Online Wills & Holistic Legacy Preservation

The planning architecture: five pillars

1) Values and goals (the compass)

Start with a two-to-six sentence statement that defines quality of life, acceptable trade-offs, and preferred care setting. Example: “If I can’t climb my four steps, share meals with my partner, or recognise family, I prefer comfort-focused care at home or hospice, and I decline ICU-level interventions.” This statement anchors every clinical fork in the road.

2) Medical preferences (the playbook)

Translate values into practical instructions:

• Resuscitation, ventilation, ICU: when acceptable, when not.
• Disease-specific choices: ICD off/on (heart failure); NIV thresholds (COPD); feeding tube stance (dementia).
• Medication boundaries: opioids for breathlessness/pain; time-limited trials for antibiotics in late dementia.
• Transfer rules: “Hospital only if symptoms cannot be controlled at home/hospice.”
• The Australian Government provides a broad framework for palliative choices across settings (palliative care). Clinically, palliative input early improves breathlessness, pain, mood, and coordination, not just end-of-life comfort.

3) Roles and responsibilities (the team sheet)

• Healthcare proxy (substitute decision-maker) who understands your values and will advocate under pressure.
• Care coordinator in the family who manages logistics and keeps the vault current.
• Clinical leads: GP, specialist (cardiology, respiratory, geriatrics), palliative service, community nursing, pharmacist, social worker, spiritual care.
• Executor for estate and digital assets (different from the proxy).
• Mapping roles prevents “everyone thinks someone else is doing it” fatigue.

4) Documentation and legal scaffold

• Advance care directive / online care directives recorded and witnessed per your jurisdiction.
• Enduring power of attorney (medical) where applicable.
• Online estate documents (will, beneficiaries) and online executor tools (asset checklists, timelines).
• Digital inheritance instructions (who handles cloud accounts, photos, social media).
• Palliative Care Australia advocates aligning legal documents with person-centred goals (palliativecare.org.au), while the NIA highlights how written preferences reduce unwanted treatment and clarify consent (https://www.nia.nih.gov/).

5) Digital backbone (the single source of truth)

Relying on a home drawer is generous to chaos. Use a digital legacy vault (e.g., Evaheld Vault) or online legacy platform to centralise:

• The latest directive, values statement, and disease-specific plans
• Online care instructions: escalation numbers, green/amber/red plans, medication lists
• Digital records: clinic letters, test summaries, paramedic handover page
• Online family archive: photos, record personal messages, life story snippets (optional but powerful)
• Digital estate tools: will, beneficiaries, asset inventory, passwords (handled via a password manager with vault pointers)
• Access controls: proxy (edit), family (read), clinicians (read link), audit logs, secure sharing
• Tie the vault to your national record where possible (e.g., upload directives into systems like My Health Record for visibility in hospital). That’s care continuity in practice.

Building the plan step-by-step

Step 1 — Set the baseline

• Write the values statement.
• Gather diagnoses, medications, allergies, and contact list (GP, specialists, community nursing, palliative).
• Upload a one-page “At-a-Glance” summary to the vault: name, conditions, goals of care, proxy, escalation rules.

Step 2 — Disease-specific “if/then” rules

Draft short scenario blocks:

• Heart failure: “If weight ↑2 kg in 3 days or ankle swelling ↑, then call GP; if breathless at rest, call palliative nurse; hospital only if pain or breathlessness uncontrolled after home measures.”
• COPD: “If sputum colour changes + fever, start standing antibiotics/pred per GP plan; if RR > 28 or accessory muscle use, call after-hours palliative; NIV acceptable at home, but no ICU ventilation.”
• Dementia: “If unable to recognise family + not eating/drinking, then comfort-first approach; no feeding tubes; treat reversible discomfort; avoid transfers unless for symptom relief.”
• Store each rule-set as online directives in the vault and share with the whole team.

Step 3 — Clinician alignment

Book a joint review (tele-palliative is fine): GP + specialist + palliative nurse + proxy. Confirm:

• Resuscitation/ICU status in the chart
• Home equipment (hospital bed, oxygen concentrator, commode) and how to order
• Respite services for carers
• Hospice integration triggers
• Document the outcomes and upload the signed summary. Palliative Care Australia provides frameworks for team-based coordination (palliativecare.org.au); the Australian Government outlines what services exist and how to access them (palliative care).

Step 4 — Communication plan

• Monthly 15-minute check-in (video or phone): status + plan tweaks
• Single shared group (email thread or secure app) for updates
• Who speaks to paramedics/hospital if you’re unwell
• Who refreshes the vault (and how often)
• The NIA stresses that clear communication reduces stress and improves the match between care and values (https://www.nia.nih.gov/).

Step 5 — Legacy layer

• Use the vault’s online memory vault to record personal messages for milestones (birthdays, graduations).
• Add an ethical will (values letter) and funeral/music preferences.
• Keep estate data tidy: online will maker outputs, online testament, executor notes, online estate management checklist.
• This doesn’t distract from care; it completes it. Families grieve better when they aren’t also treasure-hunting through lost files.

Step 6 — Security and emergency access

• Turn on MFA for the vault.
• Create a wallet Emergency Access Card: vault URL/QR, proxy phone, directive date.
• Keep a paper “first page” on the fridge/bedside with the same info.
• The rule: if a stranger finds you unwell, they should be able to put the puzzle together in under two minutes—without guessing.