A 1991 federal law, the Patient Self-Determination Act, requires that patients be informed about their right to participate in health care decisions, including their right to have an advance directive. Advance directives fall into two broad categories: instructive and proxy:

• Instructive directives allow for preferences regarding the provision of particular therapies or classes of therapies. Living wills are the most common examples of instructive directives, but other types of instructive directives, such as "Do Not Resuscitate", are also employed.
• The proxy directive, generally a Durable Power of Attorney for Health Care (DPAHC), allows for the patient to designate, in advance, a surrogate medical decision maker who can make medical care decisions for the patient if the patient is incapacitated.

A Do-Not-Resuscitate Order (DNR) instructs medical personnel, including emergency medical technicians and paramedics, not to perform CPR or use any other "heroic measures" in the event their heart or breathing stops.

Advance directives are recognized in one form or another by legislative action in all 50 states and the District of Columbia. If the directive is constructed according to the outlines provided by pertinent state legislation it can be considered legally binding.

• The majority of state laws grant immunity to medical personnel who withhold CPR. The problem for YMCAs is that they may not qualify as "medical personnel" as defined by their state's statute.
• It would be virtually impossible for a YMCA to ensure that all full- and part-time staff and all volunteers at all locations always knew about each and every DNR request the YMCA had agreed to honor.
• An association that agreed to honor a DNR request could be held liable for significant damages if a staff member who was unaware of the request administered CPR and the victim did not recover fully.

YMCAs should inform members that they will not recognize or accept DNR requests. In the event of a medical emergency, a YMCA should follow all its emergency procedures and protocols for all members, guests, and staff until the EMTs or Paramedics arrive. If the YMCA staff responding to an incident is aware of a DNR request, it should be presented to the EMT and Paramedic who should decide on whether to withhold further live saving measures.