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Six Steps to Strategic Advance Care Planning
The goal of Strategic
Advance Care Planning is a private, peaceful,
and timely dying1 and to feel peaceful about
your plan now. Confidence your plan will succeed—that
others will honor your wishes after you no
longer can speak for yourself—means you will not
consider premature dying as the only “sure way”
to prevent your being forced to endure an unwanted prolonged
dying with suffering.
The Six Steps
let you clearly state what treatment you want
when (condition). Some strategies
are designed to motivate your future physician to write the
orders you will need. Other strategies are designed to prevent
anyone from sabotaging your goal.
Step 1: Complete your “Draft”
of your “Natural Dying Living Will”
How it works:
Step 1 uses the online patient decision
aid, My Way Cards. Each card describes one of about 50
conditions2 by easy‐to‐understand words and a line drawing. Together,
they strive to comprehensively reflect what people dread most
about being forced to endure a prolonged dying in advanced dementia
and other terminal illnesses.
You can complete Step 1 on your computer, tablet, or cell
phone.3 You make an “advance treatment decision”
one condition at a time, by answering one question:
“In your judgment, will this condition—by itself—cause
severe enough suffering for you to want
If your answer is, “No, not enough suffering,” then others
will continue the default option, Feed and Treat
and try to keep you alive as long as possible.
If you answer is “Yes, suffering from this condition will
be severe enough,” then others can allow you to die of your
underlying disease by implementing Natural Dying.
This intervention can be effective even if you have “No
Plug to Pull”; that is, even if sustaining your life
does not depend on any high‐tech medical treatment because you
only need help with spoon‐feeding.
The criterion of severe suffering may be
more compelling than other criteria that other
living wills use, to answer the “When Question.”
Examples of criteria that other living wills use are:
reaching a stage of disease; inferring if your feeding behavior
is resistant; applying the laudable, but vague “Principle of
Proportionality”; assessing your “Quality of Life” is very low;
and, judging you are living in a state of “Indignity.” Many
people worry about the last two.4)
Your advance treatment decisions generate your Natural
Dying Living Will. This form strives to be clear and
specific to minimize ambiguity and to reduce conflict when others
try to interpret what you want, and
when. The intervention Natural Dying
withdraws assistance by another’s hand with hand‐feeding and
hand‐hydrating, but it never withholds food and fluid.
Instead, it includes the physician order, “Place food and fluid
in front of the patient and within his or her reach.” For Natural
Dying be effective, those in authority must
accept it. So it strives to be clinically appropriate,
legal, ethical, moral, and consistent with the teachings of
Educates you what it can
be like, for you and your loved ones, to live with advanced
dementia and other terminal illnesses (by the cards and by optional
links to online videos).
Facilitates your making
a clear and specific advance treatment decision for each condition.
Lets you express “what” intervention you want “when,” where
timing is based on your values.
Memorializes your requests
in a comprehensive, compelling, and acceptable way so your future
physician(s) and others will honor your specific requests.
your proxies/agents’ emotional burden by making their primary
role to serve as your advocate so others honor the treatment
decisions that you previously made for
Why this step is unique:
To our knowledge, this
living will includes far more conditions than other living wills—about
50, compared to others that typically have 6 or fewer.
No other living will insists
on “severe enough suffering” after broadening
the concept of suffering as the criterion for “when.” Suffering
includes: physical pain and suffering; emotional or psychic
suffering; existential suffering (meaning in life and fear of
dying); disruption of one’s life narrative; and not being able
to spare loved ones from various types of suffering.
No other living will offers
a way for physicians to answer the “When Question” so there
is no need to assess your current suffering. Pragmatically,
when “that time” may have come, physicians must only answer:
“Have you, my patient, met the clinical criteria of at least
one condition that you previously judged
would cause severe suffering?”
Step 2: Discuss your “Draft” with a healthcare
How it works:
You receive by email, a PDF of your “Draft” Natural Dying
Living Will along with our written comments. You and one of
our staff then discuss your decisions by phone. (This discussion
can also be part of an advance care planning counseling session.)
