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Comprehensive Guide to Do Not Intubate Orders in East Los Angeles
Navigating Do Not Intubate orders requires careful thought, clear communication, and properly executed documentation under California law. This guide is intended to help residents of East Los Angeles understand what a DNI order does, how it fits with other advance healthcare documents, and practical steps to make sure medical teams and family members know your intentions. LA Estate Plans assists clients with drafting directives and integrating them into an overall estate plan so that medical wishes are respected. The goal is to give you straightforward guidance so you can make informed choices and record those choices in a way that will be followed in a healthcare setting.
A DNI order specifically addresses whether you want medical staff to perform intubation in situations where you cannot breathe without assistance. Because medical decisions can be emotionally charged, having written instructions reduces uncertainty for loved ones and medical providers. In East Los Angeles, it is important to use forms and language recognized by hospitals and clinics, and to share copies with relevant parties. This section outlines why DNI orders matter, the documents commonly used alongside them, and practical advice on maintaining and communicating your directives to ensure they have the intended effect when they are needed most.
Why DNI Orders Matter for Your Healthcare Wishes in East Los Angeles
A properly executed DNI order helps make sure your preference not to receive intubation is known and honored by medical personnel. Clear written instructions reduce the chances of unwanted invasive treatment and help family members avoid making emergency decisions without guidance. For residents of East Los Angeles, having a DNI order in place can reduce stress during medical crises, provide direction to treating teams, and support alignment between your values and medical care. This legal service helps you articulate your wishes and ensures your directives are documented in a way that medical staff and facilities understand and can follow when timely decisions are required.
About LA Estate Plans and Our Work in East Los Angeles
LA Estate Plans focuses on wills, trusts, probate, and advance healthcare documents for families and individuals across East Los Angeles. Our approach emphasizes clear communication, careful drafting, and attention to how documents interact with medical procedures and state law. We work with clients to translate their medical preferences into written directives that are legally recognized and practically useful in hospital environments. By guiding clients through each step and addressing questions about execution, distribution, and medical coordination, we help people achieve peace of mind about how their healthcare wishes will be applied in times of need.
Understanding Do Not Intubate Orders in East Los Angeles
A Do Not Intubate order is a focused medical instruction that states a patient does not want intubation performed to assist breathing. Unlike broader advance planning documents, a DNI order targets a specific medical intervention and is often placed in medical records or on a physician order sheet so that hospital staff can follow it immediately. In East Los Angeles, creating a valid DNI involves making clear choices, documenting them in the proper medical or legal forms, and ensuring that healthcare providers and loved ones know where to find those documents. This ensures the patient’s wishes are honored during respiratory emergencies or surgeries.
DNI orders usually work alongside other advance care planning tools, including living wills and powers of attorney for healthcare, to form a complete picture of a person’s treatment preferences. These documents collectively guide decisions about life-sustaining measures, comfort care, and who makes choices if the patient cannot. Residents of East Los Angeles should consider how a DNI order fits into their overall plan, review it periodically, and confirm medical providers have a copy. Clear documentation and communication prevent misunderstandings and help healthcare teams comply with the patient’s stated wishes when time is of the essence.
What a Do Not Intubate Order Means
A Do Not Intubate order specifies that a patient declines intubation, which is the insertion of a breathing tube into the airway to support breathing. This directive applies when the patient cannot breathe independently and is often used when a person prefers to avoid aggressive airway interventions. DNI orders are recognized in medical records and can be recorded as physician orders so that emergency and hospital staff see them clearly. Proper documentation and discussion with medical providers help ensure that the order is applied consistently and in line with the patient’s overall care goals.
Key Steps to Establishing a DNI Order
Establishing a DNI order involves several practical steps: assessing your wishes and values, discussing options with family and healthcare providers, completing the appropriate medical or legal forms, and placing a copy in your medical records. You should also consider whether a DNI order should be combined with a living will or a durable power of attorney for healthcare to address other treatment preferences and decision-makers. Regular review and updating of documents ensures they continue to reflect current medical conditions and personal preferences, and sharing copies with those involved in your care helps make them effective when needed.
Key Terms and Glossary for DNI Orders
Understanding the common terms used in advance care planning makes it easier to create clear, legally recognized directives. This glossary explains terms you will encounter when discussing DNI orders and other healthcare documents in East Los Angeles. Knowing these definitions helps avoid confusion and aids conversations with medical teams, family members, and legal advisers. Familiarity with the vocabulary also supports better coordination between medical records and legal documents so your wishes are recorded and respected across care settings.
