act with a good aim can be allowed even if a bad result is foreseen but not intended. See Ethics and Philosophy for the full debate.

A practical point: refusing one treatment does not mean refusing care. You keep the right to pain relief, comfort, food and drink by mouth if you want them, and company.

Your right to refuse depends on mental capacity: the ability to make a particular decision for yourself.

Doctors usually check four abilities (Appelbaum, NEJM 2007):

1. Understand the facts about your condition and the options.
2. Appreciate how they apply to you, not only to people in general.
3. Reason about the options and compare them.
4. Communicate a choice, in any way: speech, writing or signs.

Capacity is decision-specific. You may have capacity to choose your lunch but not to agree to complex surgery. It can also change from day to day. Loss of capacity can be temporary, from delirium (sudden confusion, often from infection), anaesthesia or strong medicines. Then doctors should wait, if they can, until you can decide. It can also be permanent, from advanced dementia or severe brain injury. Then your advance directive or your proxy speaks for you.

England and Wales set out clear rules in the Mental Capacity Act 2005. Its principles include these (legislation.gov.uk):

• You must be assumed to have capacity unless it is shown that you lack it.
• People must take all practical steps to help you decide before saying you cannot.
• You are not to be treated as unable to decide "merely because" you make an unwise decision.
• Anything done for a person without capacity must be in their best interests, and the least restrictive option.

The third principle matters most at the end of life. A choice your doctor disagrees with is not, on its own, a sign that you lack capacity. This was Dax Cowart's complaint. He could reason clearly, yet his doctors relied on his mother's consent.

Usually the treating doctor assesses capacity through conversation and clinical judgment. There is no single test. Informed consent needs three things: capacity, enough information, and a free choice without pressure. You can withdraw consent at any time. If you think a capacity decision is wrong, ask for a second opinion or the hospital's ethics committee. Courts can settle disputes.

An advance directive is a legal document that sets out your healthcare wishes in case you cannot communicate. It only takes effect when you cannot speak for yourself.

Think of it as a letter to doctors you have not met yet. They will meet you on a day you cannot talk. The letter tells them who you are and what you want.

The main types are:

• Living will: the treatments you want or do not want.
• Healthcare power of attorney (or healthcare proxy): a person who decides for you.
• POLST form: a medical order for people who are already seriously ill. See the DNR section below.

All US states recognise advance directives, but the rules differ. Some places need witnesses or a notary (an official who confirms your signature). You do not need a lawyer.

How many people have one? Fewer than you might think. A review of 150 US studies covering 795,909 people found that only 36.7% of adults had any advance directive. Only 29.3% had a living will. People with chronic illness were barely more likely to have one (38.2%) than healthy adults (32.7%) (Yadav et al., Health Affairs 2017).

Do they work? Evidence: mixed. Here is what the main studies show:

• For: they guide care. A study of 3,746 older Americans who died between 2000 and 2006 found that 42.5% needed a decision about treatment near death. Of those, 70.3% could not decide for themselves. People who had asked for limited care got it 83.2% of the time. People who had asked for comfort care got it 97.1% of the time (Silveira et al., NEJM 2010).
• For: planning helps families. An Australian trial randomly assigned 309 hospital patients aged 80 or more. Half were offered help with planning. Among the 56 who died within six months, wishes were known and followed for 86% in the planning group, against 30% in the usual-care group. Their relatives had less stress, anxiety and depression afterwards (Detering et al., BMJ 2010).
• Against: paper often fails. In 2004, Angela Fagerlin and Carl Schneider published an essay called "Enough: The Failure of the Living Will." They argued that the policy "has not produced results" (Hastings Center Report). People struggle to predict what they will want. Forms get lost. Doctors read them differently.
• Against: planning may not change care. In 2021, three leading palliative care doctors wrote in JAMA that "a substantial body of high-quality evidence now exists demonstrating that ACP fails to improve end-of-life care" (Morrison, Meier and Arnold, JAMA 2021). ACP means advance care planning. They pointed to five large trials, with more than 15,000 patients in total. Their advice: name a trusted proxy, and focus on good conversations when real decisions come.

What does this mean for you? A form alone is a weak tool. A form plus a prepared person plus a conversation is much stronger. Simple tools help. In a trial with 414 US veterans, people given a planning website called PREPARE, plus an easy-to-read form, were more likely to have a plan six months later than people given the form alone (35% vs 25%) (Sudore et al., JAMA Internal Medicine 2017).

You can change or cancel your advance directive at any time while you have capacity. Review it after big health changes.

