What’s the Difference between a Living Will and a DNR?

Clients occasionally ask about “DNRs” and whether we prepared them as part of the estate plan during our consultations.  We do not, but we do prepare living wills.[i] A living will and a Do Not Resuscitate Order, known as a DNR, are very different documents. However, many people confuse the two. They both address end of life issues and are used in different settings, according to the article “One Senior Place: Know the difference between ‘living will’ and ‘do not resuscitate’” from Florida Today.

As a quick aside, many states articulate medical decision making differently, and that comes out in estate planning.  For example, some states have advanced care directives with more exhaustive instructions, others are very simplistic.  For this blog’s purposes, I’m focusing on living will versus DNR.

What is a Living Will?

A living will is a statement describing a person’s wishes about receiving life-sustaining medical treatment in case of a terminal illness or irreversible if the condition is incurable. It is used when you can’t speak for yourself and gives guidance to a decision-maker who will act on your behalf.  This includes choices such as whether to continue the use of artificial respiration, feeding or hydration tubes or other artificial means to prolong life.

The living will is used to make your wishes clear to loved ones and to physicians. It is prepared by an estate planning or elder law attorney, often when having an estate plan created or updated. It will be used if and when the situation arises.

What is a DNR?

A DNR is a medical directive used to convey wishes to not be resuscitated in the event of respiratory or cardiac arrest. This document needs to be signed by both the patient and their physician. It’s often printed on brightly colored paper, so it can be easily found in an emergency.

To draw the distinction a little more clearly, the living will comes into play when the doctors have done what they can and nothing else is expected to help (the terminal condition) in which case your wishes are follow, and the DNR is a request not to try and resuscitate.  Most people if they are in my office want the living will, not the DNR.

The DNR should be placed in a location where it can be easily and quickly found. In nursing homes, this is typically at the head or foot of the bed. At home, it’s often posted on the refrigerator.  It is also often used in hospital settings.  The DNR needs to be immediately available to ensure that the patient’s last wishes are honored.

When the DNR is in effect and easily found, the emergency responders will not initiate CPR if they find the patient in cardiopulmonary arrest or respiratory arrest. They may instead provide comfort care, including administering oxygen and pain management.  To be clearer, a DNR doesn’t mean doctors won’t treat you, but it means they won’t resuscitate in the event of arrest.

If a person is admitted to the hospital, their living will is placed on the chart so that it can be followed appropriately. Once a clinical determination of a terminal and irreversible condition has been made, the terms of the living will are followed.

As one more final point, clients sometimes confuse the medical power of attorney and living will.  Mary did an excellent blog cover the basics of each, their differences, and why having both is beneficial. You can find that here:

https://galligan-law.com/living-wills-and-medical-powers-of-attorney-why-they-are-important/

Reference: Florida Today (July 19, 2022) “One Senior Place: Know the difference between ‘living will’ and ‘do not resuscitate’”

[i] In Texas, we use a “Directive to Physicians.”  This is largely analogous to living wills in other jurisdictions.  Since I’m writing online and to more than just a Texas audience, I’ll use the more generic term of living will.

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How Do I Store Estate Planning Documents?

It’s a common series of events: an elderly parent is rushed to the hospital and once children are notified, the frantic search for the estate planning documents starts. It’s easily avoided with planning and communication, according to an article from The News-Enterprise titled “Give thought to storing your estate papers.” However, just because the solution is simple doesn’t mean most people address it.

As a general rule, estate planning documents should be kept together in a fire and waterproof container in a location known to and accessible by fiduciaries, and copies of some documents should be given to the fiduciaries in advance.

Most people think of bank safety deposit boxes for storage. However, it’s not a good location for several reasons. Individuals may not have access to the contents of the safe deposit box unless they are named on the account. Often a court process is necessary for permission to open a safety deposit box if no one is named on the account.

Even with their names on the account, emergencies don’t follow bankers’ hours and access may be difficult. Further, what if the Power of Attorney giving the person the ability to access the safe deposit box is inside the safe deposit box or the principal has died and the Will is in the box.   Bank officials are not likely to be willing to open the box to an unknown person and proof of that person’s authority is in the box.  This is like locking the key in the safe.

Even further, COVID and the economy have led many banks to close or not offer safety deposit boxes.  Banks don’t want to maintain as many brick and mortar locations, so that means safety deposit boxes have to go.