Do Not Intubate (DNI)
A Do Not Intubate order is a written medical instruction indicating the patient declines intubation to assist breathing. It is often placed in medical records or on physician order sheets so that emergency responders and hospital staff will know not to perform intubation when the patient cannot breathe independently. A DNI focuses specifically on the airway intervention rather than all life-sustaining treatment, and it can be used alone or together with broader advance directives. Properly documenting and communicating a DNI ensures medical teams can follow the patient’s expressed preference at critical moments.
Living Will
A living will is a written statement that outlines a person’s wishes regarding medical treatment if they become unable to communicate those choices. It typically addresses preferences about life-sustaining measures, comfort care, and other interventions, and can include instructions about intubation, feeding tubes, or resuscitation. In East Los Angeles, a living will serves as a complement to a DNI order by providing broader context for medical decisions. Making these preferences clear in a living will helps medical teams and family members align care with the patient’s values.
Advance Directive
An advance directive is an umbrella term for legal documents that record a person’s choices about future medical care. It commonly includes living wills and powers of attorney for healthcare, and can include specific orders like DNI or DNR. Advance directives help ensure that treatment choices are known if the person becomes incapacitated. Residents of East Los Angeles are encouraged to prepare these documents in a manner consistent with California requirements and to distribute copies to physicians, hospitals, and trusted family members so their instructions are accessible when care decisions arise.
Durable Power of Attorney for Healthcare
A durable power of attorney for healthcare is a legal document that appoints an agent to make medical decisions on behalf of the principal if they cannot decide for themselves. The agent is expected to act in accordance with the principal’s stated wishes and best interests. This document pairs well with a DNI order because it names who will interpret and communicate the person’s preferences in unclear situations. In East Los Angeles, designating a trusted agent and discussing your wishes with that person will help ensure your directives are respected by providers and family members.
Comparing Healthcare Directive Options in East Los Angeles
When planning for future medical care, residents can choose focused orders like a DNI, broader documents like a living will, or an agent under a durable power of attorney for healthcare. Each option has benefits depending on how specific you want your instructions to be and whether you prefer to appoint someone to make decisions on your behalf. A DNI is useful for targeting intubation preferences, while a living will covers multiple interventions and a power of attorney designates a decision-maker. Considering how the documents work together helps form a cohesive plan that reflects values and practical needs.
When a Limited Directive Like a DNI Order May Suffice:
Clear and Specific Treatment Preferences
A limited directive such as a DNI can be suitable when an individual’s preferences are straightforward and narrowly focused on avoiding a particular intervention. In cases where a person is comfortable allowing other life-sustaining treatments but has a firm preference about intubation, a DNI order provides direct instructions that medical staff can follow without interpreting broader language. This clarity helps ensure the single concern is honored, particularly in emergency settings where rapid decisions are required and there is little time to consult extended documents or family members.
Simplicity and Easier Implementation
Limited directives are often simpler to complete and communicate, which can be an advantage when time is limited or when the primary concern is one type of intervention. A DNI order can be quickly added to medical records and given to treating clinicians so it is immediately visible during crises. This straightforward approach can reduce confusion for providers and family members, making it easier to ensure the patient’s preference regarding intubation is observed. Simplicity also makes it more likely that the directive will be kept up to date and accessible when needed.
Why Broader Healthcare Planning May Be Preferable:
Holistic Coverage of Medical Decisions
A comprehensive approach addresses a range of potential medical scenarios rather than a single treatment question. Including a living will, power of attorney for healthcare, and physician orders alongside a DNI ensures that a full set of preferences are documented, including comfort care and other life-sustaining treatments. This all-encompassing planning reduces the risk of ambiguity about how to proceed in unforeseen circumstances and provides a roadmap for family members and providers when multiple medical decisions must be made over time.
Preventing Family Conflicts and Ambiguity
Comprehensive planning reduces the chance of disagreements among loved ones by providing clear written direction about treatment goals and designated decision-makers. When documents specify both treatment preferences and an appointed agent, family members can avoid conflict about what the person would have wanted. This clarity is particularly helpful during emotionally charged emergencies. A well organized set of directives assists healthcare teams in making choices consistent with the patient’s values, while minimizing disputes that can delay care or lead to undesired interventions.
