Advance Directives: When You Are Unable to Make Your Own Decisions
We like to think that we will always be capable of making our own health care decisions. Sometimes, however, it doesn’t work like that. A stroke, an automobile accident, being too frail or confused to understand medical treatment information—any number of circumstances could occur that might limit or take away a person’s immediate ability to make health care decisions.
Fortunately, you have the power to think and act ahead of time for such situations. There are two types of legal documents that are referred to as "advance directives":
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A Health Care Appointment, also called a Durable Power of Attorney for Health Care or a Health Care Proxy, is a document that lets you give someone else—usually a close friend or relative—the power to make decisions for you if a time comes when you can’t speak for yourself.
A Health Care Directive or Living Will is a document that lets you say what kinds of care you would or would not want if you were nearing the end of your life. A health care directive usually refers to “life-sustaining measures.” These are advanced medical treatments that can keep a person alive past the time when death would very likely occur. Examples include:
- CPR—emergency restarting of a person’s heart or breathing.
- Ventilation—using a machine to breathe for a person.
- Dialysis—mechanically cleaning and filtering the blood, usually the work of the kidneys.
- Tube or needle feeding—giving basic nutrition to a person who has lost the ability to swallow.
- Antibiotics—fighting an infection that could hasten death.
Health Care Appointments
If you were unable to make health care decisions for yourself, who would be the person you would most trust to make those decisions for you? That is the person you should appoint as your health care representative. If for some reason your first choice person were not available to act for you, who would be your second choice? Most forms designating a health care representative allow you to name an alternate.
Although no one is under any obligation to fill out a Health Care Appointment, it is the most flexible sort of advance directive. Your health care representative can make decisions for you in a wide variety of unforeseen situations. Your representative has a legal obligation to make decisions for you based on what you would have chosen for yourself. Therefore, the appointment of a health care representative significantly extends your ability to control your health care decisions.
If you wish to name an individual as your health care representative, it is a good idea to ask the person if he or she is willing to take on that responsibility. If the person agrees, then you should sit down with him or her and have a frank, detailed conversation about your feelings and values concerning health care and the kinds of treatment you would or would not want. Along with this conversation, be sure to give your health care representative copies of your advance directives.
Health Care Directives
If death were near, would you want your life to be extended by use of a ventilator? What about a feeding tube? What about antibiotics? Some people would respond "yes" to some or all of these questions; others would answer "no." If you fill out a health care directive, that document will ask you for your preference regarding specific treatments if you were at the end of your life. It is a common misperception that you should fill out a living will only if you don’t want any life-sustaining treatment at all. In fact, your living will allows you to specify precisely what treatments you would like and which ones you would refuse. Most health care directives also have a space to write down any preferences not covered in the specific treatment questions asked.
As with the appointment of a health care representative, you don’t have to fill out a living will. Having such a directive, however, lets you specify in advance which treatments make sense to you at the end of life. It is another way of extending your control over your own health care.
If you do fill out a health care directive, give a signed and witnessed copy to your primary physician, your health care representative, your hospital, and any other major health care institution or organization with which you are connected. It is also wise to share the contents of your living will with your family and close friends. Let them know what you would want. Doctors and hospitals may become uncomfortable when the family is surprised by a family member’s wishes as stated in a living will, especially if family members disagree with the patient’s wishes. You can make it easier for everyone by talking openly with your loved ones about what you would want.
Other Opportunities for Advance Health Care Planning
Along with advance directives, it is helpful to consider three more aspects of advance health care planning. Although not technically advance directives, they are important ways of planning ahead for choices to be made when you can’t make choices for yourself.
Personal Values Statements
Personal values statements are becoming more common as a way of clarifying and supplementing a person’s advance directives. Values statements provide a detailed profile of a person’s views, goals, and underlying personal values concerning health care. A values statement indicates not only what kind of care a person desires, but also why he or she desires it. It is an expression of a person’s beliefs and priorities in the person’s own words. Although values statements do not have the legal weight of advance directives, when used with advance directives, they extend a sense of clarity about what the person would want and why.
DNR Orders and POLST Forms
A do-not-resuscitate order (DNR order) is an instruction a doctor puts in a patient’s medical record with the informed consent of the patient or the patient’s health care representative. It says, in effect, "If this person’s breathing or heart stops, do not start cardio-pulmonary resuscitation (CPR) or any other measures to restart those vital functions." The legal status of DNR orders varies from state to state, so be sure to check with your doctor if you have questions.
In many states, if you wish NOT to be resuscitated, you can wear a medic-alert necklace or bracelet with that information, or you can carry a DNR card in your wallet. Another approach in many states and communities is for the physician and patient (or health care representative) to both sign a set of physician’s CPR orders on a standard, brightly colored form. This form, which is sometimes called a POLST (Physician Orders for Life-Sustaining Treatment) form, can then be posted on the refrigerator at home, or it can travel with the patient. First responders to a 911 call are trained to look for this form and will follow its instructions when they find it.
Organ donation is a person’s voluntary gift of organs or tissues, either for transplanting to another person or for medical research. In many states, people are asked if they wish to be organ donors when they renew their driver’s licenses. Many advance directive forms also have a place for a person to say whether he or she wishes to be a donor. As with other advance health care directives, if you wish to be an organ donor, it is helpful to share that information with your family or other loved ones. This minimizes the possibility of confusion or controversy at the time of your death.
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