The review of your “Draft” Natural Dying Living Will asks
if your decisions seem consistent with each
other, and if they are credible, clinically appropriate,
and conform to generallyacceptable medical practice.
If your decisions seem deliberative, it will
easier for your proxy/agent to motivate your future treating
physician(s) to write orders that honor your endof‐ life wishes.6
Why this step is unique:
To our knowledge, no other organization provides comments
and discusses “Draft” responses with planning principals. We
have over seven years of experience in helping patients consider
the best decisions for their future incapacitated selves. People
typically change between 2 and 12 decisions.7 Yet
planning principals often feel these few changes were important
for them to feel at peace now; that their living will reflects
what they really want.8
Step 3: Again, use the online patient
decision aid, My Way Cards. This time you will complete
your “Final” Natural Dying Living Will.
How it works:
Consider your discussion in Step 2 and any subsequent thinking,
reading, viewing of instructional videos, and discussions with
family members, proxies/agents, and other trusted authorities
and counselors. After you complete the online program again,
we will send you a PDF by email. You can review it and make
any needed final changes. Then we will send you by U S Postal
Service, your “Final” Natural Dying Living Will. This will be
printed on heavy stock color paper.9 To make it legally
valid, you can sign this form and have it witnessed or notarized.
This step gives you the opportunity to demonstrate that you
made your difficult, possibly lifedetermining decisions in a
diligent and deliberative way, and that your decisions were
consistent over time.10 In addition to reflecting
your decisions, the “Final” Natural Dying Living Will incorporates
strategic wording to motivate your future physician(s) to honor
your wishes. Example: if physicians who ignore your wishes risk
losing their legal immunity and a lawsuit.
Why this step is unique:
To our knowledge, no other organization offers planning principals
two opportunities to make advance treatment
decisions as they complete their living wills.11
Nor does any other living will “warn” physicians about the possible
consequences of ignoring your known wishes.
Step 4: RECORD your oral testimony on
VIDEO during an interview. Use this opportunity to explain
WHY you made each treatment decision, and to add personal
DETAILS. Demonstrate your decision‐making capacity.
How it works:
Your interview can be in‐person in our office, or where you
currently reside. If you cannot travel, or if you live far from
our network of counselors, you can use our secure, private,
HIPAA‐compliant Internet video program. We can send you the
finished video on a thumb drive, upload it to YouTube using
its privacy settings, and store it on our server.
Step 4 lets you inform others exactly what
you want for each treatment decision in your “Final” Natural
Dying Living Will. This is your opportunity to convince
your future physician(s) and others to honor your requests.
Finally, those who view the video can see that you had
capacity (were mentally competent) to make
these decisions if you demonstrated that: you understood
and appreciated the consequences of the two
treatment options (Treat & Feed versus Natural
Dying), and you used logical reasoning to make
a set of treatment decisions that you expressed
Step 4 is especially important for patients
who have a diagnosis or condition that may affect thinking,
memory, or judgment. Examples include: Mild Cognitive Impairment,
early dementia, brain trauma or tumors, high doses of medications
to treat pain, and severe liver or kidney failure. Your interviewing
counselor can express a clinical opinion about capacity that
carries more clinical and legal weight than a lay person’s opinion
regarding “sound mind.” Experienced counselors can follow a
semi‐structure interview to elicit your responses. In the future,
other clinicians can view the video to assess your decision‐making
capacity. Either way may prevent future conflict so others honor
your wishes promptly.
Note: Checking a few boxes cannot fully reflect your nuanced
wishes and strong feelings. But after you complete the video,
you may feel that you have spoken for yourself. If someday,
you lose capacity and cannot speak for yourself, others can
view your video to learn and to appreciate what
you really wanted, and why.
Step 4 can: (A) help you avoid prolonged
suffering; (B) reduce your loved ones’ anxiety about making
the decision you want (that may reduce their grief); (C) settle
the issue your having capacity to make informed decisions; and,
(D) help your proxy/agent persuade your treating physician to
write orders to honor your end‐of‐life goals.