A living will is a written statement of your wishes for medical treatment at the end of life. It usually applies if you are terminally ill, permanently unconscious or in the final stage of an illness. It often covers:

• Life support: a ventilator, tube feeding (artificial nutrition and hydration) and dialysis.
• CPR: whether you want it if your heart stops.
• When to stop: the conditions under which you want treatment withheld or withdrawn.
• Pain and comfort: for example, that comfort should come first even if it makes you drowsy.
• Organ donation: whether you want to donate organs or tissue.
• Other values: religious wishes, where you hope to be cared for, who you want near you.

Write about values, not only machines. No form can predict every situation. Your values guide doctors when something happens that your form did not imagine. Many hospitals use the Serious Illness Conversation Guide, made by Ariadne Labs and the Dana-Farber Cancer Institute (Nova Scotia Health). Try its questions on yourself:

• "If your health situation worsens, what are your most important goals?"
• "What are your biggest fears and worries about the future with your health?"
• "What abilities are so critical to your life that you can't imagine living without them?"
• "If you become sicker, how much are you willing to go through for the possibility of gaining more time?"
• "How much does your family know about your priorities and wishes?"

Limits. Each US state has its own form, and some need witnesses or set wording. Using your state's official form makes it more likely to be valid. Even then, doctors may read it differently than you meant, and it may not be at hand in an emergency. This is why a proxy matters too.

Where to find forms. Health departments and hospitals offer free forms. Five Wishes is a plain-language form from the charity Aging with Dignity. It covers a proxy, treatment wishes, comfort, spiritual needs and messages for loved ones. It meets the legal requirements in 46 US states, and more than 44 million copies have been given out (Five Wishes). For step-by-step help, see How to Write a Living Will.

A DNR (Do Not Resuscitate) order tells healthcare workers not to do CPR if your heart stops or you stop breathing. Some hospitals call it DNACPR (do not attempt CPR) or AND (allow natural death).

A DNR means no chest compressions, no electric shocks to restart the heart, and no breathing tube at the moment of cardiac arrest. It applies only to CPR. It does not mean "do not treat". You still receive all other care.

Why people choose it. CPR on television almost always works. Real CPR often does not. In 1996, researchers watched 97 episodes of popular medical TV shows. Of the patients who got CPR, 67% appeared to leave hospital alive (Diem et al., NEJM 1996). In real US hospitals in 2017, about 25% of adults who had CPR after cardiac arrest survived to leave hospital (Andersen et al., JAMA 2019). For people who are frail or very ill, the chances are usually lower.

Doctors know this. In a 2013 survey of 1,081 doctors at two US medical centres, 88.3% chose DNR status for themselves when filling in a sample advance directive (Periyakoil et al., PLoS One 2014). This does not mean you should choose the same. It means you should ask your doctor what CPR would really mean for someone like you.

Who can ask for one? Any adult with capacity. For patients without capacity, a proxy or family can ask, based on the patient's known wishes or best interests. A doctor must write the order. It is a medical order, not a legal document like a living will. A hospital DNR may not apply once you leave the hospital.

POLST forms fill that gap. POLST is a portable medical order for people who are seriously ill or very frail, not for healthy adults (POLST). You and your clinician sign it. It travels with you between home, care home, ambulance and hospital. It covers CPR and also wider choices: full treatment, limited treatment, or comfort measures only. Some states call it MOLST, POST or MOST.

Oregon's registry studied 31,294 POLST forms signed in 2012. The average person was 76.7 years old. In all, 68.4% had chosen DNR. The most common choice was DNR with comfort measures only (34.4%). But about 10% chose combinations that would need interpreting in a crisis (Schmidt et al., Resuscitation 2014). Clear wording matters.

A healthcare proxy is the person you choose to make medical decisions if you cannot. Other names are healthcare agent or surrogate. You name them in a healthcare power of attorney (in England and Wales, a Lasting Power of Attorney for health and welfare). Their power starts only when you lack capacity. While you can decide, you decide.

Their job is to decide as you would have wished. Lawyers call this substituted judgment. If your wishes are not known, they decide based on your values and best interests.

The hard truth about guessing. Even close family get it wrong more often than we expect. A review of 16 studies with 2,595 patient-proxy pairs found that proxies predicted patients' treatment wishes correctly 68% of the time (Shalowitz et al., Archives of Internal Medicine 2006). They were wrong in about one case in three. Surprisingly, being chosen by the patient, or having talked about it before, did not make proxies more accurate. Evidence: mixed. These studies used imagined scenarios, not real decisions.

The weight they carry. A review of 40 studies with 2,854 proxies found that at least one in three felt a heavy emotional burden from deciding. It often lasted months, sometimes years. The most common feelings were stress, guilt and doubt. What helped most was knowing what the patient wanted (Wendler and Rid, Annals of Internal Medicine 2011).