Benefits of a Comprehensive Healthcare Directive Approach
Taking a comprehensive approach to advance care planning ensures that a variety of medical decisions are addressed before a crisis. This reduces uncertainty, helps family members follow your wishes, and supports medical teams in delivering care that aligns with your values. Comprehensive planning often includes written directives, appointment of a healthcare agent, and coordination with medical records. Together these steps create a cohesive framework that guides treatment across settings and over time, offering clarity and practical direction when rapid decisions are required.
Comprehensive directives also increase the likelihood that your preferences will be recognized and implemented by hospitals and clinics. When instructions are clear and accessible, healthcare providers can act in accordance with them without prolonged deliberation. This is particularly important in emergencies where immediate action is necessary. Having a complete set of documents also reassures family members and reduces the stress of decision-making, since they can follow documented wishes and rely on the authority of appointed decision-makers when advocating on behalf of the patient.
Enhanced Communication Among Care Team
Comprehensive directives encourage conversations among patients, loved ones, and medical teams, ensuring everyone understands the goals of care. When preferences are discussed and recorded, family members are better prepared to support those decisions and to interact with clinicians consistently. Clear communication reduces misunderstandings about patient values and prevents last-minute disputes. It also allows healthcare providers to make care recommendations that align with the patient’s overall wishes, improving the quality of decision-making during difficult moments.
Legal Recognition and Reliability
When advance directives are properly documented and executed, they provide legally recognized guidance that hospitals and clinics are more likely to follow. Proper execution under California standards, correct witnessing where required, and placement in the medical record strengthen the durability of these documents. Reliability comes from using clear language and ensuring designated agents understand their role, which helps avoid disputes and supports consistent implementation of care preferences across different medical settings and treatment teams.
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Practical Tips for Managing Your Do Not Intubate Orders
Keep Your Documents Updated
Regular review of your DNI order and related advance directives ensures they reflect your current health status and personal wishes. Changes in medical condition, personal beliefs, or family circumstances can affect how you want medical interventions handled. Periodically revisit your documents, especially after major health events or changes in relationships, and make updates as needed. Also confirm that your medical providers have a copy of the latest version and consider placing a copy in your primary care chart so that emergency teams can access it quickly when required.
Communicate Clearly with Loved Ones
Ensure Your Orders Are Accessible to Providers
To make a DNI order effective, provide copies to your primary care physician, specialists, and regular treatment facilities, and ask that it be placed in your medical record. Carry a card or note in your wallet with instructions on where documents are stored and whom to contact. Consider giving copies to close family members and the person appointed under your durable power of attorney for healthcare. Accessibility reduces delays in honoring your wishes and helps emergency personnel act in line with your directives without unnecessary confusion or delay.
Reasons to Consider a Do Not Intubate Order in East Los Angeles
There are several reasons people establish DNI orders, including personal beliefs about medical interventions, a desire to avoid prolonged mechanical ventilation, and to ensure comfort-focused care at the end of life. Having the order in place gives individuals control over a specific intervention and reduces the burden on family members who might otherwise face difficult decisions without guidance. A DNI order can be an important component of a broader advance care plan and provides clarity for clinicians and loved ones during emergencies.
Another reason to consider a DNI order is to align medical treatment with quality of life preferences and palliative goals. For people with chronic respiratory conditions, frailty, or terminal illness, intubation may not be consistent with desired outcomes. Recording a DNI order helps to ensure that medical teams can respond appropriately to the patient’s wishes. This legal step also supports coordinated planning across care providers so that decisions made in critical moments reflect the patient’s values and priorities.
Common Situations Where a DNI Order May Be Appropriate
DNI orders are commonly considered by those with progressive respiratory illnesses, individuals nearing the end of life, and older adults who wish to avoid invasive airway procedures. Situations that prompt consideration include diagnoses where intubation is unlikely to improve long-term outcomes, personal preferences for comfort care, and scenarios where the burdens of aggressive treatment outweigh expected benefits. Discussing these possibilities with clinicians and loved ones helps determine whether a DNI order aligns with a person’s overall care goals.