Why this step is unique:
To our knowledge, no other organization uses a semi‐structured
interview that follows guidelines developed over several years
of professional experience whose goal is for counselors to elicit
as fully as possible, the planning principal’s end‐of‐life wishes.
Nor do other organizations structure the interview so a counselor
can conclude with an opinion regarding your decision‐making
Step 5: Strategies to motivate your physician
to write the orders you need, and other strategies to prevent
anyone from sabotaging your plan.
How it works:
We send you a PDF that includes two documents, the
Natural Dying Agreement and the Natural
Dying Affidavit. They include a comprehensive set of
legal/medical/logistical strategies. You and your physician
sign certain pages. A person who has no conflict of interest
can sign another page. All potential members of your Decision
Committee sign their page, which makes this part of the Agreement,
a “bilateral contract.” As Decision Committee members who signed,
they become your currently active proxy/agent and alternative
proxies/agents. By signing, they will have agreed to the following:
(A) They will serve as your advocate so others will honor your
end‐of‐life wishes. (B) They will implement any strategy needed
to fulfill your end‐of‐life goals. (C) They agree for others
to observe their behavior, and if necessary, be replaced by
another member of your “Decision Committee” if the other members
judge the currently active proxy/agent’s behavior is ineffective
(as defined in the Natural Dying Agreement).
The Natural Dying Affidavit allows you to swear in front of a notary
that your statement is true and correct. This makes it possible
for the Natural Dying Affidavit to be admitted as evidence in
a court of law. Ironically, this strategy may prevent the need
to go to court. Here’s why: If those who oppose your decisions
fear a court will read the Affidavit and honor your specific
wishes, they may avoid going to court and stop challenging your
You can put into place a comprehensive set of strategies
designed to persuade your physician and others to honor your
end‐of‐life wishes and to overcome common challenges who might
otherwise sabotage your goal of attaining a private,
peaceful, and timely dying.
Fourteen examples of challenges
after you reach a condition that you judged causes severe
enough suffering to want others to implement Natural
Dying, and want others to stop spoon‐feeding:
(A) You fear one or more relatives might try to influence
your physician not to honor your end–of–life wishes
based on their different (perhaps religious) beliefs.
(B) Even the “you” whom you may someday become can oppose
your wishes. (Note: Below, the new, future incapacitated “you”
is called your “now‐self,” while the past,
capacitated “you,” who just completed your Natural Dying Living
Will, is called your “then‐self.”) While your
“now‐self” cannot talk, your “now‐self” can still grunt and
point to the food and fluid placed nearby. Observers conclude
your “now‐self” wants spoon‐feeding to continue...
But the condition you have reached is one your “then‐self” wanted
spoon‐feeding to stop.
(C) One or more third parties observe you receive spoon‐feeding
from a caregiver. They point out how you open your mouth without
resistance. They argue your (apparent) willingness means your
“now‐self” changed your mind and then claim you now want spoon‐feeding
(D) A third party claims it is illegal or immoral to stop
spoon‐feeding since it is “basic care,” not “medical treatment.”
(E) Your currently active proxy/agent does not advocate effectively
for your end‐of‐life wishes, but will not step down so an alternate
can serve you. This situation can occur for many reasons. It
may be more likely if your first choice proxy/agent becomes
unavailable. But going to court to replace your currently active
proxy/agent can take a long time and cost a lot of money.
(F) You need medications to prevent you from hurting yourself
or others, or to get relief from mental anguish. But your physician
cannot give you medication until a competent person signs a
(G) You want to live where you are, until you die. But after
facility administrators learn that your living will requests
Natural Dying, they ask you to move out.
(H) Your doctor recently signed a “Physicians Order for Life‐Sustaining
Treatment” form. But it conflicts with your Natural Dying Living
Will, whose previous instructions you still want.
(I) You want total relief from all types of unbearable pain
and suffering. But your physician fears others will criticize
him/her for committing “slow euthanasia,” or for not following
this ethical guideline of the American Medical Association:
“Palliative Sedation is not an appropriate
response to suffering that is primarily existential.”
