Advanced Directives

Ask the DOC

In last week’s column about mechanical ventilation, I briefly touched on the topic of advanced directives. Today I would like to expand on that topic. In essence, advanced directives lay out specific instructions to healthcare providers based on your wishes in the event that you do not have the ability or capacity to make them yourself. These documents are known as durable power of attorney for health care, a living will, or a healthcare proxy.

Both a living will and durable power of attorney for health care allow you to name an individual, usually referred to as an agent, to make healthcare decisions for you. Your agent may make decisions about starting or stopping treatments (including invasive therapies like mechanical ventilation), undergoing tests, surgery, and other treatments. Your agent may also decide about enrolling in hospice care. If you have a living will, your agent will use that document to guide decisions made on your behalf.

When choosing an agent, you should select an adult whom you trust and who is comfortable taking on this responsibility. You may also select second and third agents (called “successor agents”) who serve as backup should your primary agent be unavailable. It is critical that you discuss your values, wishes, and goals with your agent(s). Topics you should cover include:

  • What is most important to you in your life?
  • Do you prioritize living as long as possible or avoiding prolonged disability?
  • How important to you is avoiding pain?
  • Do you have spiritual, religious, or cultural beliefs that should be considered?
  • Would you rather die at home or be in the hospital in the final days or weeks of life?
  • Do you have existing advanced directives (such as a living will) that outline your preferences for life-sustaining care, such as CPR, mechanical ventilation, and artificial nutrition or hydration (tube feeding)?

Every adult should complete a durable power of attorney for health care, including younger and healthy individuals, because they may suddenly lose their decision-making capacity due to an accident/injury or unexpected illness. Clinicians caring for those unable to make their own decisions and who have no health care agent must follow state laws, including the selection of individual decision makers (called surrogates).

The default surrogate is typically the patient’s guardian or spouse, and the priority order of surrogates includes adult child, parent, sibling, or other more distant relatives or friends. This order varies from state to state, and most states assume that the patient would choose life. This means, in the absence of any health care documents that specifically state the patient’s wishes, medical staff may legally institute artificial feeding for the patient despite the surrogates’ objections. Remember, a state-appointed surrogate may not be the person you would want making decisions for you and may be unaware of your wishes.

Each state has its own durable power of attorney for health care form, which can be downloaded for free or obtained at your physician’s office. The form must be signed by you and witnessed by another individual. Some states require the use of a notary, and although no state requires an attorney to complete the form, an attorney can be very helpful in ensuring that your wishes will be clearly stated and understood.

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 By Peter Galvin, MG

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