Chronic Respiratory Conditions
People with chronic respiratory diseases sometimes choose a DNI order to avoid prolonged mechanical ventilation that may offer limited benefit or impair quality of life. In these conditions, intubation can lead to extended hospital stays, invasive procedures, and outcomes that differ from the patient’s goals. A DNI order clarifies the patient’s preference regarding airway management and supports clinicians in aligning treatment options with the individual’s long-term care objectives, while also guiding family members through decision-making in acute situations.
Advanced Age and Frailty
Older adults and those with significant frailty may opt for a DNI order as part of an emphasis on comfort and minimizing burdensome interventions. Intubation can be especially stressful and may not restore the level of functioning the person desires. By documenting a DNI preference, individuals can ensure that their care focuses on quality of life and symptom management rather than invasive airway support. Clear documentation and discussion with appointed decision-makers help ensure that these wishes are honored when time-sensitive choices arise.
Terminal Illness
For individuals with terminal diagnoses, a DNI order can be a way to prioritize comfort and dignity in the final stages of life. Many people choose to avoid interventions that extend life at the cost of increased discomfort or decreased clarity of values. A DNI order, in conjunction with palliative care planning and a living will, helps ensure treatment aligns with the patient’s preferences and that family members and clinicians understand the focus of care. Proper documentation supports consistent application of those preferences in medical settings.
We're Here to Help with DNI Orders in East Los Angeles
Why Choose LA Estate Plans for Your Healthcare Directives
LA Estate Plans focuses on clear, practical estate planning and healthcare directive services in East Los Angeles. Our approach centers on listening to your values and translating them into written documents that hospitals and clinics will recognize. We prioritize communication and careful drafting so your DNI order integrates smoothly with other advance directives and medical records. Our process is designed to make complex decisions easier to document and share with those who will carry out your wishes.
Clients benefit from guidance on how to present DNI orders to providers and family members and on the practical steps needed to ensure directives remain current and accessible. We explain California requirements for valid documents, coordinate the signing process, and advise on distribution to the right people and institutions. This support helps minimize misunderstandings and increases the likelihood that your medical preferences will be followed in urgent situations.
Our team assists with both the legal and logistical sides of advance care planning, including reviewing existing documents, recommending updates, and advising on where to file or submit directives for easy access. We help clients consider how DNI orders work alongside living wills and powers of attorney for healthcare and offer practical tips for maintaining and communicating those choices so they are effective when most needed.
Schedule a Consultation to Discuss Your DNI Order
Our Process for Establishing DNI Orders in East Los Angeles
Our process is structured to clarify your wishes and convert them into properly executed documents that medical teams can follow. We begin with a conversation about your values, medical history, and any existing directives, then prepare and review a draft DNI order tailored to your intentions. After finalizing language and ensuring legal formalities are met, we assist with signing, distribution, and placement in medical records so your instructions are both accessible and actionable when care decisions arise.
Step 1 — Initial Consultation and Information Gathering
During the initial consultation we discuss your health background, preferences regarding intubation and other interventions, and any current advance care documents. This conversation helps identify which forms are appropriate and how a DNI order should be phrased to reflect your wishes. We also talk about who you trust to make decisions on your behalf if needed and how to coordinate communication with family and medical providers to ensure the directive will be effective in practice.
Initial Consultation
The first meeting focuses on understanding your priorities and explaining the options available under California law. We review common scenarios, the differences between DNI, DNR, and living wills, and help you determine whether a standalone DNI order or a broader set of directives best meets your needs. This stage is an opportunity to ask questions and receive clear information about how each choice will operate in a hospital or emergency setting.
Understanding Your Preferences
We take time to explore how you feel about resuscitation, intubation, and other life-sustaining treatments, and whether you prefer comfort-focused care. This helps ensure the language used in your DNI order matches the situations you have in mind. We also discuss the role of a healthcare agent, who will help interpret and advocate for your wishes if you cannot communicate directly, and make sure the agent understands the responsibilities involved in carrying out your directives.
Step 2 — Drafting and Reviewing Your DNI Order
After clarifying preferences we prepare the appropriate forms and a clear written DNI order that can be integrated into medical records. We review the draft with you, make any required adjustments to ensure the language reflects your intentions, and explain how the order will be used in practice. This review step is essential to avoid ambiguous wording and to confirm that your wishes will be understood and applied by healthcare professionals.