(J) A third party petitions a hearing in a court of law.
Although your “then‐self” was informed that your Living Will
and other forms were legally valid, and they still are—the opposing
third party argues that the judge should not admit these forms
into evidence since you did not swear an oath when you signed
(K) An anonymous third party believes that withdrawing spoon‐feeding
is elder abuse and requests an investigation that can lead to
your prolonged dying and suffering—even if your wishes eventually
(L) Your physician, or the facility in which you reside,
refuses to honor your Natural Dying Living Will when your proxy/agent
requests, refuses to let your proxy/agent or loved ones take
you home, and state they will request the use of force, if necessary,
to prevent your proxy/agent or your loved ones from trying to take you home,
as per the results of the Adult Protective Services investigation.
(M) The legal department of the facility where you reside
points out that the statute in your state, or the regulations
of Medicare or another organization requires them to always
offer you food and fluid.
(N) You reside in a nursing home or memory care unit whose
medical director is a member of The Society for Post‐Acute and
Long‐Term Care Medicine (AMDA). This professional organization
adopted their Ethics Committee’s recommendation to continue
“comfort feeding” until your “now‐self” either refuses
to be spoon‐fed, or seems distressed by the
act of spoon‐feeding.
Your current ability to function is so diminished that you
cannot show any refusal behavior, but you still want to die.
Another possibility: Your physicians think your distress
is caused by the act of feeding, but something else is causing
your distress, which could be treated if recognized, although
this is difficult. Your AMDA physician follows the “ethical”
protocol to stop “comfort feeding.” This causes you to die prematurely—before
you would want to die.
Why this step is unique:
Most advance directives assume that if the planning principal
clearly states what specific interventions
are wanted when, then their future physicians
will (automatically) honor her wishes. In contrast,
Strategic Advance Care Planning considers a clear and
specific living will as necessary but not sufficient;
as a good beginning, but not enough to expect success; as an
ample statement of wishes, but lacking effective strategies
to make sure others will fulfill them. Example: A physician
may consider your expressed wish to stop others putting food
and fluid in your mouth if you meet the clinical criteria of
a certain condition as just one factor to consider. Other factors,
such as the ones listed above may seem more important to physicians
or third parties.12
Step 6: Store all your forms and videos
in a registry so that clinicians and appropriate others
can retrieve them readily.
How it works:
This optional step is an invitation to join our national
MyLastWishes.org You (or we) can upload all your
Strategic Advance Care Planning forms and videos. You will receive
a laminated business‐sized MyWCard that has
a barcode that clinicians and appropriate others can scan using
their cellphone or tablet to readily retrieve your forms and
videos. Clinicians can also input some of your relevant demographics
in their computer.13
You can optionally record 3 or more short videos that inform
emergency first responders precisely what you want at various
phases of your life. A common set of examples: (A) Now,
you want Cardiopulmonary Resuscitation (CPR).
(B) Later, if you become very sick, Do Not Attempt
to Resuscitate (DNAR). (C) If you reach
a condition that you judged “severe enough” to implement Natural
Dying, (DNAR + Natural Dying). When first
responders or other healthcare providers scan the 2‐dimensional
barcode, your menu can be set so the appropriate video will
A relevant fact: the best forms, videos, and strategies can
serve you only if your physicians have access to them when they
may honor your requests. Step 6 provides makes this possible.
You can keep your MyWCard in your wallet at
all times (in case of an emergency). If someday, you become
seriously ill, you can wear the card along with a signed POLST
form, and perhaps add a Medallion (metal dog tag). In many states,
emergency first responders are legally mandated to respond to
standard messages on Medallions. One treatment refusal can be
important so your dying is not prolonged, if
you want Natural Dying: “NO IV or fluids by any route.”
Why this step is unique:
Some registries operate primarily in one state. Some organizations
store only short (90 second) videos but not long videos of your
complete living will. (The average Natural Dying Living Will
from Step 4 is an hour long.) Few registries offer automatic
streaming. To our knowledge, no registry include all of the
Want more information?
