Advance Care Planning, sometimes called an advance directive is a generic term used to describe a document/the documents that outline your medical care preferences. This planning process helps adults at any age or stage of health understand and share their personal values, goals, and preferences regarding future medical and personal care. Planning is a gift you give your loved ones. It helps your loved ones have an understanding of your wishes when they are asked to make choices about your medical care. Advance Care Planning is not a single decision; it is a process that occurs over a lifetime as goals and values change. Steps in the Advance Care Planning process include: Think about your wishes for future care if you became seriously ill. Your wishes may be shaped by your experiences, cultural and religious views, your values, and your goals. Select a health care agent – someone that you trust to make medical decisions for you if you can’t make them yourself. Discuss your wishes with your health care agent and other loved ones. This step is sometimes difficult, but it is very important and may help avoid future conflicts and errors in choices. Complete an Advance Care Planning document, like an Advance Directive. In some situations, a health care provider might suggest also completing a Physician Order for Life-Sustaining Treatment (POLST) form. Make copies and share copies with your health care agent, physicians/healthcare providers, and loved ones. Make sure that your Advance Directive is in your medical record. Periodically review your Advance Care Planning documents to be sure names, contact information, and healthcare wishes haven’t changed. Adapted from ULCA Health, 2024; pennmedicine.org Keep in mind that these terms and their definitions may vary from state to state. Please further your own research by checking with your state for the most recent definitions of these terms, as they can change.

POLST is for people who are seriously ill or have advanced frailty. They are out-of-hospital medical orders, meaning that they travel with you (hospital, nursing home, etc.). These orders must be completed and signed by a healthcare provider. POLST orders tell other providers what you want and are used only when you cannot communicate to the medical team. Different states use different names such as POST, MOLST, MOST, etc. POLST is voluntary, and this form is best utilized in ongoing goals-of-care conversations with your medical team and support system to best understand your needs and goals (such as code status). Keep in mind that these terms and their definitions may vary from state to state. Please further your own research by checking with your state for the most recent definitions of these terms, as they can change.

Embalming is a process that temporarily preserves a corpse, slowing down its natural decomposition. According to the Federal Trade Commission (FTC), “No state law requires routine embalming for every death. Some states require embalming or refrigeration if the body is not buried or cremated within a certain time; some states don’t require it at all. In most cases, refrigeration is an acceptable alternative” (via The FTC Funeral Rule). Many people of Orthodox Jewish, Hindu, and Muslims faith do not embalm their dead, believing the body should be buried as close to the time of death as possible, typically within 24-48 hours (via Parthemore Funeral Homes). Others may opt for services like direct cremation, which don’t require any form of preservation. Yet, throughout history and across cultures, humans have employed various methods to preserve their dead, with the modern version of embalming we are now familiar with beginning during the American Civil War. Embalmers would follow battles, set up their tents, and preserve the bodies of fallen soldiers, enabling the soldiers’ bodies to be returned to their families by train in the north. Even in the 1800s people noted the costly nature of the embalming process, sharing the sentiment that it was financially inaccessible for the average American. Yet, once President Abraham Lincoln’s embalmed body was taken on a two-week tour of the U.S., the embalming process had captivated the public’s imagination. Entrepreneurs saw this as an opportunity to turn profits, convincing the public that embalming must be necessary for sanitation and appearance of the deceased, of which neither are. “Embalming is what, in the early 20th century, turned funeral homes from small community offerings into an industry, and funeral directors into paid ‘experts.’” (via The Order of the Good Death). “This is not to say there are never reasons to embalm, most notably the use of embalming in doing complex restorative work on a badly injured body. In the Black community the work of skilled embalmers “often involved masking the effects of violent deaths, such as lynchings,” while the rituals and elegance of Black funerals helped to provide dignity and reverence that too often evade the Black body in life” (via The Order of the Good Death). Again, embalming is not always necessary, but that doesn’t stop funeral homes from prohibiting (and profiting off) you and your loved ones’ wishes. Since funeral homes operate as private businesses, they decide which policies and requirements they’ll impose and which ones they won’t. The FTC writes, “Many funeral homes have a policy requiring embalming if the body is to be publicly viewed, but this is not required by law in most states. Ask if the funeral home offers private family viewing without embalming. If some form of perseveration is a practical necessity, ask the funeral home if refrigeration is available” (via The FTC Funeral Rule). Knowing the state laws around embalming practices can help you in making the most informed decision for you and your loved one. In Pennsylvania, the law requires licensed funeral directors to embalm, place in a sealed casket, or refrigerate a body if final disposition (burial or cremation) does not occur within 24 hours. Pennsylvania law also states that the responsibilities and duties of a licensed funeral director are to acquaint “oneself with the religious practices or customs of families the funeral director serves and [adjust] services to conform their belief” (49 Pa. Code § 13.201). New Jersey law requires embalming to occur when there are no plans to bury, cremate, or refrigerate a body within 48 hours of death (via Cornell Law School). It is important to note that New Jersey regulations also state: “(a) In seeking or offering to sell funeral goods or funeral services to the public, it is a deceptive act or practice for a funeral provider to: 1. Represent that State or local law requires that a deceased person be embalmed when such is not the case; 2. Fail to disclose that embalming is not required by law except in certain special cases. (b) To prevent the deceptive acts or practices mentioned in (a) above, as well as the unfair or deceptive acts or practices defined in N.J.A.C. 13:36-9.16 and 9.17(a), funeral providers shall: 1. Not represent that a deceased person is required to be embalmed for direct cremation, immediate burial, a funeral using a sealed casket, or if refrigeration is available and the funeral is without viewing or visitation and with a closed casket when State or local law does not require embalming; and 2. Provide on the general price list the disclosure statement required pursuant to N.J.A.C. 13:36-9.7(d)2.” (via Cornell Law School).