So naming a proxy is a gift, but only if you prepare them. An unprepared proxy is like a pilot handed a plane with no flight plan.

How to choose. Pick someone who:

• knows your values, or is willing to learn them;
• will speak up for you, even to doctors or relatives who disagree;
• can stay calm under stress;
• is likely to be reachable when needed.

They do not have to be family. You can also name a backup. Your proxy must be an adult, usually 18 or older. In most US states, your own healthcare providers cannot be your proxy, to avoid a conflict of interest.

Conversations to have. What makes life meaningful to you? What would be worse than death for you? When would you want treatment to stop? Should your proxy follow your words exactly, or use judgment? See How to Choose a Healthcare Proxy and How to Talk to Family About End-of-Life Wishes.

Rights on paper still need people to act on them.

Speak early and clearly. Put your wishes in writing and share them with your doctors, family and hospital. Bring a friend or advocate to important appointments. For complex decisions, ask for a family meeting with the whole care team.

Talking early does not cause harm. A US study followed 332 people with advanced cancer and their carers (Wright et al., JAMA 2008). Patients who had talked with their doctor about end-of-life care were no more depressed than others. In their last week, they were much less likely to be put on a ventilator (1.6% vs 11.0%) or admitted to intensive care (4.1% vs 12.4%). More aggressive care at the end was linked to worse quality of life for patients and more depression in grieving carers. Evidence: mixed. This was an observational study, so it shows a link, not proof of cause.

Ask for palliative care early. Palliative care focuses on comfort and quality of life. The modern hospice movement began with Dame Cicely Saunders, who opened St Christopher's Hospice in London in 1967. She put its spirit in two short lines:

"You matter because you are you. And you matter until the end of your life." — Cicely Saunders, quoted by Hospice UK

In a landmark trial, 151 people with advanced lung cancer were randomly given early palliative care or usual cancer care. The palliative care group had better quality of life and fewer depression symptoms (16% vs 38%). They had less aggressive care at the end, and yet they lived longer: a median of 11.6 months against 8.9 months (Temel et al., NEJM 2010). Evidence: strong for better quality of life in this group. A later review of 43 trials found no clear effect on survival either way (Kavalieratos et al., JAMA 2016). Learn more in Palliative Care.

Look after dignity, too. Dignity therapy is a short talking therapy. A person records what matters most in their life, as a document for their family. In a trial with 441 patients, it did not reduce distress overall. But patients said it helped their sense of dignity and changed how their families saw them (Chochinov et al., Lancet Oncology 2011). Evidence: mixed.

When wishes are not honoured:

1. Ask for the hospital's patient advocate or ombudsman.
2. Ask for an ethics consultation.
3. Involve your healthcare proxy.
4. Write down what happened, with dates and names.
5. Consider moving to another doctor or hospital if possible.

Healthcare providers can be held legally responsible for ignoring a valid advance directive. Families can ask a court to settle a dispute. In an emergency, practical solutions usually come first.

The right-to-die movement campaigns for people to choose how and when they die, including through assisted dying where it is legal. It grew from the patient rights movement, but it goes further. Refusing treatment is legal almost everywhere. Assisted dying is legal in only some places.

History. The movement grew in the 1970s, as cases like Karen Ann Quinlan's drew public attention. The British author Derek Humphry co-founded the Hemlock Society in California in 1980. After a name change and a merger, its national body became part of Compassion & Choices in 2004 (Wikipedia). Other groups include Death with Dignity in the US and Dignity in Dying in the UK.

Two public figures changed many minds:

• Brittany Maynard was 29 when she learned in 2014 that she had terminal brain cancer. She moved from California to Oregon, where assisted dying was legal, and spoke out publicly. Her story helped California pass its End of Life Option Act in 2015 (Wikipedia).
• Terry Pratchett, the fantasy author, announced in 2007 that he had early-onset Alzheimer's disease (Wikipedia). He presented the 2011 BBC documentary Terry Pratchett: Choosing to Die, which won an International Emmy in 2012 (Wikipedia).

Legal turning points.