“Living with Advanced Dementia‐‐What is it really like? Feb
4, 2017” A 14–minute glimpse of why Advanced Dementia is considered
among the most cruel, most burdensome, and most prolonged of
any terminal illness—for patients, loved ones, and caregivers.
Preview our online patient
decision aid that fully explains our approach and make decisions
about 12 (of the 50 conditions), with no obligation at:
If you are concerned about a relative who has already reached
the stage of advanced dementia, but whose living will is ineffective
or does not exist, you can learn about (and even begin) our
other protocol, Now Care Planning, by going
online here: surveymonkey.com/r/Now-Care-Planning-for-Dementia
The costs for each step and the entire bundled
package are available upon request.
[This material is copyrighted
and protected by an application pending with the USTPO.]
Cost and approximate times to complete each step:
Step 1, Draft Natural Dying Living Will:
Cost: $95. Time: 45 to 75 minutes. Total time will be 12 minutes
longer if you view the recommended 14‐minute instead of the
2‐minute video to learn what it is like, for patients and for
their loved ones, to live with advanced dementia.
Step 2, discuss your decisions: Cost: $35.
Time: 5 to 15 minutes to read and discuss the comments about
your “First Draft.” If purchased at the same time as Step 1:
$25, For patients who have health insurance, this step can be
part of a session of advance care planning counseling.
Step 1 and Step 2: $120, if purchased at
the same time. (Save $10.)
Step 3a, “Final” Natural Dying Living Will:
Cost: $50. Time: 30 to 50 minutes to complete the patient decision
“Upgraded Final” Natural Dying Living Will:
For a limited time, you can upgrade your Final NDLW if your
version is 2018 or older: Step 3b:
Cost: $35 if you want us to email you the PDFs. Step
3c: $45 if you want us to print it on heavy stock colored
paper and send it you by USPS.
Step 4, Interview and video: Cost: Could
be “no cost” if you ask your proxy/agent or a friend or loved
one to conduct the interview.15 If you ask Dr. Terman or one
of his trained clinical colleagues, the cost will be between
$150 and $400 per hour. Interviews typically last between three‐quarters
of an hour, and one and a half hours.
Step 5, Natural Dying Agreement and Affidavit:
$50. Time: Depends on how quickly others sign their respective
Step 6, national registry to store your forms and
videos: Cost: Membership in
MyLastWishes.org depends on the duration of membership
you choose. Examples: $45 for one year; $195 for life. Ordering
a Medallion (metal dog tag) so that emergency first responders
will honor your CPR/DNR wishes, costs about $80. Time: half
hour to register and complete the form to indicate the information
you want on your MyWCard (and Medallion).
Stanley A. Terman, PhD, MD
Psychiatric Alternatives and Wellness Center Medical Director, CEO of Caring Advocates Effective Living Wills for Dementia, Etc. (DBA)
To view videos on Advance Care Planning,
learn about our training program, and read
professionals’ and patients’ testimonials:
If you want to forward someone the LINK to this e-brochure,
you can copy it from here: caringadvocates.org/acp.php
Stanley A. Terman is a board-certified
psychiatrist and bioethicist,
has an MD from U. of Iowa
and a PhDfrom MIT. To attain
the goal of a peaceful, timely dying, Dr. Terman
developed Strategic Advance Care Planning
with input from clinical, bioethical, legal, pastoral
colleagues, and patients. He also created Now Care Planning
for incompetent patients with advanced illness who no longer
can complete living wills.
In caring for psychiatric patients, he prescribes
medications only when necessary. His approach to psychotherapy
can include strategic, existential, psychodynamic, cognitive
behavioral, and meta-cognitive, as well as couple therapy. He
honors people’s dignity by respecting two goals: they
want to change and they need to
Dr. Terman welcomes Medicare beneficiaries.
