An advance directive is a written document in which people clearly specify how medical decisions affecting them are to be made if they are unable to make them, or to authorize a specific person to make such decisions for them.
Description
Advance directives are recognized in most industrialized countries of the world. In the United States, by law, the creation of an advance directive is the right of all competent adults. The goal of this legislation is to empower all health care consumers to make their own judgments regarding medical decision-making, to approve of potential treatment they believe they would want, and to refuse care they do not perceive as being in their best interest. These directives are generally divided into living wills or durable powers of attorney.
Federal law requires that all health care providers (health maintenance organizations, or HMOs, skilled nursing care facilities, hospices, home health care providers, and hospitals) make information regarding
advance directives available to all people in their care. Many states require that two people witness such advance directives.
Living wills
Living wills go into effect while the individual is still living, but is unable to communicate his/her wishes regarding care. Traditionally, a living will has specified the individual's wishes concerning procedures that would sustain life if he/she were terminally ill. Newer advance directives do not limit such preferences to terminal illness but instead go into effect whenever the individual is unable to speak for him/herself.
There are several ways of preparing a living will. Sometimes a preprinted form is provided, or people may create their own form, or may simply write down their wishes. Though all 50 states and the District of Columbia recognize the validity of advance directives, each state's laws have differences as to whether one or all of these types of preparation of the document are legal and binding in that state. It is recommended that people speak to their attorney or physician to ensure that their wishes are carried out.
Durable power of attorney for health care
A durable power of attorney for health care is the second type of advance directive. This is a signed, dated, and witnessed document that authorizes a designated person (usually a family member or close friend) to act as an agent, or proxy. This empowers the proxy to make medical decisions for a person when the person is deemed unable to make these decisions him/herself. Such a power of attorney frequently includes the person's stated preferences in regard to treatment. Several states do not allow any of the following people to act as a person's proxy:
the person's physician, or other health care provider
the staff of health care facilities that is providing the person's care
guardians (often called conservators) of the person's financial affairs
employees of federal agencies financially responsible for a person's care
any person that serves as agent or proxy for 10 people or more
As in the case of living wills, regulations regarding such powers of attorney vary from state to state. Some states provide printed forms, and require witnesses, while other states do not.
Causes
As medical advances provide greater than ever means of extending life, it becomes increasingly important for people to evaluate which of the available means they would wish used. If this is not done, people run the risk of having health care providers make critical decisions regarding their care. The absence of advance directive information can also create dilemmas and increased stress for loved ones. Some of the terms describing now-routine medical interventions that can maintain life under dire circumstances include:
cardiopulmonary resuscitation (CPR), the use of chest compressions and/or mouth-to-mouth resuscitation to restart heart beat and/or respirations
ventilators or respirators that physically deliver oxygen via a tube into the windpipe when the lungs are unable to work on their own
Life-sustaining care encompasses the use of machinery or equipment that prolongs life by keeping the body functioning. Examples of life-sustaining care include hyperalimentation, tube feedings, and kidney dialysis.
In contrast, life-enhancing care, sometimes referred to as Care and Comfort Only, involves the provision of high quality, but non-heroic medical care until death occurs naturally. Important examples of life-enhancing care include administration and monitoring of medications,
carrying out other measures to control pain, comfort measures such as bathing and massage, and offering food and fluids.
Special concerns
Though specifics vary, all states have laws allowing people to spell out their health care wishes for a time when they might be unable to speak for themselves. But, as noted, there is a potential for disparity in how advance directives are interpreted. In most hospitals, an ethics committee is available to assist and support both patients and families faced with decisions regarding medical care. In 1995, the American Association of Retired Persons (AARP), with the help of the American Bar Association (ABA) and the American Medical Association (AMA), produced a combined living will and power of attorney for health care document that provides very specific and detailed statements of a person's wishes. Further information regarding the laws in individual states can be obtained from the AARP, ABA, or AMA.
The AARP recommends that those individuals considering making an advance directive address the following issues:
What the person's goals for medical treatment are: Should treatment be used to sustain life, regardless of the quality of that life?
Who should act as the person's proxy or agent? It is important for the person making an advance directive to actually speak with this designated person and make his/her wishes known.
Though there is no formula for specificity, the AARP recommends that instructions be made as clear and specific as possible, but should not restrict the proxy from making informed decisions at the time that cannot be anticipated in advance.
To ensure that an advance directive is carried out, copies of it should be given to a person's physician, proxy, family, or any other interested party.
Resources
BOOKS
Clayman, Charles A., M.D. American Medical Association Home Medical Encyclopedia. New York: Random House, 1989.
Doukas, David J., and William Reichel. Planning for Uncertainty, A Guide to Living Wills and Other Advance Directives for Health Care. Baltimore, MD: Johns Hopkins University Press, 1993.
ORGANIZATIONS
Choices In Dying, Inc., 200 Varick Street, New York, New York10014-4810. (800) 989-WILL.
American Association of Retired Persons Legal Counsel for the Elderly., P.O. Box 96474, Washington, DC, 20090-6474.
—Duly qualified; having sufficient ability or authority; possessing all the requirements of law.
Dialysis
—A technique used to remove waste products from the blood and excess fluid from the body as a treatment for kidney failure.
Hyperalimentation
—The administration of a nutrient solution into a large, central vein near the heart. It is often used supplementary to eating, but can provide complete nourishment.
Tube feeding
—Administration of nourishment, in nutritionally complete solutions, via tube into the stomach or intestines. Tubes can be either nasogastric, or inserted through the nose into the stomach via the esophagus, or surgically implanted directly into the stomach. These are usually used to sustain life when a person is unable to eat or take fluids by mouth.
QUESTIONS TO ASK THE DOCTOR
What is the prognosis for my type of cancer?
What are the possible treatments?
What are the side effects of these treatments?
What are the laws in my state regarding living wills and durable powers of attorney for health care?
How can I ensure that my wishes will be carried out regarding advance directives?
