California Advance Directive Treatment Preferences: Ventilator, Feeding Tube, and CPR

The hardest section of any advance directive is Part 2 — Individual Health Care Instructions. You're being asked to make hypothetical decisions about medical interventions most people only vaguely understand: mechanical ventilation, artificial nutrition and hydration, cardiopulmonary resuscitation.

Writing vague preferences like "no heroic measures" creates exactly the ambiguity that leaves families paralyzed and doctors guessing. California law (Probate Code Section 4701, Part 2) allows you to be as specific as you want — and the more specific you are, the more likely your wishes will actually be followed.

Mechanical Ventilation (Ventilator)

A ventilator breathes for you through a tube inserted into your windpipe (intubation). It's used when your lungs can't maintain adequate oxygen exchange on their own.

Questions to answer in your directive:

• Short-term trial: Would you accept a ventilator for a defined period (48-72 hours) to see if your condition improves?
• Long-term dependence: If doctors determine you'll never breathe independently again, should the ventilator continue?
• Specific conditions: Would you accept ventilation after a stroke but not in end-stage cancer? After surgery but not for progressive neurological disease?

Clear language example: "I accept mechanical ventilation as a time-limited trial of no more than 7 days if my physicians believe recovery of independent breathing is possible. If after 7 days I cannot breathe without the ventilator and recovery is unlikely, I direct my agent to authorize withdrawal and transition to comfort care."

Artificial Nutrition and Hydration

This covers two interventions:

• Feeding tubes (nasogastric tube through the nose, or PEG tube surgically placed in the stomach) delivering liquid nutrition
• IV fluids (hydration through a needle in your vein or a central line)

These are separate decisions. You might want IV hydration for comfort (dry mouth and thirst are distressing) while refusing tube feeding in a condition where you'll never eat independently again.

Questions to answer:

• Temporary vs. permanent: Would you accept a feeding tube during recovery from surgery but not if you have advanced dementia and can no longer swallow?
• Hydration separately: Even if you refuse nutrition, do you want IV fluids continued for comfort?
• Specific scenarios: Many people want artificial nutrition after a potentially recoverable stroke but not in end-stage Alzheimer's where the body is shutting down

Clear language example: "If I am permanently unable to swallow due to a progressive neurological condition, I do not want a feeding tube placed or maintained. I do want IV hydration and oral comfort care (ice chips, mouth swabs) for as long as it provides comfort. If I cannot swallow due to a potentially recoverable condition, I accept a feeding tube for up to 30 days while recovery is assessed."

Cardiopulmonary Resuscitation (CPR)

CPR involves chest compressions, electric shocks (defibrillation), drugs, and intubation to restart a stopped heart. Television shows a 70% survival rate. Reality is closer to 10-12% for out-of-hospital cardiac arrest, with significantly lower rates for elderly patients or those with serious illness.

Surviving CPR often means broken ribs, brain injury from oxygen deprivation, and ICU admission on a ventilator. For frail or seriously ill people, the question isn't just "do you want to be resuscitated" but "what are you likely to wake up to?"

Your directive should address:

• Blanket preference: Do you want CPR attempted in all circumstances, never, or only under certain conditions?
• Condition-dependent: You might want CPR if your heart stops unexpectedly while otherwise healthy, but not if you're already in end-stage organ failure
• Quality of life after: If CPR succeeds but leaves you ventilator-dependent or with significant brain damage, would you want life support continued?

Clear language example: "If my heart stops and I am otherwise in reasonable health, I want CPR attempted. If my heart stops in the context of a terminal illness, end-stage organ failure, or advanced dementia, I do not want CPR — transition to comfort measures only."

How These Interact with a POLST

Your AHCD instructions are a planning document. If you want these preferences to become immediately actionable medical orders (especially relevant if you're seriously ill, elderly, or entering hospice), your physician can translate them into a POLST form.

The POLST's three sections map directly to these preferences:

• Section A: CPR (attempt or do not attempt)
• Section B: Medical interventions (full, selective, or comfort only — covers ventilation)
• Section C: Artificial nutrition (long-term, trial period, or none)

Putting It in Writing

The California Advance Directive & Living Will Kit includes a structured treatment preferences worksheet that walks you through each intervention with plain-language explanations of what the treatment actually involves, realistic outcome data, and condition-specific scenarios. You complete the worksheet first, then transfer your decisions into your AHCD using legally precise language that matches California's statutory framework.

See more California guides →