Roadmaps

Many people know they “should” get things in order, but aren’t always sure where to begin—or how the pieces fit together. This roadmap offers a clear, step-by-step way to reflect on your values, organize essential health and financial documents, and identify the people who can support you if circumstances change.

While working with trusted professionals—such as elder law or estate-planning attorneys, fiduciaries, financial advisors, care managers, and health care providers—is often the best way to ensure plans are thorough and legally sound, this roadmap gives you a practical foundation so you understand your options and know what you’re walking into before those conversations begin.

Health Care Planning

  • Consider your values and priorities (comfort, independence, safety, remaining at home, quality of life, or something else).

    These values form the foundation for every future decision.

  • Identify the people and professionals who will support your care. This includes trusted family or friends involved in your care, your Health Care Proxy / Medical Decision-Maker, as well as your medical and care coordination teams.

    Write down everyone’s names and roles so each person understands who does what.

  • Health Documents protect your medical wishes during life and clarify who can act for you.

    At a glance, they typically include:
    - Advance Directive / Living Will
    - Health Care Proxy / Agent
    - HIPAA Release Forms
    - POLST (when medically indicated)
    - Up-To-Date Emergency Contact & Medication List
    -Additional important medical information and/or documents, such as pharmacy information, allergy list, summary of medical conditions, copies of insurance cards, emergency contacts, hospital/clinic portals or logins.)

    Create a simple, accessible place to store this essential paperwork

  • Share your wishes early and clearly with family and trusted confidants early. This reduces stress, prevents conflict, and gives your family a roadmap to follow if they ever need it.

    Have honest conversations with your health care providers about possible health or cognitive changes, risks, or progression of conditions.

    Understanding what may be ahead helps you make informed decisions long before a crisis.

  • This is not a one-and-done event. Review your documents and decisions every few years, or any time there is a major health, life, or relationship change.

    Needs evolve, and your planning should evolve with them.

A Deeper Dive into Health Care Planning

Financial & Legal Planning

  • What do you want to preserve? What future needs should be planned for (e.g., long-term care, home safety, retirement income)?

  • Durable Power of Attorney (POA) for finances; Fiduciary or professional trustee if appropriate and A trusted Attorney

    Write down everyone’s names and roles so each person understands who does what.

  • Financial and Legal Planning Documents protect your assets, manage finances, and guide decision-making.

    • Will (instructions for distributing assets after death). DO NOT confuse with a living will, which is a healthcare advanced directive.

    • Trust(s) (to manage assets during life and after)

    • Durable Financial POA

    • Beneficiary designations (on accounts & insurance policies)

    Durable Financial Power of Attorney

    • Names someone to handle financial, legal, and property matters if you cannot

    Will (Last Will & Testament)

    • Directions for your assets after death

    • Names an executor

    Trusts

    • Manage assets during life and after

    • Can help avoid probate and protect finances

    Beneficiary Designations

    • Instructions on accounts like retirement funds and insurance policies

    Estate Planning Documents

    • Additional documents depending on your needs (trusts, asset organization, letters of instruction, etc.)

    Plan for Long-Term Care Costs
    Explore:

    • Long-term care insurance

    • Medicaid planning (if relevant)

    • Savings strategies

    • Future housing options

  • Gather account lists, passwords, property documents, insurance, and contacts — and store them safely.

  • Update documents after major life changes or new financial goals.

A Deeper Dive into Financial Planning

Building Your Health & Care Roadmap

Most people know they “should” get their medical and other healthcare documents in order, but they’re not always sure where to begin or what each form actually does. This roadmap offers a simple, step-by-step way to think about your values, organize essential documents, and identify the people who may support you if your health changes. Each section below is introduced briefly here, and we’ll explore every area in more depth further down the page.

Whether you're planning proactively or navigating new medical or cognitive challenges, having these pieces in place protects your wishes, eases decision-making for loved ones, and helps ensure you remain at the center of your care.

  • Consider your values and priorities (comfort, independence, safety, remaining at home, quality of life, or something else).

    These values form the foundation for every future decision.

  • Identify the people and professionals who will support your care. This includes trusted family or friends involved in your care, your Health Care Proxy / Medical Decision-Maker, as well as your medical and care coordination teams.

    Write down everyone’s names and roles so each person understands who does what.

  • These documents protect your preferences and clarify who can act for you.