Although he is voluntarily NOT an enrolled provider,
Medicare will usually reimburse its “allowable amounts”
if patients submit claims. Patients who prefer not to travel
may use Dr. Terman’s private, secure,
Call (415) 237-0377
Advance Care Planning colleagues:
Nate Hinerman, PhD, is Associate Professor
and Chair of Psychology in undergraduate programs at Golden
Gate University. He is also a psychotherapist, specializing
in advance care planning, and grief counseling. He organizes
international conferences on death, dying and bereavement, and
leads local organizations devoted to the expansion of hospice
and palliative care services.
Michele Senbertrand is a Geriatric Advance
Practice Registered Nurse Practitioner, Psychotherapist and
Elder Care Manager. She had 16 years of experience advocating
and caring for elderly in New York City before moving to the
San Francisco Bay area, where her practice will increasingly
focus on advance care planning.
Mara Kubrin, a Speech Language Pathologist,
focuses on communication, cognition, swallowing, and informed
decision-making. Mara prioritizes patients’ quality of
1 This patient decision aid can also be used by those who want to live as long as possible, regardless of suffering.
2 Conditions are described in terms of what others can observe (outside) and what patients feel (inside). There
is no implied correlation between any condition and one (or more) diagnoses. Example: A person may have
irreversibly and completely lost the ability to respond to others. The cause could be total paralysis due to ALS or
a stroke; severe cognitive impairment from physical or chemical trauma; or advanced dementia. Living wills do
not need to identify what caused this loss of function. Living wills need only to describe the result, for you to
consider. Your task is simply to judge each condition if it will, or will not, cause severe suffering.
3 The version of cards printed on cardboard can be spread out on a desk or a kitchen table.
4 Many worry about the last two criteria because they could begin a dangerous slippery slope that might lead to
this disaster: Granting some people the authority to judge whether the lives of others are, or not worth living.
5 In contrast, traditional advance directives empower proxies/agents and expect them to make current
treatment decisions on behalf of the incapacitated patient using their substituted judgment.
6 Subsequent steps can allow you to demonstrate that, as you made these life‐determining decisions for your
future self, you were not only diligent, deliberative, but also consistent over time.
7 For example, view the video from Melissa Cook’s Step 4: Why I Changed My Mind‐‐From Natural Dying to Treat
& Feed‐‐for Certain Symptoms of Advanced Dementia (20 min. 8/2012). youtu.be/qA0TQS1Pmwk.
8 This step is optional, but strongly recommended. If you are satisfied with your Natural Dying Living Will, or not worried
about future challenges and obstacles to honoring your end‐of‐life wishes, that’s your choice. Whatever your reason, we
can promptly email you a printable PDF of your Natural Dying Living Will that omits the word, “Draft.” You can make this
form legally valid if you print it, sign it, and have it appropriately witnessed or notarized.
9 You will also receive three clarifying forms that are designed to strengthen your requests.
10 Although the word “Final” modifies “Natural Dying Living Will,” you can always change your decisions if you
still have mental capacity. Your revised version can be called your “Updated Final” Natural Dying Living Will.
11 Other living wills typically require one or a few checks from a choice of boxes or a signature at the bottom.
12 Success seems likely on its face, but to our knowledge resolving these conflicts have not been tested clinically or in court.
Yet one goal that defines success is a dying that is private, where conflicts that arise are resolved at the bedside. While no
one meant to keep successes secret, it is not likely that we, or the public, would have been informed about it.
13 You will receive copies of your barcodes on sticky labels that you can paste on your POLST form, driver’s license, health
insurance card, and other places.
14 It is your proxy/agent’s responsibility to make sure only the appropriate POLST form is available.
15 Having a counseling healthcare provider conduct the interview is highly recommended for planning principals
who currently have a diagnosis of a brain disorder that affects thinking, memory, or judgment. Examples: Mild
Cognitive Impairment, early dementia, brain trauma or tumors, high doses of medications to treat pain, liver or
kidney failure. A clinician’s opinion about capacity can carry more clinical and legal weight than lay person’s
opinion regarding “sound mind.” Both can state the patient made her decisions voluntarily.