When you store estate planning documents, a well-organized binder of documents in a fire and waterproof container at home makes the most sense.

Certain documents should be given in advance to certain organizations or individuals.  For instance, health care documents, like a Medical Power of Attorney, Directive to Physicians (Living Will) and HIPAA authorizations, may be given to your agents, as well as to your primary care physician or to the medical facility if you go in for a procedure.  This way, agents have the necessary documentation should an emergency occur, and medical systems can add the documents to their file for you.  This way everyone (especially medical providers) are on the same page about your wishes and who will speak on your behalf.

Mary touched on other items that shouldn’t be kept in a safety deposit box in this article.  https://galligan-law.com/things-you-should-not-keep-in-your-safe-deposit-box/  

Financial Powers of Attorney should be given to each financial institution or agency in preparation for use, close in time to when you expect to need it.

This may feel onerous, however, imagine the same hours spent communicating with banks plus the immense stress if the need to use it is time sensitive. Banks often want to review POA’s in advance of their use before accepting them, and that may take several weeks.

If your estate plan includes a trust, you’ll want your trustees’ to have a copy when you are ready to give it to them, and the original can be kept safe with your documents.

Wills are treated differently than POA documents. Wills are usually kept at home and not filed anywhere until after death.

Also, with all documents, especially the Will, it is important to track and keep safe the originals.  You may sometimes be able to probate copies of Wills, but it’s better to keep the original secure and avoid the need to probate a copy.  This is less critical for other documents, but the same policy holds.

Having estate planning documents properly prepared by an experienced estate planning attorney is the first step. Step two is ensuring they are safely and properly stored, so they are ready for use when needed.

Reference: The Times-Enterprise (June 11, 2022) “Give thought to storing your estate papers”

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Does a Supplemental Needs Trust have an Impact on Government Benefits?

I wanted to touch on a topic that has come up quite a lot recently, namely, how to leave property to individuals with disabilities.  The key to this, in most cases, is to create a Supplemental Needs Trust (SNT) which will allow individuals with disabilities to retain inheritances or gifts without eliminating or reducing government benefits, like Medicaid or Supplemental Security Income (SSI).  Using the SNT allows them to receive additional funds to pay for things not covered by their benefits.

Having an experienced estate planning attorney properly create the SNT is critical to preserving the individual’s benefits, according to a recent article titled “Protecting Government Benefits using Supplemental Needs Trusts” from Mondaq.

Individuals who receive SSI must be careful, since the rules about assets from SSI are far more restrictive then if the person only received Medicaid or Social Security Disability and Medicaid.

The trustee of an SNT makes distributions to third parties like personal care items, transportation (including buying a car), entertainment, technology purchases, payment of rent and medical or therapeutic equipment. Payment of rent or even ownership of a home may be paid for by the trustee.

The SNT may not make cash distributions to the beneficiary. Payment for any items or services must be made directly to the service provider, retailers, or other entity, for benefit of the individual. Not following this rule could lead to the loss of benefits as giving the money to the beneficiary counts against their benefit’s asset limit.

Now, some families who already have a loved one utilize government benefits might be familiar with SNTs generally.  If that’s the case, there is a second aspect of SNTs to be familiar with which is whether the SNT is funded with the individuals’ assets or other people’s assets.

If the SNT is funded using the person’s own funds, it is called a “First-Party SNT” This is a useful tool if the disabled person inherits money, receives a court settlement or owned assets before becoming disabled.

If someone other than the person with disabilities funds the SNT, it’s known as a “Third-Party SNT.” These are most commonly created as part of an estate plan to protect a family member and ensure they have supplementary funds as needed and to preserve assets for other family members when the disabled individual dies.

The most important distinction between a First-Party SNT and a Third-Party SNT is a First-Party SNT must contain a provision to direct the trust to pay back the state’s Medicaid agency for any assistance provided. This is known as a “Payback Provision.”

The Third-Party SNT is not required to contain this provision and any assets remaining in the trust at the time of the beneficiary’s death may be passed on to residual beneficiaries.

Many estate planning attorneys (ourselves included) us a “standby” SNT as part of their planning, so their loved ones may be protected, in case an unexpected event occurs and a family member requires benefits.

References: Mondaq (May 27, 2022) “Protecting Government Benefits using Supplemental Needs Trusts”

 

 

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