What Happens When You Don’t Have a Living Will

Nobody plans to be in a situation where they cannot speak for themselves. Yet every year, millions of Americans face exactly that scenario — after a stroke, a car accident, a sudden cardiac event, or the progression of a serious illness. When that moment comes, the presence or absence of a living will can determine everything: the care you receive, the burden on your family, and even the relationships your loved ones have with each other afterward.

Default treatment: everything possible

When there is no living will and no designated healthcare agent, the default in American medicine is to provide all available treatment. Physicians are trained — and often legally obligated — to preserve life. That means CPR, mechanical ventilation, feeding tubes, dialysis, and any other intervention that might keep you alive.

For some people, that is exactly what they would want. But for many others, it is not. Studies suggest that a significant majority of Americans would prefer comfort-focused care over aggressive treatment if they had a terminal illness with no chance of recovery. Without a living will, however, that preference goes unrecognized. The medical system defaults to doing everything, regardless of whether “everything” is what you would have chosen.

Who decides for you?

If you have not designated a healthcare agent (also called a healthcare proxy or durable power of attorney for healthcare), your state’s laws determine who makes decisions on your behalf. Most states have a statutory hierarchy that typically follows this order:

1. Spouse or domestic partner
2. Adult children
3. Parents
4. Adult siblings
5. Other relatives or close friends (varies by state)

This hierarchy may or may not reflect who you would actually want making decisions for you. Your estranged spouse might have legal authority over your supportive sibling. Your parents might outrank your long-term partner if you are not legally married. The person the state designates may not know your wishes — or worse, may have their own agenda about your care.

Family conflict: the hidden cost

When families have no written directive to guide them, disagreements about care are almost inevitable. These conflicts are not about bad intentions — they are about love, fear, guilt, and fundamentally different perspectives on what constitutes a good death.

One adult child may feel that stopping treatment is “giving up” on their parent. Another may feel that continuing aggressive treatment is causing unnecessary suffering. A spouse may want to honor what they believe their partner would have wanted, while the children disagree. These disputes happen in hospital hallways, in ethics committee meetings, and sometimes in courtrooms.

The emotional damage can be permanent. Families that go through contentious end-of-life decisions without a clear directive frequently report fractured relationships that never fully heal. Siblings stop speaking to each other. Marriages strain under the weight of guilt and second-guessing. The grief of losing a loved one is compounded by the grief of losing family relationships.

Lessons from landmark cases

Some of the most well-known cases in American law illustrate what can happen when there is no clear advance directive.

The Terri Schiavo case (1990-2005) became a national controversy when Terri Schiavo’s husband and parents disagreed for 15 years about whether to remove her feeding tube after she entered a persistent vegetative state. Terri had no living will. The case went through multiple courts, involved the Florida legislature, the U.S. Congress, and the President. It divided a family and a nation. Terri’s husband maintained she would not have wanted to be kept alive in that condition; her parents insisted she would have wanted to continue living. Without a written document from Terri, there was no definitive answer.

The Nancy Cruzan case (1983-1990) reached the U.S. Supreme Court, which ruled that a state could require “clear and convincing evidence” of a patient’s wishes before allowing the withdrawal of life-sustaining treatment. Nancy, who was in a persistent vegetative state after a car accident, had no formal advance directive. Her parents fought for years to have her feeding tube removed, ultimately succeeding only after finding additional witnesses who could testify to her verbal statements about her wishes.

These cases are extreme, but variations of them play out quietly in hospitals and nursing homes every day. Most never make headlines. But the pain they cause is just as real.

The financial reality

Unwanted end-of-life care is not only emotionally devastating — it can be financially ruinous. ICU care in the United States costs thousands of dollars per day. Aggressive treatment for a patient who would have preferred comfort care can result in bills that burden surviving family members for years.

Research published in the Annals of Internal Medicine found that patients with advance directives who indicated a preference for comfort care had significantly lower healthcare costs in their final week of life — not because they received less care, but because they received more appropriate care. Comfort-focused approaches cost less than aggressive intervention, and patients and families report higher satisfaction.

The emotional toll on decision-makers

Perhaps the cruelest consequence of not having a living will is the burden it places on the people who love you. Making life-or-death medical decisions for someone else — without knowing what they would have wanted — is a weight that can follow a person for the rest of their life.

Studies of surrogate decision-makers show high rates of anxiety, depression, and post-traumatic stress, particularly when they were uncertain about the patient’s wishes. A spouse who authorizes the withdrawal of a ventilator without knowing if their partner would have wanted that may carry guilt for decades. A child who insists on continued treatment may later wonder if they prolonged their parent’s suffering.

A living will does not eliminate grief. But it does eliminate doubt. And removing that doubt is one of the greatest gifts you can give the people you love.

It only takes a few minutes

Creating a living will does not require an attorney (though one can help with complex situations). It does not cost a fortune. It does not require you to predict every possible medical scenario. It simply requires you to think about your values, make some decisions about specific treatments, and put those decisions in writing.

The alternative — leaving your family to guess, argue, and agonize during the worst moments of their lives — is not a neutral choice. Doing nothing is itself a decision, and it is one that shifts the entire burden onto the people you care about most.