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Advance Directives

Making Treatment Decisions Now for the End of Life

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Updated January 24, 2014

More than three quarters of us want some sort of say about the healthcare that comes at the end of life. We expect our wishes to be followed whether or not we can still communicate. Over half of us expect a spouse or other family member to be able to make decisions for us if we cannot.

Getting your wishes at the end of life entails some sort of advance directive, which is just what it sounds like - a way to direct end of life decisions in advance.

Generally, there are two advance directives for patients to outline the care at the end of life: living wills and durable powers of attorney for healthcare (known as a health care proxy). There is also a Do Not Resuscitate (DNR) order, which comes from a physician rather than a patient and orders the healthcare team not to provide CPR for the patient.

Each of these advance directives has limits and advantages. Also, depending on where you live, each of these advance directives may or may not be honored by emergency responders or the staff at the hospital emergency department.

Living Wills

Patients who would like to make decisions in advance for themselves can write down their wishes in a living will. The living will seeks to explain as many details of end of life decisions as possible. Some states require specific forms for living wills to be valid - others do not.

Living wills are a good option for those folks who want to make decisions ahead of time and not burden family members. Unfortunately, living wills cannot cover all possible scenarios and may not adequately address the patient's needs when the time comes. Living wills also often rely on physicians to make the final determination of a patient's condition, something physicians aren't always capable or willing to do.

Living wills also do not have the ability to define a proxy decision-maker for the patient, which means if it isn't covered by the living will, then the physician will have the final say.

Durable Power of Attorney for Healthcare

If a patient wants to name a proxy to make decisions once the patient is no longer capable of doing so, he or she must create a durable power of attorney for healthcare. This document places a friend or family member in charge of making decisions for the patient and usually provides the proxy with guidelines for making those decisions. It is important to tell the person you are appointing your proxy that you have made this decision, and also discuss with them what your general wishes are, so that they can act in your best interest.

While it is always wise to have a healthcare proxy, keep in mind that state laws vary. For example, in New York, health care proxies cannot make the decision to withhold artificial nutrition or hydration. So – when appointing a healthcare proxy, it is important to specifically state those wishes in your living will.

Durable powers of attorney for healthcare will often name a succession of proxies, in the unlikely event that one or more of the proxies also become incapable of making decisions at the same time as the patient. For example, it's a good idea for spouses who often ride in the same car to name someone besides each other as proxies (since they may be involved in a serious car accident together).

Also, keep in mind that a regular power of attorney is not the same as power of attorney for healthcare, which specifically addresses end-of-life decisions.

Who Decides If I Don't?

In many states, courts are beginning to recognize the role of family as de facto proxies, even in the absence of a durable power of attorney for healthcare. This is easy to do in the case of elderly couples with only a spouse to make decisions. Larger families, however, often disagree over decisions - making it imperative to name a proxy.

Will the Ambulance Crew Honor My Advance Directive?

Yes…and no. It really depends on the state. In many cases, the broad scope of documents like durable powers of attorney and living wills make it very difficult for emergency responders to follow. Responders often must make split-second life-or-death decisions and do not have the time to comb through a complicated legal document.

Proper DNR orders, however, are usually honored by ambulance staff.

Unfortunately, DNR orders are so cut-and-dried, they don't always allow for nuances in treatment. If a patient has a DNR order, the healthcare team is obliged to withhold CPR, something that isn't always in the best interest of the patient.

It may be better to not have a DNR order, allow responders to do whatever it takes, and let a designated proxy make decisions at the hospital once the patient is either stabilized or not. Even if a DNR order is issued, it's important to have some other form of advance directive to cover the rest.

References:

  • Arras, J. "Ethical issues in emergency care." Clin Geriatr Med. Aug 1993 PMID: 8374863

     

  • Cohen, N.H., and H.B. Kummer. "Ethics update: lessons learned from Terri Schiavo: the importance of healthcare proxies in clinical decision-making." Curr Opin Anaesthesiol. Apr 2006 PMID: 16552217

     

  • Crippen, D, et al."Debate: what constitutes 'terminality' and how does it relate to a living will?." Crit Care. 2000 PMID: 11123876

     

  • Fade, A.E. "Advance directives: keeping up with changing legislation." Todays OR Nurse. Jul-Aug 1994 PMID: 8066588

     

  • Manifold, C.A., A. Storrow and K. Rodgers. "Patient and family attitudes regarding the practice of procedures on the newly deceased." Acad Emerg Med. Feb 1999 PMID: 10051901

     

  • Perry, J.E., L.R. Churchill and H.S. Kirshner. "The Terri Schiavo case: legal, ethical, and medical perspectives." Ann Intern Med. 15 Nov 2005 PMID: 16287796

     

  • Singer, P.A., S. Choudhry and J. Armstrong. "Public opinion regarding consent to treatment." J Am Geriatr Soc. Feb 1993 PMID: 8426030

     

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