Advance Directives- An Introduction

Advance Directives are important legal documents, but are sometimes misunderstood. Generally speaking, advance directives designate another person or persons to make decisions or take actions on your behalf should you be unable to do so for yourself. They can also be designed to state your own wishes and preferences.

Many people have such directives around legal and/or financial matters. For example, they may have a will or a living trust or they may have a document authorizing their spouse to gain access to financial accounts or pay bills or sell assets if they were to become unable to do so themselves or jointly.

Advance Directives for Medical Care (so-called "Living Wills") make your wishes known about medical care and designate people to make medical decisions for you if you become unable to state them for yourself. For example, you will typically be asked to state a preference around organ donation and around prolonging life in the event that you are in a coma or persistent vegetative state ("brain dead") or some terminally ill condition.

Please be aware that your wishes around artificially prolonging your life only become applicable when you are already brain dead or in a coma or terminal condition. Advance Directives generally do not address your preferences or wishes around scenarios that could lead up to being terminally ill or brain dead.

For example, you may have strong feelings about the roles of interventions or procedures such as dialysis or emergency brain surgery in dire emergencies where you are already so sick that cannot discuss them for yourself. It is okay to add these wishes to your Advance Directive.

Advance Directives allow extra space for the addition of any further statements that you may care to make. In California, they do not require an attorney to draft. They simply require your signature and either a notary public or the signatures of two persons who know who you are.

However, you may wish to enlist the aid of an attorney if such a directive seems complicated or unclear.

This site has state-specific free downloads of Advance Directive forms.

Five Wishes (produced by the non-profit Aging With Dignity) is an advance directive that more fully addresses your feelings around comfort and is a bit more specific around examples of life-sustaining interventions or procedures and allows you to address them as you see fit. The document costs $5, but can be previewed for free as a .pdf document.

This form from the Attorney General's office of the State of California is also freely available.

We also have a handout on this subject and sample forms from the California Hospital Association for your use. Feel free to ask for one next time you are in the office!

Pharmacokinetics: What happens to the medicines I take?

Folks often ask questions about their medicines (whether over-the-counter or prescription) that have to do with how long they last, or how long it will be before they take effect, or how long until side-effects may go away or for the medicine to be out of circulation.

A handy principle or "rule of thumb" has to do with what happens to medicines after you take them; this is known as pharmacokinetics. (On the other hand, what they do after you take them is called pharmacodynamics.) Mind you, this rule of thumb only applies when a medicine is being taken regularly and as directed. This means that it is being taken in the instructed amount and frequency and not "as needed" or "now and again". However, this rule of thumb applies to nearly any medicine by any route (swallowed, injected, i.v., etc.).

How much of a medicine (dosage) and how often it needs to be taken (frequency) has to do with how quickly your body metabolizes or breaks it down, and then how quickly it is excreted out of your body. For the vast majority of medicines, the liver breaks them down, and then they are excreted in your urine.

When taken at the directed dose and frequency, a medicine does not stay at a fairly constant and effective level in your blood stream until after the 4th dose. This is called steady state.

For example, if today you start taking a pill for pain that is supposed to be taken three times every day, then a steady and pain-relieving amount will start to be maintained in your system by later tomorrow. On the other hand, if you start one that is a once a day pain pill, it will not reach a steady level until five days from now.

Similarly, if you are taking a medicine regularly and feel that it is causing troublesome side effects it will not be entirely gone until after the fourth missed dose.