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Advance Directives

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Keeshia Whiteside

Advance Directives and Living Wills
Health care advance directives are legal documents that communicate a person's wishes about health care decisions in the event the person becomes incapable of making health care decisions. There are two basic kinds of advance directives: living wills and durable powers of attorney for health care. * A living will expresses, in advance, a person's instructions or preferences about future medical treatments, particularly end-of-life care, in the event the person loses capacity to make health care decisions. * A durable power of attorney for health care appoints a person (called a health care agent or proxy, health care representative, or other name depending on the state) to make decisions for the person (the principal) in the event of incapacity to make health care decisions.
Normally, people communicate their wishes directly to their doctors. But when a person no longer has the capacity to make or communicate a health care decision, another way to make and communicate a decision is needed. That is the role advance directives play. If no advance directive has been prepared, someone else not of the person's choosing may be called on to make health care decisions. Many states authorize default surrogate decision makers, usually next of kin. When state law does not authorize a default surrogate decision maker, doctors and hospitals still usually turn to next of kin, although the extent of their legal authority becomes less clear. In the rare event that the issue is referred to a court, courts generally prefer to name a family member as guardian or conservator to make health care decisions, but they may also turn to a friend or a stranger to direct care. A durable power of attorney for health care (and, in some cases, a living will) eliminates almost any need for the courts to get involved and helps ensure that the person's health care decisions will be respected.
Living Will
A living will is a limited document that expresses a person's preferences for future medical care (it is called a “living" will because it is in effect while the person is still alive). In many states, the document is more formally called a medical directive to doctors or a declaration. The focus of a living will is usually end-of-life care, but it can include instructions about any aspect of care or treatment. Living wills become effective only when the person has lost capacity to make health care decisions and the person has a particular condition defined by state law—usually a terminal condition or permanent unconsciousness. Some states recognize additional conditions such as an end-stage condition (for example, advanced Alzheimer disease) or any condition specified in the living will.
Many people believe that death is preferable to being perpetually dependent on medical equipment or having no hope of returning to a certain quality of life. Others feel just as strongly that extreme heroic measures and technology should be used to extend life as long as possible, regardless of the degree of medical intervention required or the quality of life that results. A living will allows a person to express either of these preferences (or any intermediate measure that the person finds acceptable).
To be legally valid, a living will must comply with state law requirements such as those regarding how the document is signed and witnessed or what must be included in the text of the document. Many states have specific forms available for people to use if they choose. People can usually find examples of acceptable forms from hospitals and other health care providers, local offices on aging, or law (bar) association web sites.
Examples of language: Typically, living wills address the issue of when the goals of treatment should change from aggressive, curative efforts to primarily efforts that provide comfort care and allow a natural death. Everyone draws this line somewhat differently depending on their values, beliefs, and goals. In their living will, some people give mainly general guidance, whereas others also give instructions about particular treatments, such as artificial nutrition and hydration (tube feeding), cardiopulmonary resuscitation (CPR), or mechanical ventilation.
Everyone's situation and wishes are unique and complex. Thus, the brief examples of living will language included here are provided simply to help illustrate the wide variety of issues. For example, to indicate a preference for full aggressive medical treatment, the document might state: "I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery, the burdens of the treatment, or the cost of the procedures." It should be noted, however, that the person's choice has certain limits. For example, health care practitioners are not required to provide treatments that are medically inappropriate or clearly futile.
To prevent heroic attempts to extend life, the document might state: "If I have a terminal condition or am in a persistent vegetative state from which I am not expected to recover, and life support will only delay the moment of my death, I do not want my life to be prolonged, and I do not want life-sustaining treatment (including artificial feeding and hydration) to be provided or continued.”
Still others may draw this line differently. For example, they might want the document to state: “If I have permanent and severe brain damage (for example, I can open my eyes, but I cannot speak or understand) and I am not expected to get better, I do not want my life to be prolonged, and I do not want life-sustaining treatment (including artificial feeding and hydration) to be provided or continued.”
In all cases when people refuse care through an advance directive, health care providers are nonetheless always required to provide comfort measures as needed for the person's condition.
Limitations: Living wills have substantial limitations. For example, they generally address only a narrow range of end-of-life decisions, they cannot realistically anticipate all the serious medical circumstances the person may face in the future, and the written document may not be available at the time and place needed. Also, peoples' preferences often change as they develop a terminal illness or with the passage of time. Living wills are often done long before serious decisions actually need to be made, so highly specific directions may not have been intended for new and unforeseen circumstances. Nevertheless, a living will can provide general guidance to health care practitioners and the person's surrogate decision makers in the face of serious illness.

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