The Most Important Conversation to Have Before You Die

Talking about your advance care directive with your loved ones will make life — and death — easier later on.

By Dana G. Smith

Instead of talking about politics around the Thanksgiving table this year, consider a less fraught topic: death.

It’s something few of us want to think about, but death is a fact of life that we will all encounter, often first as a caregiver and then, inevitably, when we reach our own.

As uncomfortable as it can be, discussing what medical care you want to receive at the end of your life is “one of the most loving things” you can do for your family, said Dr. Jennifer Gabbard, the director of the Palliative Medicine Research Program at the Wake Forest University School of Medicine.

Understanding your wishes ahead of time can make difficult decisions a little easier on your loved ones and comfort them in knowing that they’re doing the right thing.

These discussions aren’t just for people in their golden years, either. If you’re young and healthy, you can frame it as an “in case I get hit by a bus” conversation, said Omni Kitts Ferrara, the director of education at the International End-of-Life Doula Association.

Death is a fraught topic, so it’s worth thinking about how to make these conversations less stressful for your family and friends. Here’s a framework for what to cover.

Yes, we’re talking about an advance care directive.

With end-of-life care, there are two main things to think about, discuss and ultimately put into writing. The first is what types of treatments you do or don’t want to receive, often called a living will. The second is who you would like to communicate your preferences and make decisions about your care if you are unable to, known as your health care power of attorney. Together, these instructions make up your advance directive — documents you can share with your family and with your doctor to file away with your medical records.

Advance directives don’t need to be completed by a doctor or lawyer, but they do need to be signed by yourself and at least one witness. The exact requirements differ from state to state — in some places, the forms must be notarized — so be sure to look up what your state calls for.

First, focus on your living will.

Before you discuss your wishes with others, it can be helpful to complete a living will so that you’re clear about your own thoughts on the topic. Some large health care systems have forms that they can provide to patients, or you can find one online. Several experts we spoke with recommended the website Five Wishes as a helpful resource.

Generally, the living will boils down to whether you “want palliative care just to treat your symptoms,” or whether you “want aggressive treatment no matter what the prognosis,” said Caitlin Cassady, an end-of-life social worker and co-author of the book “Dying at Home: A Family Guide for Caregiving.”

Some living wills ask if you would want specific life-extending medical interventions, such as being put on a ventilator or having a feeding tube. However, because it can be challenging to wrap your head around what these procedures might actually entail, many living wills focus on your values and priorities — in addition to, or even in lieu of, specific treatments.

For example, they may ask: What brings meaning to your life, and how would you feel if you were unable to do those things? What living conditions would be unacceptable to you? These types of questions are valuable to think about, and to explore with the people closest to you.

A living will is different from a D.N.R. (do not resuscitate) order or a POLST (physician orders for life-sustaining treatment), which are both intended for people who doctors think have a more imminent risk of dying. These forms are provided and filled out by hospital staff and only cover specific medical interventions, like CPR or intubation.

Keep in mind that a living will is not a “one and done thing,” Dr. Gabbard said. Your desires will likely change as you age, or a terminal illness may adjust your plans, so revisit it every couple of years.

And each time you do, talk it through with your family. Because while completing a living will is a crucial step, discussing your wishes with your loved ones can be just as important.

Next, designate your health care power of attorney.

While your family should stay informed about your medical wishes, your health care power of attorney will officially communicate your preferences to your medical team and make decisions about your care if you are unable.

Your health care power of attorney can be anyone you want — they don’t have to be a relative — but there are a few things to consider when thinking about whom to pick, Ms. Cassady said: How close are you with the person, and can you have hard conversations with them? Would they be able to carry out your wishes, even if that meant stopping lifesaving treatment? How are they in a crisis?

“Who do you think makes really good decisions in stressful situations?” Ms. Cassady said. Living wills “really don’t cover everything, and people often find themselves in situations making decisions that they never even thought they would make.”

It’s essential to talk with your pick ahead of time to make sure they’re comfortable being in that position. And it’s probably worth informing those you haven’t chosen, too. “People can feel really hurt if you don’t communicate” who you chose and why, Ms. Cassady said. The last thing you want is conflict — or an all-out fight — during a medical emergency.

While death can be a scary subject to broach, you may be surprised by how you feel after. “When we consider our own mortality,” Ms. Ferrara said, “it has an interesting way of reflexively reminding us that we are alive.”

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The Most Important Conversation to Have Before You Die