• Oregon (1994). Voters approved the Death with Dignity Act. It came into use in 1997.
• Colombia (1997 and 2021). On 20 May 1997, the Constitutional Court ruled in C-239/97 that the right to live with dignity includes the right to die with dignity, for terminally ill people who freely consent (Constitutional Court). In 2021, ruling C-233/21 removed the need for a terminal illness, for people with intense suffering from a serious and incurable illness or injury (Constitutional Court).
• Pretty v. United Kingdom (2002). The European Court of Human Rights ruled that "no right to die" can be derived from the right to life in Article 2 of the European Convention (Wikipedia).
• Gonzales v. Oregon (2006). The US Supreme Court ruled 6 to 3 that the federal Attorney General could not use drug laws to block Oregon's law (Cornell LII).
• Carter v. Canada (2015). On 6 February 2015, Canada's Supreme Court ruled unanimously that a total ban was unconstitutional for "a competent adult person who" clearly consents and has a "grievous and irremediable medical condition" (Wikipedia).

Who uses these laws, and why? A major 2016 review in JAMA found that typical users are older, white and well educated, and more than 70% have cancer. Pain is mostly not the main reason. In no place it studied was there evidence that vulnerable groups were using these laws at higher rates than the general population (Emanuel et al., JAMA 2016). The review is now ten years old, and critics argue that newer, broader laws need fresh study.

Oregon's latest report fits the pattern. Of 400 people who died under its law in 2025, 92% were in hospice care. Their most common concerns were loss of autonomy (89%), being less able to enjoy activities (89%) and loss of dignity (65%). Being a burden on family was reported by 39.8%, and worry about pain control by 37.0% (Oregon Health Authority, 2025 data). In Canada, MAID (medical assistance in dying) made up 5.1% of all deaths in 2024 (Health Canada).

Where things stand in October 2026:

• United States: medical aid in dying is legal in 13 states and Washington, DC (Death with Dignity). Delaware's law started on 1 January 2026 (Death with Dignity), New York's on 5 August 2026 (NY Department of Health) and Illinois's on 12 September 2026, after a federal judge declined to block it (Capitol News Illinois).
• France: its assisted dying law was upheld by the Constitutional Council and published in August 2026. It covers adult French nationals and long-term residents with an incurable condition causing unbearable pain (The Guardian).
• Uruguay: in October 2025, its Senate passed the Dignified Death law. It became the first country in Latin America to legalise assisted dying through a law passed by its parliament (BBC).
• Jersey: its law received Royal Assent on 9 July 2026. The service is planned to start late in 2027 (Government of Jersey).
• England and Wales: Kim Leadbeater's bill passed the Commons in 2025 but ran out of time in the House of Lords in April 2026. On 11 September 2026, MPs rejected a new bill by 286 votes to 270 (The Guardian). Scotland's parliament rejected its bill by 69 to 57 in March 2026 (BBC).
• Canada: on 7 October 2026, the justice minister said a bill this autumn will keep excluding people whose only condition is a mental illness, with no end date. That change had been due in March 2027 (CBC News).

Laws change fast. Always check an official source. For every country, see Legal Landscape.

This is one of the newest and hardest questions in patient rights. An advance request is a request for assisted dying made while you still have capacity, to be carried out later, after you have lost it. It matters most to people facing dementia.

• Quebec has allowed advance requests since 30 October 2024, for people with a serious and incurable illness that will take away their capacity. Canada's federal Criminal Code still does not allow them (Health Canada).
• Canada may change this. On 7 October 2026, the justice minister said the coming bill would "open the door" to advance consent. The illness would have to be incurable and cause intolerable suffering. MPs will work out the details in committee (CBC News).
• The Netherlands lets a doctor act on a written request made earlier. On 21 April 2020, the Dutch Supreme Court confirmed that such a statement can replace a spoken request when dementia has taken away capacity. But doctors must stay alert to signs against it. A person with severe dementia who acts in a way that shows a will to live cannot be given euthanasia (BMJ Medical Ethics blog). Such cases are rare. In 2025, Dutch review committees received 499 reports involving dementia. Most of these people could still make the request themselves. Across all 10,341 reports, only 11 involved people who could no longer decide about their request (RTE).

Why is it so hard? Evidence: early. People consulted by Health Canada raised these worries (Health Canada):

• How do you know when the moment described in the request has come?
• What if the person now seems content?
• What if the person seems to resist, but can no longer understand?

Here is a way to picture it. Imagine writing a letter today to the person you might be in ten years. You set the rules for them. But they may feel very differently about their life than you imagine now. Whose voice should count more: the person who wrote the letter, or the person living the life?

There is no easy answer. Reasonable people, including people with dementia and their families, disagree.

Many disabled people strongly support patient rights. Many also oppose assisted dying. These two views fit together better than they first seem to.

Not Dead Yet is a US disability rights group formed in 1996 (Not Dead Yet). Its central argument is that assisted dying laws create a "double standard". Healthy people who want to die get suicide prevention. Ill or disabled people may get help to die. It says this is discrimination (Coleman, Disability and Health Journal 2010).

