Advance Directive — Decide in Advance What Really Matters

A living will is a written statement in which a person with the capacity to give consent specifies in advance—in the event that they later become incapable of making decisions—whether they consent to or refuse certain examinations, medical treatments, or medical procedures. It has been legally regulated in Germany since 2009. The key requirements for its legal validity are set forth in Section 1827 of the German Civil Code (BGB):

• Written form with a handwritten signature
• Capacity to give consent at the time of execution
• Specific provisions that apply to the actual life and treatment situation
• No indications that the patient has since changed their mind

If these requirements are met, the advance directive is binding on physicians—even if they disagree. Notarization is not required.

The most common reason advance directives cannot be implemented is vague wording. A statement like “I do not want life-sustaining measures” sounds clear—but it isn’t. What is a life-sustaining measure? Administering antibiotics for pneumonia in an elderly patient? Dialysis? Mechanical ventilation? Each of these measures can prolong life, and each is appropriate in very different situations.

A good advance directive therefore specifies two levels in concrete terms:

Level 1: The Situation

In which specific clinical situations should the directive take effect? Typical phrasing:

• Imminent death
• The terminal stage of an incurable, fatal illness
• Brain damage resulting in a persistent loss of the ability to understand and communicate (e.g., following a persistent vegetative state or severe dementia in old age)
• Severe, permanent brain damage following a stroke in old age or an accident

Level 2: The Measure

Which specific treatments are desired or refused? Typically:

• Resuscitation measures in the event of cardiac arrest
• Mechanical ventilation
• Artificial nutrition via a feeding tube (PEG) or intravenously
• Dialysis
• Antibiotics for infections during the terminal phase
• Blood transfusions
• Intensive care treatment

The key is to state: “In situation X, I do not want measure Y—but I do want Z.” This creates a set of instructions that can actually be followed in an emergency.

An example of a viable formulation: “If I am in the terminal stage of an incurable, fatal illness, I do not wish to receive artificial nutrition or resuscitation measures. I expressly request consistent pain and symptom management, even if this cannot rule out the possibility of a shorter life.”

In addition to the advance directive, the power of attorney is the second key document. While the advance directive specifies what should happen, the power of attorney determines who is authorized to make decisions on your behalf if you are no longer able to do so yourself.

Its importance is often underestimated: Without a power of attorney for healthcare, not even your spouse or adult son can make decisions about your medical treatment without court proceedings. The guardianship court must order legal guardianship—a process that can take weeks and is emotionally taxing.

A good power of attorney for healthcare includes:

• Clear designation of one or more authorized representatives
• Scope of the power of attorney—health care, residence, and financial affairs
• Clear provisions for multiple agents—authorized to make decisions jointly or individually
• Location of filing and registration in the Central Advance Directive Registry of the Federal Chamber of Notaries

→ For a comprehensive overview of palliative care: Palliative Care in Old Age.

• Formulated too generally: “No life-prolonging measures” without context is legally weak. Specify concrete situations and concrete measures.
• Using only form templates: Checkbox forms are helpful as a starting point but are rarely sufficient. The individual situation and personal wishes must be clearly conveyed.
• Outdated: A living will from 2010 may no longer reflect your current wishes in 2026. Recommendation: Review, date, and reaffirm it every two to three years.
• Drafted without consulting family members: A directive that no one knows about is often ineffective. The people who are supposed to represent you in an emergency must be aware of your wishes.
• Drafted without consulting your primary care physician: Your primary care physician can provide medical advice on the specific wording and authoritatively advocate for the document in a hospital setting.
• Only vaguely refers to dementia: In cases of dementia in old age, the situation is often not a “dying process” but rather “severe, permanent cognitive impairment with loss of the ability to communicate.” This situation must be explicitly stated.
• No durable power of attorney: Without it, the advance directive is often ineffective in practice.
• Cannot be located: The directive must be found in an emergency. It should be filed with the Central Advance Care Planning Registry, with a copy kept by the family doctor and another by authorized relatives.

Every adult—not just when ill

Living wills and powers of attorney are not just for the elderly or sick. An accident can lead to an inability to make decisions at any age. The standard recommendation of the German Society for Palliative Medicine: Every adult should have both documents.

In old age—by age 70 at the latest

For people over 70, the likelihood of developing dementia increases significantly. Ideally, one should exercise their legal capacity before cognitive deficits arise. Anyone who waits until after a diagnosis of dementia in old age to draw up a directive faces legal uncertainties regarding their capacity to give consent.

After a serious diagnosis

In cases of cancer, progressive neurological diseases, severe heart failure in old age, or lung disease, a living will is not an optional add-on—it is part of sensible treatment planning. It enables discussions with the care team about realistic treatment goals and desired limits on treatment. In addition, it is advisable to address palliative care in old age at an early stage.

In the early stages of dementia

In the early stages of dementia, legal capacity is usually still intact. This window of opportunity is crucial—it closes as the disease progresses. An early, clearly worded advance directive provides invaluable protection for the later course of the disease. A geriatric assessment can also help determine the right time.

→ On early diagnosis and the importance of early intervention: Dementia in old age.

1. Reflect and Have Conversations

The best advance directive is the result of a process, not a form. Take your time—weeks, not hours. Talk to people you trust: What is important to you? What situations would you find unbearable? Which treatments would you want, and which would you not?

2. Discuss it with your primary care physician

Your primary care physician can explain medical terms and advise you on the specific wording. Many primary care practices offer structured conversations about advance planning—so-called “Advance Care Planning” discussions.

3. Form or Custom Wording

The Federal Ministry of Justice provides templates, as do medical associations, hospice organizations, and the Federal Chamber of Notaries. These templates are a good starting point, but they do not replace the need for individual customization and clarification.

4. Signature and Date

The document must be in writing and bear your handwritten signature and the date. Notarization increases legal certainty but is not required.

5. Filing and Notification

Provide copies to your primary care physician, authorized representatives, and closest relatives. For a small fee, the Central Advance Directive Registry (ZVR) of the Federal Chamber of Notaries records the existence of an advance directive and the contact information of the authorized representatives. This enables hospitals to quickly access the information that an advance directive exists.

6. Regular Review

Every two to three years and whenever a significant event occurs (new diagnosis, change in life circumstances). It is not always necessary to draft a new one—often, simply signing it again with the current date and a brief confirmation that the will remains in effect is sufficient.

If you are no longer able to make decisions for yourself and no advance directive exists, the treatment team must determine your presumed wishes—based on past statements, personal values, or religious or philosophical beliefs. This is often only partially successful. If there is a disagreement between family members and the medical team, a court ruling may be necessary—a situation that is stressful for everyone involved.

An advance directive is therefore not only an expression of one’s own will—it is also a gift to one’s loved ones. It spares them from having to make decisions while grieving and under time pressure. In conjunction with early delirium prevention and targeted deprescribing, it is part of forward-looking geriatric care planning. Frailty syndrome and the associated impairment of decision-making capacity also make early planning particularly important.

• If you have a complex medical history
• If you’re unsure about the specific wording
• If there are conflicts within the family regarding the appropriate course of action
• If cognitive decline is beginning—such as mild cognitive impairment (MCI)—to ensure the ability to give informed consent
• After a serious diagnosis to help focus on specific goals

Points of contact include primary care physicians, hospice organizations, palliative care specialists, medical associations, attorneys, and notaries. Geriatric outpatient clinics also frequently offer support with advance planning.

→ For holistic care planning: Geriatric Assessment.