Executing Advance Medical Directives

Questions to Consider Before Executive Advance Medical Directives

Most of us have heard about tragic cases such as those of Karen Ann Quinlan and Terry Schiavo, in which young women, in the prime of life, suffered accidents that left them brain dead with no hope of recovery. As a result of such landmark cases, the topic of advance medical directives has received significant attention. Physicians, social workers, and other medical providers have been required to explain the importance of advance medical directives to patients and to offer the opportunity to patients to complete said directives. Many of us at one time or another have said, “If I were in a coma and not expected to recover, I would want someone to pull the plug!” Of course in real life, it is not so easy to make such decisions. Yet if you give such issues serious thought, and you still agree with such a sentiment, it is critical to put such desires in writing. Most of the time, that is the only assurance you will have that your healthcare wishes will actually be complied with.

Simply put, an advance medical directive is a document, drafted by the patient that clearly spells out what types of care and treatment the individual would want in the event that future circumstances leave them unable to discuss these wishes with medical providers.

There are three primary types of advance medical directives, Living Wills (otherwise known as Declarations to Physicians) and Powers of Attorney for Healthcare documents. A newer form, called the Five Wishes document, combines the tenets of the Living Will and Power of Attorney for Healthcare.

The Living Will

The Living Will is a concise document that applies to only two sets of circumstances: incapacity due to terminal illness or persistent vegetative state. If either of these circumstances exists, the document offers medical providers guidance about whether or not to administer non-oral nutrition and hydration or other life-prolonging treatments. The Living Will does not appoint a surrogate decision maker and does not speak to any other interventions than those mentioned, including whether or not to place the individual into a skilled nursing or other care facility.

Durable Power of Attorney for Healthcare

The Power of Attorney for Healthcare document is a much more comprehensive document. It gives the individual the ability to appoint primary and secondary health care surrogate decision makers that would assume responsibility for advocating for the individual’s healthcare wishes. It also gives the individual the ability to articulate what those wishes would be. The document gives the individual the chance to address issues such as placement in a care facility and issues such as non-orally ingested nutrition and hydration. The Power of Attorney for Healthcare differs from the Durable Power of Attorney form in that it only becomes effective in the event that the individual should become incapacitated as verified by two physicians or one physician and one psychologist. This gives the individual protection from those that would seek to prematurely take over decision making. And because the document allows the individual to be as precise as possible in stating their wishes, the surrogate does not have the power to overrule the wishes as stated in the document.

For that reason, it is imperative that individuals completing this form of advance directive be as comprehensive in stating their wishes as possible. In order to help facilitate the completion of a meaningful and useful document, I have prepared the following list of considerations.

  • When choosing your primary and secondary surrogates, choose persons that you know will be able to advocate for your wishes and not simply those that seem to be the most obvious choices. Sometimes spouses and children have difficulty making end-of-life decisions because they are too close to you. While spouses and children are often wonderful agents, it is imperative that you spell out your healthcare wishes clearly prior to committing to a particular surrogate. Be sure to choose those that share your values and beliefs and can commit to upholding your wishes under any circumstances.
  • If you are in a terminal state or persistent vegetative state, do you want to receive non-orally ingested nutrition and hydration?
  • Under the same set of circumstances, would you want to be placed on life support systems such as ventilators?
  • Do you want to be listed as a full-code or a DNR. That means, would you want to receive CPR in the event of a witnessed sudden death (e.g. cardiac or respiratory arrest?)
  • How do you feel about kidney dialysis?
  • How do you feel about blood transfusions?
  • Would you want to be an organ donor? If so, are there any limitations on what you would donate?
  • Do you give your agent authority to admit you to an assisted living facility or nursing home? If not, what do you think should be done if you can no longer care for yourself in a less-restrictive setting?
  • If you are unable to take anything by mouth, would you authorize the use of intravenous pain medications, rectally administered pain medications or pain patches? What about other intravenous medications?
  • Are there any restrictions that you would place on the use of intravenous treatments?
  • Is there a limit on the amount of time that you would accept such things as tube feeding, IV treatments or other life-sustaining treatments before deciding to stop them?
  • Do you have any religious considerations that would dictate what treatments you would or would not accept?
  • Would you want or not want to receive care in a hospice setting?
  • Are there any circumstances in which you would cede your right to make healthcare decisions to your primary care provider?

The Five Wishes Form

This document is legally recognized in about 42 of the 50 United States, therefore, check to be sure that your state is one that recognizes it prior to completing this form. The Five Wishes form includes language encompassing almost every aspect of end of life decision making for your consideration. This includes physical, emotional, social and spiritual considerations. The comprehensive nature of this document leads the patient into meaningful dialogue with his or her chosen healthcare agents. This ensures that the end of life process will be as pain-free as possible while adequately addressing one's spiritual and emotional needs.

Guardianship and Protective Placement

The only thing that can supercede an advance medical directive is the appointment of a legal guardian. Yet even an appointed guardian is required to act in the best interest of the ward. That means that if there is an advance directive, the guardian would be required to follow those directives unless they conflict with state law or have become obviously no longer in the best interest of the ward. Issues that may be considered no longer in a ward’s best interest may include decisions that would lead to unnecessary pain and suffering, those that would prematurely end the ward’s life despite the medical certainty of a full or mostly full recovery within a reasonable time frame, or the need to place the ward in a care facility that is best equipped to meet their physical care needs. The latter would also require an order of protective placement.

You Don't Need a Lawyer

The only thing that can supercede an advance medical directive is the appointment of a legal guardian. Yet even an appointed guardian is required to act in the best interest of the ward. That means that if there is an advance directive, the guardian would be required to follow those directives unless they conflict with state law or have become obviously no longer in the best interest of the ward. Issues that may be considered no longer in a ward’s best interest may include decisions that would lead to unnecessary pain and suffering, those that would prematurely end the ward’s life despite the medical certainty of a full or mostly full recovery within a reasonable time frame, or the need to place the ward in a care facility that is best equipped to meet their physical care needs. The latter would also require an order of protective placement.

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© 2010 Jaynie2000

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