In January 2021, UN human rights experts raised the alarm about laws that allow assisted dying for disabled people who are not near the end of life. They said: "Disability should never be a ground or justification to end someone's life directly or indirectly" (quoted by the Council of Canadians with Disabilities).

Their concerns include:

• Pressure. People may feel they are a burden, especially if care is poor or costly.
• Missing support. People may ask to die because they lack housing, care or company, not because of the illness itself.
• Gatekeeping. Doctors must judge who is "terminal" or "suffering enough", and those judgments can be wrong or biased.

Data from Canada shows why these worries are taken seriously. In 2024, loneliness or isolation was reported by 21.9% of MAID recipients whose death was reasonably foreseeable. It was reported by 44.7% of those whose death was not. Health Canada says it was never the only source of suffering (Health Canada).

Supporters of assisted dying answer that disabled people should not be denied a choice others have. They point to safeguards and to the JAMA review that found no sign of higher use by vulnerable groups (Emanuel et al., 2016).

Dax Cowart, in his own way, spoke to both sides. He wanted the right to say no. He also said this about the system that saved him:

"If they're going to override a patient's wishes, then they ought to be there to help him override the deficiencies that he's left with." — Dax Cowart, Orlando Sentinel, 1989

A right to choose means little without real support to live.

Many people are surprised to learn that most major faiths accept refusing some treatment at the end of life. Most still reject euthanasia and assisted suicide.

Catholic Church. The Vatican's 2020 letter Samaritanus bonus calls euthanasia "an intrinsically evil act, in every situation or circumstance." But it also says it is lawful "to renounce treatments that provide only a precarious or painful extension of life." It accepts advance directives that refuse such treatment, but not ones that ask for euthanasia. Food and fluids should normally continue, unless the body can no longer absorb or use them (Vatican).

Jewish, Christian and Muslim leaders together. On 28 October 2019, leaders from the three Abrahamic faiths signed a joint statement in the Vatican. Rabbi Avraham Steinberg of Israel proposed the idea. Signers included the Muslim scholar Syamsul Anwar of Indonesia's Muhammadiyah (Vatican News). The statement:

• calls euthanasia and assisted suicide "inherently and consequentially morally and religiously wrong";
• says that when death is near, it is justified to withhold treatments "that would only prolong a precarious life of suffering";
• calls for the best possible palliative care for every dying patient (Holy See Press Office).

Within each faith, scholars and believers hold a range of views. Buddhist and Hindu traditions also have their own teachings on intention, suffering and the timing of death. See Religious Views for each tradition in depth.

If faith matters to you, say so in your advance directive. Name any religious adviser you want involved.

The idea that you decide about your own body is now common. How it works in practice differs a great deal.

• United States, England and Wales, and Canada: strong rights to refuse treatment and to plan ahead, set out in the cases and laws above. Canada also allows MAID for eligible adults since 2016.
• Taiwan: the Patient Right to Autonomy Act came into force in 2019, the first law of its kind in Asia (Hospice Foundation of Taiwan). To make an advance decision, you must first have a planning consultation at a hospital. The decision must then be notarised or witnessed by two adults, and recorded on your national health insurance card (Taiwan law database). By early 2025, more than 93,000 people had signed one: less than 1% of adults.

Taiwan's numbers show something found almost everywhere. A right that is hard to use is a right few people use.

You do not need to be ill to plan. Dax Cowart, Karen Quinlan and Nancy Cruzan were all young and healthy until one sudden day.

Five practical steps:

1. Think. Answer the five questions from the Serious Illness Conversation Guide above. Write your answers down, even in rough form.
2. Choose. Pick a healthcare proxy and a backup. Ask them if they are willing.
3. Talk. Have one real conversation with your proxy and your family. Tell them what matters to you, not only which machines you want.
4. Write. Fill in your local advance directive form. Get it witnessed or notarised if required.
5. Share. Give copies to your proxy, your doctor and your hospital. Keep one where people can find it. Review it every few years, and after any big change in health.

Questions to sit with:

• What would a good day look like for you, if you became very ill?
• Is there any condition you would find worse than death? Or is more time always worth it to you?
• Who in your life would find these decisions hardest? How can you make it easier for them?

If you are reading this because you feel you cannot go on, please talk to someone today. You can find a helpline here.

Dax Cowart never changed his mind about what was done to him. He also never claimed his later life was empty. "It's possible to live a happier life than I ever thought," he told a reporter in 1989. "I've conceded that for a long time now" (Orlando Sentinel).

He held both truths at once. He was glad of his life, and he believed it should have been his to choose. That is the patient right in one sentence: not that every choice will be easy or wise, but that it will be yours.