Drafting the DNI Order
Drafting focuses on concise, specific language that medical staff can follow in emergencies. We ensure the form indicates the refusal of intubation clearly, and that any related preferences are noted so clinicians can make consistent decisions. The draft is prepared with attention to California standards and hospital practices, and we advise on how to present the order to hospitals and clinics so it is recognized and placed in the medical chart.
Customizing Language and Answering Questions
We tailor the directive to align with your values and to avoid confusion in urgent situations. During review we answer questions about potential scenarios, explain how the order interacts with other documents, and discuss the practical steps to ensure it is available to treating personnel. This collaborative stage helps make the directive both legally sound and practically effective, reducing the chance of misinterpretation in high-stress medical environments.
Step 3 — Finalizing, Signing, and Distribution
Once the DNI order is finalized we assist with proper execution, including signatures and witnessing if necessary under California rules. We also advise on where to file copies, how to inform your healthcare providers, and which family members or agents should receive copies. Making sure the directive is accessible to those who need it is a key final step so medical teams can act in accordance with your wishes when they are called upon to make immediate decisions.
Execution and Witnessing
We guide you through the signing process to meet legal formality requirements and to ensure the document will be recognized by hospitals. Depending on the type of form, witnessing or notarization may be recommended. We explain which steps are necessary under California law to strengthen the directive’s validity so that treating clinicians and institutions can accept and follow the order without delay during an emergency.
Ensuring Accessibility of Documents
After execution we recommend practical measures to make sure your DNI order is seen by the right people and placed in medical records where clinicians can find it quickly. This includes providing copies to your primary care doctor, hospital, and any specialists, giving copies to your designated decision-maker, and keeping a record of where official copies are stored. These steps reduce the chance of confusion and help ensure your wishes are honored when the need arises.
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Frequently Asked Questions About Do Not Intubate Orders in East Los Angeles
What is a Do Not Intubate (DNI) order?
A Do Not Intubate order is a written medical instruction stating that a patient does not want intubation, which is the placement of a breathing tube to assist or replace natural breathing. The order focuses specifically on the airway intervention and is placed in medical records or included as a physician order so that hospital staff, emergency responders, and other care providers will be aware of the patient’s directive in situations where they cannot communicate. A DNI can be used alone or as part of a broader set of advance care documents, depending on an individual’s preferences. A DNI order is practical for people who have firm preferences about avoiding intubation but may be open to other treatments. Because it targets one particular intervention, the language needs to be clear and placed where clinicians can find it quickly. Discussing a DNI order with your healthcare provider and family helps ensure the order is recorded correctly and that those who may be called upon to act on your behalf understand how to follow your wishes when necessary.
How do I create a valid DNI order in California?
To create a valid DNI order in California you typically begin by discussing your wishes with your treating physician and completing the appropriate medical or physician order form recognized by the facility. It is also advisable to prepare supporting advance directives, such as a living will or a durable power of attorney for healthcare, to give full context to your care preferences. Ensuring the order is placed in your medical record and providing copies to the relevant clinicians increases the chance it will be followed when urgent decisions are needed. It is helpful to involve legal counsel when you want to integrate a DNI into an overall estate or healthcare plan, and to confirm any witnessing or signing requirements. You should also communicate the order to your appointed decision-maker and family members and check periodically that the document remains on file with your primary care provider and any hospitals you use. These steps make the directive more reliable and easier for medical teams to implement.
Can I change or revoke my DNI order?
Yes, you can change or revoke your DNI order at any time as long as you remain mentally competent to make healthcare decisions. To revoke the order you can provide written notice, complete a new directive that supersedes the previous one, or tell your treating physicians and have the revocation documented in your medical record. Clear communication with family and your healthcare proxy is important so that everyone knows your current wishes and can act accordingly. After making a change, provide updated copies to your doctors, hospitals, and the person you designated for healthcare decisions and ask that the new instructions be placed in your medical chart. Keeping a record of the most recent version and where it is stored helps prevent confusion and ensures that medical personnel will follow the current directive in urgent situations.
How is a DNI different from a DNR?
