© Stanley, Lande & Hunter 2001
A health care advance directive is a document in which you give instructions about your health care if, in the future, you cannot speak for yourself. You give your "agent" or "proxy" the power to make health care decisions for you. You also can give instructions about the kind of health care you do or do not want.
In a traditional Living Will, you state your wishes about life-sustaining medical treatments if you are terminally ill. In a Health Care Power of Attorney, you appoint someone else to make medical treatment decisions for you if you cannot make them for yourself. An Advance Directive combines these two documents into a comprehensive statement and provides any specific instructions you desire.
Why Is It Useful?
Unlike most Living Wills, an Advance Directive is not limited to cases of terminal illness. If you cannot make or communicate decisions because of a temporary or permanent illness or injury, an Advance Directive helps you keep control over health care decisions that are important to you because you state your wishes about any aspect of your health care, including decisions about life-sustaining treatment, and choose a person to make and communicate these decisions for you.
Appointing an agent is particularly important. At the time a decision needs to be made, your agent can participate in discussions and weigh the pros and cons of treatment decisions based on your wishes. Your agent can decide for you wherever you cannot decide for yourself, even if your decision-making ability is only temporarily affected.
Unless you formally appoint someone to decide for you, many health care providers and institutions will make critical decisions for you that might not be based on your wishes. In some situations, a court may have to appoint a guardian unless you have an advance directive.
An Advance Directive also can relieve family stress. By expressing your wishes in advance, you help family or friends who might otherwise struggle to decide on their own what you would want done.
What To Consider Before Making An Advance Directive
FIRST - WHAT ARE MY GOALS FOR MEDICAL TREATMENT? The Advance Directive may determine what happens to you over a period of disability or at the very final stage of your life. You can help others respect your wishes if you take some steps now to make your treatment preferences clear.
While it is impossible to anticipate all the different medical decisions that may arise, make your preferences clear by stating your goals for medical treatment. What do you want treatment to accomplish? Is it enough that treatment could prolong your life, whatever your quality of life? Or, if life-sustaining treatment will not restore consciousness or your ability to communicate with family members or friends, should treatment stop?
Once you have stated your goals of treatment, your family and physicians can make medical decisions for you on the basis of your goals. If treatment would help achieve one of your goals, the treatment would be provided. If treatment would not help achieve one of your goals, the treatment would not be provided. In formulating your goals of treatment, it is often helpful to consider your wishes about different end-of-life treatments and then asking yourself why do you feel that way. If you would not want to be kept alive by a ventilator, what is it about being on a ventilator that troubles you? Is it the loss of mobility, the lack of independence, or some other factor? Would it matter if you needed a ventilator for only a few days rather than many months? The answers to these kinds of questions will reflect important values that you hold and that will help you shape your goals of treatment.
SECOND - WHO SHOULD BE MY AGENT? Choosing your agent is the most important part of this process. Your agent will have great power over your health and personal care if you cannot make your own decisions. Normally, no one oversees or monitors your agent's decisions. Choose one person to serve as your agent to avoid disagreements. If you appoint two or more agents to serve together and they disagree, your medical caregivers will have no clear direction. If possible, appoint at least one alternate agent in case your primary agent is not available.
Speak to the person (and alternate agents) you wish to appoint beforehand to explain your desires. Confirm their willingness to act for you and their understanding of your wishes.
THIRD - HOW SPECIFIC SHOULD I BE? An Advance Directive does not have to give directions or guidelines for your agent. However, if you have specific wishes or preferences, it is important to spell them out in the document itself. Also discuss them with your agent and health care providers. These discussions will help ensure that your wishes, values and preferences will be respected. Make sure to think about your wishes about artificial feeding (nutrition and hydration), since people sometimes have very different views on this topic.
At the same time, you cannot cover all the bases. It is impossible to predict all the circumstances you may face. Simple statements like "I never want to be placed on a ventilator" may not reflect your true wishes. You might want ventilator assistance if it were temporary and you then could resume your normal activities. No matter how much direction you provide, your agent will still need considerable discretion and flexibility. Write instructions carefully so they do not restrict your agent's authority in ways you did not intend.
FOURTH - HOW CAN I MAKE SURE HEALTH CARE PROVIDERS WILL FOLLOW MY ADVANCE DIRECTIVE? Regardless of the laws about Advance Directives, some physicians, hospitals, or other health care providers may have personal views or values that do not agree with your stated desires. As a result, they may not want to follow your Advance Directive.
Most state laws give doctors the right to refuse to honor your advance directive on conscience grounds. However, they generally must help you find a doctor or hospital that will honor your directive. The best way to avoid this problem is to talk to your physician and other health care providers ahead of time. Make sure they understand the document and your wishes, and they have no objections. If there are objections, work them out, or change physicians.
Once you sign an Advance Directive, be sure to give a copy of it to your doctor, your agent, your lawyer, close relatives, and anyone else who may be involved m your care.