A home funeral, also known as community after-death care, is when individuals who are not funeral directors decide to provide some form of after-death care and it allows time to honor the life of the departed. It is legal to care for your own dead in every state, and may involve: completing the necessary paperwork, such as preliminary death certificates and transport permit transportation of the body body care celebration and ritual making, buying, or renting caskets, urns, shrouds, etc. having them lay in honor disposition of the body WHY HAVE A HOME FUNERAL? because you can; it’s your legal right! allows time to slow down and creates space for those who are grieving. allows the community to follow the wishes of the dying and grieving. having access to more time, privacy, and/or hands-on engagement may result in a more meaningful experience, which may also benefit the grieving process. ​may cost less money if you aren’t paying for the services of a funeral home. (via the National Home Funeral Alliance)

With the awareness of climate change and the human species’ effect on the changing world, many individuals have become interested in death care practices which are more environmentally-friendly than traditional burial practices and cremation. Although traditional burial practices often offer cultural, religious, and spiritual connections as well as deep-seated meaning in the process of how people bury their loved ones, more natural death care practices (also known as Green Burial) is an option for those who wish to select an after-death option which is more environmentally focused. Differing from traditional burial, green burial practices do not allow for the embalming of bodies, and only utilize materials which are biodegradable, such as shrouds or biodegradable caskets, such as wicker or seagrass caskets. With new practices in green deathcare, many folks continue to utilize traditional burial and cremation options due to limited local resources, as well as financial factors. Please see the Resources section for a less-expensive cremation option in the Philadelphia area (Philadelphia Cremation Society). Friends of Green Burial PA maintains a list of green burial grounds in Pennsylvania, New Jersey, Maryland, and New York. Below is a list of Green Burial disposition options specifically available within the New Jersey and Pennsylvania states, with resources accompanied below for further information. Because green burial practices are relatively new, please see the below resources for updated bills and legislation. Options available currently in New Jersey: Natural Organic Reduction: Natural Organic Reduction (NOR), otherwise known as human composting or terramation, is legal in New Jersey, and offers a process in which human remains are converted into soil after a heating process which utilizes such materials as wood chips and alfalfa. Recompose, a Washington state-based company, is the first full-service funeral home in the U.S. offering this service, with options for transportation available to their specific sites. Alkaline Hydrolysis: Another eco-friendly option available to individuals in NJ is Alkaline Hydrolysis, otherwise known as water cremation. In this more environmentally-friendly cremation option, human decomposition is achieved through a water-dissolution process. The Green Burial Council offers further information on these specific etc-friendly disposition processes, as well as current resources available, and legislation. Options currently available in Pennsylvania: In Pennsylvania, human composting is currently not a legal option, nor is there current legislation available for alkaline hydrolysis. However, there are many funeral homes and cemeteries which offer green burial options for individuals interested in receiving a more environmentally-friendly post-death care option. There are currently three options for green burial practice in PA, which include: Hybrid: This option states that a traditional cemetery also includes a section for green burial. Natural burial: Cemeteries which offer natural burial options focus on the idea of natural burial through ensuring the ongoing maintenance of the current landscape of the cemetery. Conservation burial: In this option, natural burial sites are supported by conservation organizations, in which the focus remains on restoring and preserving the natural habitat of the cemetery. U.S. Funerals Online offers specific resources and guidance for locating green funeral services in your specific area.

A will, or a last will and testament, is a legal document that describes how you would like your property and other assets to be distributed after your death and designates your executor to administer your estate and may designate a guardian if you have any minor children.