A DNI order specifically addresses the refusal of intubation, while a DNR, or Do Not Resuscitate order, tells healthcare providers not to perform cardiopulmonary resuscitation if the heart stops or breathing ceases. They address different medical interventions: intubation deals with airway support, while DNR relates to resuscitation efforts. It is possible for someone to have both orders, one, or neither depending on their preferences, and they can be used together to reflect the scope of care the person desires. Understanding the distinction helps patients and families choose the right combination of directives. Discuss these options with your medical team to see how each order applies to likely clinical scenarios and whether both or other documents, such as a living will, should be included to provide comprehensive guidance on care preferences and limitations.
Who should I tell about my DNI order?
You should inform your primary care physician, any specialists who manage your care, and the hospitals or clinics where you may receive treatment about your DNI order. Provide copies to these providers and ask that the order be placed in your medical records so clinicians can access it during emergencies. Also give a copy to the person you appoint under a durable power of attorney for healthcare and to close family members who might be involved in decisions about your care. Openly discussing your DNI order with your appointed decision-maker and family members reduces the risk of misunderstandings and ensures those people can advocate for your wishes when necessary. Make sure everyone knows where the official copies are kept and how to inform treating personnel about their existence to avoid delays in honoring the directive.
Will healthcare providers follow my DNI order?
Healthcare providers are generally expected to follow valid medical orders and advance directives that are properly documented in a patient’s medical record. A DNI placed as a physician order or clearly included in hospital documentation is more likely to be recognized and followed by clinicians in emergency situations. To increase the likelihood the order is honored, ensure it is completed in the correct form, placed in the chart, and communicated to relevant staff and facilities. There are rare circumstances where immediate clinical judgment, legal constraints, or unclear documentation can complicate adherence, so it is wise to make sure language is precise and that appointed decision-makers and family members are informed. If concerns arise about whether a directive will be followed, asking clinicians how the order will be recorded and applied can clarify the practical steps needed to ensure compliance.
Do I need additional documents besides a DNI order?
A DNI order is often best used with other advance care planning documents to provide a full picture of your medical preferences. A living will can describe broader wishes about life-sustaining treatment and comfort care, while a durable power of attorney for healthcare designates someone to make decisions if you are incapacitated. These additional documents help address situations not covered by a DNI and provide guidance for decisions beyond airway management. Combining documents reduces ambiguity and helps healthcare teams and family members act consistently. Providing copies of all relevant documents to your medical providers and appointed decision-maker ensures that your wishes across multiple scenarios are available and that someone is authorized to interpret and communicate those wishes when necessary.
How often should I review my DNI order?
You should review your DNI order and related advance directives whenever your health status changes, after significant medical events, or when your personal circumstances or preferences shift. Periodic review, such as annually or after major life changes, helps confirm that the documents reflect your current wishes and remains consistent with your broader care goals. Ensuring the latest version is on file with providers helps avoid confusion in emergencies. Additionally, review directives when there are changes in relationships, such as a new appointed decision-maker or a change in family dynamics, and after receiving new medical advice that might affect the likely outcomes of interventions. Keeping everyone informed and updating the documentation ensures that your directives will guide decisions in line with your present intentions.
Can a family member override my DNI order?
A properly documented DNI order should be followed by healthcare providers, and a family member should not override it if the directive is clear and valid. The purpose of documenting a DNI is to communicate the patient’s wishes directly to medical staff so that those wishes take precedence over family preferences in emergency decisions. Ensuring the order is in the medical record and that a designated healthcare agent is aware of the directive reduces the likelihood of family disagreement affecting care. If conflicts arise, clinical teams often consult institutional policies, ethics committees, or legal counsel to resolve disputes while attempting to honor the patient’s documented preferences. Clear documentation, open communication with family members, and making sure medical staff are aware of and can access the directive are practical steps you can take to protect your stated wishes from being overridden.
How can LA Estate Plans help with my DNI order?
LA Estate Plans helps with DNI orders by explaining options, preparing clear written directives, and coordinating the completion and placement of forms so they will be recognized by medical providers in East Los Angeles. We assist in drafting language that accurately reflects your preferences, advise on the complementary documents you may need, and guide you through signing and distribution to ensure accessibility when decisions are urgent. Our role is to help translate personal choices into practical documentation that can be used by clinicians and loved ones. We also provide guidance on communicating your wishes to appointed agents and family members and offer practical steps for storing and sharing the directive with primary care physicians and hospitals. By helping to integrate a DNI order into a broader advance care plan, we aim to reduce uncertainty and ensure your healthcare choices are clearly documented and readily available when they must be acted upon.