    At a glance, they typically include:
    - Advance Directive / Living Will
    - Health Care Proxy / Agent
    - HIPAA Release Forms
    - POLST (when medically indicated)
    - Up-To-Date Emergency Contact & Medication List
    -Additional important medical information and/or documents, such as pharmacy information, allergy list, summary of medical conditions, copies of insurance cards, emergency contacts, hospital/clinic portals or logins.)

    Create a simple, accessible place to store this essential paperwork

  • Share your wishes early and clearly with family and trusted confidants early. This reduces stress, prevents conflict, and gives your family a roadmap to follow if they ever need it.

    Have honest conversations with your health care providers about possible health or cognitive changes, risks, or progression of conditions.

    Understanding what may be ahead helps you make informed decisions long before a crisis.

  • This is not a one-and-done event. Review your documents and decisions every few years, or any time there is a major health, life, or relationship change.

    Needs evolve, and your planning should evolve with them.

Choosing Your Health Care Proxy

A Health Care Proxy (also called a Health Care Agent, Medical Power of Attorney/Medical POA, Durable Power of Attorney for Health Care or Health Care Surrogate) is someone you trust to make medical decisions that honor your values and preferences. This could be a family member, partner, friend, or another trusted individual.

This person becomes your voice, making choices that reflect your values, preferences, and quality-of-life priorities. Having the right person in place protects you, reduces family stress, and ensures that your wishes remain at the center of your care.

Why you should consider naming more than one: Life can be unpredictable. Having a backup agent ensures continuity if your primary agent cannot serve. But remember, if you choose more than one person , be sure everyone understands their role.

  • • Who knows me well enough to understand what matters most to me?
    • Who can manage stress and communicate with medical teams clearly?
    • Who would honor my wishes even if they differ from their own?
    • Who is realistically available if something unexpected happens?
    • If I had a sudden medical crisis, who would I want in the room?

Should we have downloads/PDFs of:

  • Healthcare Planning Worksheet

  • State-specific examples of Advance Directives (State-Specific)”

  • “Meet with a Clinician or Attorney to Review Your Forms”

To add to informational or definitions: CPR, ventilators (risks and benefits); ICD and pacemakers (instructions/information about turning them off if not directed in advance directive); artificial food/feeding tubes

Types of care: Palliative care, hospice care (Read more about end-of-life care at www .nia .nih .gov/ health/end-of-life. Use the Care and Treatment Decisions: What Would You Choose? worksheet on page 57 to help think through care and treatment decisions commonly included in a living will)

How To Make Your Advance Directives Official To make your decisions about care and treatment official, you can complete a living will. Similarly, once you decide on your health care proxy, you can make it official by completing a durable power of attorney for health care. The living will and durable power of attorney for health care forms are commonly part of the advance directive forms available for free in most states.

Where To Find Advance Directive Forms
You can establish your advance directive for little or no cost. Many states have their own forms that you can access and complete for free. Here are some ways you might find free advance directive forms in your state:

• Contact your State Attorney General’s Office.

• Reach out to your local Area Agency on Aging or the Eldercare Locator/ Call the Eldercare Locator 800-677-1116 or visit https://eldercare .acl .gov.

• Download your state’s form online from one of these national organizations: AARP, American Bar Association, or National Hospice and Palliative Care Organization.

• If you are a veteran, contact your local Veteran’s Affairs (VA) office. The VA offers an advance directive specifically for veterans.

Some people spend a lot of time in more than one state due to, for example, visiting children and grandchildren. If that’s your situation, consider preparing advance directives using the form for each state, and keep a copy in each place, too. There are websites that enable you to create, download, and print your forms, but some websites may charge fees. Before you pay, remember there are several ways to get your forms for free. Some free online resources include: • PREPARE for Your Care (https://prepareforyourcare .org), an interactive online program that was funded in part by NIA. It is available in English and Spanish. • The Conversation Project (https://theconversationproject .org), a series of online conversation guides and advance care documents available in English, Spanish, and Chinese. The Conversation Project is a public engagement initiative led by the Institute for Healthcare Improvement.

If you use forms from a website, check to make sure they are legally recognized in your state. You should also make sure the website is secure and will protect your personal information. Read the website’s privacy policy and check that the website link begins with “https” (make sure it has an “s”) and that it has a small lock icon next to its web address.