A healthcare or medical power of attorney, also called a durable power of attorney for health care, is one type of advance directive. The person you chose to be in this role may be known as the representative, surrogate, agent, or proxy, and is someone who can make healthcare decisions for you if you are unable to communicate your decisions yourself. They work closely with your health care team to ensure your care and treatment preferences are followed. Check with your state to be sure you understand the terms and definitions used, as these terms and definitions can vary from state to state. Keep in mind that these terms and their definitions may vary from state to state. Please further your own research by checking with your state for the most recent definitions of these terms, as they can change.

A death certificate is a government issued document stating the time, place, and cause of death of an individual. In order to complete a death certificate, (1) gathering information like the date of birth, race, and ethnicity of the deceased, is necessary. (2) A doctor or medical examiner must certify the cause and sign off on a cause and date of death. (3) The certificate may need to be certified by a registrar. Once these steps are completed, the certificate is registered with the state, allowing for official certified copies to be made for your records and use. Death certificates are crucial for accessing life insurance and pension beneficiary benefits, transferring titles of ownership for things like cars and property, closing financial accounts, settling estates, canceling accounts with utility companies, and serving as documentation for a widowed person to remarry. They can, however, take several weeks to be processed and often require a small processing fee. It is recommended to order 20 copies. Read more about the history of death certificates here. Pennsylvania law (35 P.S. Sec. 450.105) states that a physician must sign a death certificate within 96 hours of the death occurring. Physicians can complete this form through the Division of Vital Records Electronic Death Registration System (EDRS) via the PA Department of Health. In circumstances when a death occurs at home or may be suspicious in nature, the county Coroner’s Office can issue a death certificate. See the Pennsylvania Department of Health’s page for more information about death certificates and how to apply for one. Cost is $20.00 regardless of the quantity ordered. In New Jersey it is the responsibility of the medical examiner to conduct the proper identification, complete a physical examination and provide a description of the deceased as well as sign the description (N.J. Admin. Code § 8:70-6.1). See the New Jersey Department of Health’s page for more information about vital records, what they call death certificates, and how to apply for one. Cost is $5.00 for processing, $5.00 for online authentication fee, and $12.00 for shipping.

Hospice care focuses on the total-care, wellbeing, comfort, and quality of life of a person living with a terminal illness (with a 6-month or less prognosis as certified by a physician, if the illness takes its expected course) and their loved ones. Many hospice charges are covered by Medicare.

Medical Aid in Dying, otherwise known as its acronym MAiD, is an option for terminally ill adult patients (18+ years of age) who wish to experience a death which is person-centered and allows a sense of autonomy, choice, and dignity in their end-of-life process, especially if the end-of-life process becomes too distressing due to pain, for instance. MAiD is a process which involves ingesting a medication to hasten death. Terminal patients must exhibit mental capacity as well as the physical ability to ingest the medication independently in order to qualify for this end-of-life option, in addition to a physician who is able to certify the patient’s 6-month or less terminal prognosis (if the disease follows its expected course). Upon patients beginning to explore this option for themselves, patients and their physician/medical team often explore not only the option of MAiD, but all available end-of-life support options, including hospice care, as part of this process. This ensures that the patient is aware of all available resources before making a final decision that best meets their needs and desires for their end-of-life experience. MAiD is not currently legal in all 50 states in the U.S. Specifically in our region, MAiD was officially legalized in New Jersey in 2019. However, MAiD is not currently legal in Pennsylvania, with a death with dignity bill currently pending called the Pennsylvania Compassionate Aid in Dying Act (HB453). Resources: https://www.acamaid.org/ https://www.compassionandchoices.org/our-issues/medical-aid-in-dying https://www.nj.gov/health/advancedirective/maid/ https://www.nolo.com/legal-encyclopedia/pennsylvanias-compassionate-autonomous-right-the-end-life-care-act.html https://deathwithdignity.org/states/pennsylvania/

A living will is a type of advance directive. It is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, such as pain management or organ donation. From mayoclinic.org

A durable Power of Attorney legally designates power to your chosen agent where you are unable to act on your own to execute financial documents and make financial decisions. Your healthcare proxy and durable power of attorney (if they are different people) need to work closely and cooperatively to facilitate all of your medical and financial end of life requirements. Keep in mind that these terms and their definitions may vary from state to state. Please further your own research by checking with your state for the most recent definitions of these terms, as they can change.

Five Wishes is a type of advance directive that is written in everyday language and helps people express their personal, spiritual, medical, and legal wishes. It helps people describe what good care means to them and allows the caregiver(s) to know exactly what the person who completes the Five Wishes wants for their end of life care. It is important to make certain that your completed Five Wishes conforms with the legal requirements of your state in order to be legally enforceable and accepted by your hospital and medical provider. This document is recognized as a legal form in 42 states, including NJ and PA.