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When a family questions a living will

■ Background and terminology The term “living will” is frequently used interchangeably in healthcare with “advance directive,” although their definitions differ slightly. A living will is a patient’s written expression of his or her wishes regarding the withholding of life-sustaining treatment in the event of a terminal condition or permanent unconsciousness. An advance directive is a written document informing others about the patient’s wishes regarding endof-life treatment decisions in the event that the patient becomes unable to communicate his or her own wishes. The term “durable power of attorney” for healthcare is a legal designation that empowers an agent or proxy identified by the patient to make healthcare treatment decisions when he or she has lost cognitive capacity. This proxy or surrogate is obligated under the legal principle of substituted judgment to make treatment decisions in the manner in which the patient would have if he or she was able to speak for himself or herself. Most recently, some states have merged the living will and the durable power of attorney for healthcare into a proxy directive called an “Advance Directive for Healthcare.” In the absence of a formal proxy designation through a durable power of attorney for healthcare or an advance directive for healthcare, most states have enacted legislation called default surrogate consent, or family consent laws that list the order or hierarchy of permissible surrogate decision makers. The scope of their respective decision-making authority varies widely among states. The issue that has confounded healthcare providers and families is the clear determination of the “terminal condition” or “permanent unconsciousness.” Advance directives do not rely on decisions regard-