 Where To Keep Your Advance Directives
Make copies of your advance directive forms and store them in a safe place. If you created forms online, download and print copies and share the password with your proxy

Give copies of your advance directive to:

• Your health care proxy and alternate proxy

• Your health care providers

Other important people in your life might need to know about your plans, too. For example, you might share your wishes with close family members, trusted friends, or your lawyer. Because you might change your advance directive in the future, it’s a good idea to keep track of who receives a copy. It can also be helpful to bring a copy with you if you go to the hospital. Tear out the Advance Directive Wallet Card found on page 46 and keep it with you.

 

Where Can Caregivers and Family Members Find Resources and Support?

• Consider working with a geriatric care manager . A geriatric care manager is usually a trained nurse or social worker who is used to working with older adults and their families. They can help you identify needs, make short- and long-term plans, coordinate medical services, choose care personnel, and more. They can be especially helpful when family members live far apart. You can also find local, state, and national organizations and services that help provide support for patients and caregivers. For example, they may offer support groups, patient and caregiver education, transportation services, and other resources.

• Alzheimer’s Disease Research Centers (ADRCs): NIA supports ADRCs at major medical institutions across the United States. For people and families affected by Alzheimer’s and related dementias, ADRCs offer help obtaining diagnosis and medical management, Alzheimer’s and related dementias information and resources, opportunities to participate in clinical trials, and support groups and other special programs for families. • Eldercare Locator: The Eldercare Locator can help you find services in your community. Call 800-677-1116 or visit https://eldercare .acl .gov. • Respite care services: Respite care provides short-term relief for primary caregivers at home, in a health care facility, or at an adult day center. It can be arranged for just an afternoon or for several days or weeks. Most insurance plans do not cover these costs. You must pay all costs not covered by insurance or other funding sources. Medicare and Medicaid may offer some assistance paying for respite care in certain situations.

 

Plan for Other Decisions

You might also want to prepare for other possible decisions as you age. This may include considerations around long-term care and future health care, making estate and financial plans, planning for a funeral or memorial service, and deciding on a burial or cremation. In this section, you can learn more about each of these decisions.

 

When planning for long-term care, it may be helpful to think about: • Where you will live as you age and how your home can best support your needs and safety • What services are available in the community and how much they will cost • How far in advance you need to plan so that you can make important decisions while you are still able Many types of long-term care are not covered by Medicare, so planning for how to pay for long-term care is also important. You can learn more about long-term care options at www .nia .nih .gov/ltc.

 

How To Establish a Will and Create a Financial Plan for Your Estate In addition to advance directives for health care, you can establish advance directives for financial matters. These forms, which help document and communicate your financial wishes, must be created while you can still make decisions. Chapter 6: Plan for Other Decisions 42 Advance Care Planning: A Conversation Guide Three common documents are included in a financial directive: • A will specifies how your estate — your property, money, and other assets — will be distributed and managed when you die. A will can also address care for children under age 18, adult dependents, pets, as well as gifts and end-of-life arrangements, such as a funeral or memorial service and burial or cremation. If you do not have a will, your estate will be distributed according to the laws in your state.

• A durable power of attorney for finances names someone who will make financial decisions for you when you are unable. • A living trust names and instructs a person, called the trustee, to hold and distribute property and funds on your behalf when you are no longer able to manage your affairs.

Medical Orders

State-Specific Medical Orders

California: CA uses POLST as the primary medical order for documenting resuscitation preferences and other life-sustaining treatments. A POLST form: must be signed by a clinician and may include DNR/DNI orders as part of the form. Emergency responders and hospitals rely on POLST for real-time decisions

Contact: Jennifer Ballentine, CEO
Coalition for Compassionate Care of California
2530 River Plaza Drive, Ste. 110 Sacramento, CA 95833
Phone: (916) 489-2222; Fax: (888) 789-9475
Email: jballentine@coalitionccc.org

Program: POLST - Physician Orders for Life-Sustaining Treatment
Website: http://www.polst.org/california

New York: NY uses MOLST to document DNR and other treatment decisions. MOLST forms are signed by a clinician and become part of your medical record. Physician-signed medical orders are required for emergency care decisions

Connecticut: CT recognizes DNR orders as separate medical orders. These must be written and signed by a physician and are required for DNR preferences to be honored in emergencies

MOLST - Medical Orders for Life Sustaining Treatment

Contact: Barbara Cass, Branch Chief, Health Care Quality and Safety
State of Connecticut, Department of Public Health
Phone: (860) 509-7400
Email: barbara.cass@ct.gov

Program: MOLST - Medical Orders for Life Sustaining Treatment
Website: http://www.polst.org/connecticut