Advanced Directives Clarify End-Of-Life Medical Preferences, Ease Family Stress
What kind of medical care would you want if you became incapacitated due to injury or illness and were unable to express your wishes? One way you can maintain control in a situation like this is to record your preferences for medical care while you are still healthy and to share these decisions with your family and physician.

Advance directives are legal documents that describe the end-of-life medical care you want doctors and other healthcare professionals to provide in the event you become unable to make or to state decisions (if you are comatose or have a dementing illness, for example). In addition to communicating your medical preferences, advance directives can spare your loved ones the confusion and stress of making decisions about your care while you are sick.

If you become comatose or mentally incompetent and you haven't prepared an advance directive, it will be left to your family, doctor and hospital to make medical and end-of-life decisions in your stead. If these parties can't reach an agreement (about whether treatment should be continued or withdrawn, for example), it may be necessary to call in a judge to make a decision.

Advance directives "make your wishes clear and make it much easier for your loved ones to act on your behalf," says attorney Brent Kato, an elder law specialist with the San Francisco firm Kato Feder & Suzuki. "If you don't do this advance planning, your loved ones may end up going to court to make decisions, which can be expensive and acrimonious."

Advance directives typically state that you don't want certain kinds of treatment, such as surgery or tube feeding, but they can also say that you do want certain treatments no matter how ill you become. They take many forms, including living wills, durable powers of attorney for healthcare and do not resuscitate orders.

A living will is a legal document that states your decision to accept, withhold or withdraw life-prolonging medical care in the event you become terminally ill, permanently comatose or in a vegetative state and can no longer make decisions. A living will does not allow you to select another person to make decisions for you. The document cannot be revoked or interfered with by third parties (e.g., physicians or family members) if it has been executed according to the procedures defined in applicable law.

A durable power of attorney for healthcare (DPA/HC) is another kind of advance directive. This legal document names a healthcare proxy - a person you have chosen to make healthcare decisions for you if you are unable to do so at any time, not just at the end of life. A DPA/HC transfers medical decision-making power to the person you have chosen (usually a spouse, relative or other trusted individual). This power begins with and continues through the period of your incapacity, and it is the duty of the DPA/HC proxy to select the medical options that most closely adhere to your stated preferences.

When preparing a DPA/HC, it is important to make sure the proxy you select will be comfortable in this decision-making role, says Kato. "This why it's a good idea to name some alternative proxies," he adds.

Living wills and DPA/HCs typically address such treatments and issues as:

* Whether you want to be resuscitated if breathing or heartbeat stops

* Use of ventilators, artificial nutrition and hydration, antibiotics, dialysis and breathing machines

* Organ and tissue donation

A DPA/HC is a more flexible directive than a living will, in part because it applies to a wider spectrum of future medical conditions and it is not limited to end-of-life situations. The proxy designated by a DPA/HC may also have greater ability to voice and enforce your wishes than a living will, which describes specific treatments or refusals and is therefore less flexible.

To cover all your bases, it is possible to prepare both a living will and a DPA/HC. More and more, however, the distinction between the two directive types is becoming blurred - some states now combine them in a single document that both describes your treatment preferences and names a proxy.

A do not resuscitate (DNR) order is a third kind of advance directive. A DNR instructs physicians, paramedics, hospital staff and other healthcare providers not to perform CPR or other resuscitative measures if your heart stops or you stop breathing. You can use an advance directive form - in California, the Emergency Medical Services Prehospital Do Not Resuscitate Form is an official state document developed by the California EMS Authority and the California Medical Association - or inform your doctor in advance that you don't want to be resuscitated. In this case, your doctor will place a DNR order in your medical chart.

The DNR directive does not affect the provision of other emergency medical care, including treatment for pain, difficulty breathing, major bleeding or other medical conditions.Though all states legally recognize some form of advance directive, it is important to note that laws vary from state to state. DNR orders are accepted by doctors and hospitals in all states, and living wills and DPA/HCs are legal and well-established in most states, including California. No law or court has invalidated the concept of advance directives and an increasing number of statutes and court decisions support them.

But even if these directives aren't enforceable under some circumstances, they can still be useful in guiding your doctor and family in making decisions about your medical care. It's better to express your wishes in some kind of written document than not to express them at all.

Advance directives can be changed or canceled at any time, so long as you are considered of sound mind to do so. If you are still able to think rationally and communicate your wishes in a clear manner and you wish to alter an advanced directive, your changes should be written, signed and notarized. If you are unable to put your changes in writing, you may communicate your updated instructions orally to your doctor and loved ones. Wishes expressed in person will usually be honored in place of the ones made earlier in writing.

Advance directives are not limited to the elderly - anybody age 18 and older can prepare an advance directive.

Research shows that people who are seriously or terminally ill are the most likely to have an advance directive, often because they want to increase their peace of mind and control over their death. However, you might want to consider writing an advance directive even if you are in good health, as accidents or serious illness can happen suddenly. Documenting your wishes today means your family won't have to make heart-wrenching decisions later.

Public awareness about advance directives has grown in recent years, due largely to highly publicized legal cases - like those of Terri Schiavo and Nancy Cruzan - involving comatose patients whose families wanted to withdraw treatment. Yet most Americans haven't prepared directives themselves - among those age 50+, just 45 percent have a durable power of attorney, according to a recent survey by AARP.

The actual preparation of advance directives is relatively easy. They do not have to be complicated legal documents; rather, they can be short, simple statements that you write yourself about your treatment preferences in certain circumstances. You can also request or download advance directive forms from a variety of sources, including your state health department or department on aging. You can also call a lawyer or ask your doctor to provide a form.

But the process of preparing an advance directive is, of course, more complicated than simply filling out a form. It takes time - and can be psychologically challenging - to think about death, the kind of care you want (or don't want), how artificial life support would affect your dying process, the conditions that would make your life intolerable and other issues. It is often helpful to discuss your thoughts and choices with your family, friends, physician, clergy and other people whose opinions you value.

If you are having trouble making decisions about end-of-life healthcare issues, you may want to ask your physician to provide you with a Values History form. A Values History is a questionnaire that can be used to complement a living will and DPA/HC. It asks you to identify your values and beliefs regarding terminal and end-of-life treatments. The Values History can help you, your family and your doctor gain a deeper level of meaning about the care you want in the future.

It's also a good idea to have your advance directives reviewed by your doctor or a lawyer to make sure its terms are understood exactly as you intended. When you are satisfied with your directive, it should be signed, dated, and witnessed and/or notarized. You should provide copies to your family and your doctor, and store the document in a safe, accessible place. You should also verify that your advanced directive is included in your medical record. One solution is to register your advance directive with the U.S. Living Will Registry, which makes your choices available to healthcare providers and family members wherever and whenever needed.

For information about advance directives, access to forms and registering your directives, see the U.S. Living Wills Registry's website at http://www.uslivingwillregistry.com. The American Bar Association provides a Consumer's Tool Kit for Health Care Advance Planning, and the American Hospital Association provides a Put It In Writing section. The Emergency Medical Services Authority's "Guidelines for EMS Personnel Regarding Do Not Resuscitate Directives" are available online. AARP offers an array of information about end-of-life planning online.

(This article originally appeared in the Summer 2007 issue of Bay Area Summit)

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