March 18, 2005 - The Terri Schiavo case is tragic whether or not you believe her feeding tube should be removed. But much of the fighting could have been avoided if she had a living will.
There is a lesson here for everyone. If you want a clear mandate on what should happen to you if you end up in Schiavo's condition, enact a living will.
Here is how to go about it.
What are advance directives?
Advance directives are legal documents in which patients express their wishes about the kind of health care they want to receive should they become unable to make their own treatment decisions. There are two types of advance directives: the living will and the power of attorney for health care. Check with an attorney to find out what is available in your state.
What is a living will?
A living will is a legal document. It states in advance a person's desire to receive, or to withhold, life-support procedures. This is put into use if someone becomes permanently unconscious or terminally ill and unable to make decisions.
When does it apply?
The living will applies only when two doctors determine that the patient is either in an irreversible coma or is suffering from a terminal illness and is unable to make decisions for him/herself. As long as a patient is able to make health care decisions, the living will cannot be used.
What treatments are covered?
The living will permits the withholding or withdrawal of any treatment that might be considered life-prolonging or that artificially extends the dying process. Some states have special provisions that allow artificial nutrition and hydration to be withheld or withdrawn when patients are in an irreversible coma.
Who can complete a living will?
Anyone over the age of 18 years who is of sound mind can complete a living will. To be legal, it must be witnessed by two adults or can be notarized.
Can a living will be revoked?
A living will can be revoked by the patient at any time and in any manner, with the patient simply tearing up the living will document, expressing orally to witnesses the desire to revoke the document, or in writing. Health care professionals who witness such revocations will document them in the medical record.
What is a durable power of attorney for health care?
The durable power of attorney for health care is a document that allows patients to specify in advance who should make health care decisions for them should they become unable to make their own health care decisions.
When does a durable power of attorney for health care take effect?
The durable power of attorney for health care takes effect anytime the patient loses the ability to make his or her own health care decisions. Unlike the living will, the patient does not need to be terminally ill or suffering from an irreversible coma.
What treatments are covered?
The durable power of attorney for health care document allows a patient to name someone with broad or specific powers to provide consent or refusal for any type of health care. Durable powers of attorney for health care are very flexible documents, allowing both the naming of someone to make decisions for the patient when the patient is unable to do so, and the specification of the treatments that the patient wants or does not want to receive.
Who can be given durable power of attorney for health care?
Anyone over the age of 18 can be named except for the doctor (or those employed by the doctor) who is providing care to the patient. The person named has no legal obligation to serve and is not responsible for the financial costs associated with treatment.
Who can complete a durable power of attorney for health care?
Any adult of sound mind may complete a durable power of attorney for health care. Living wills and durable powers of attorney for health care are often prepared without the assistance of lawyers by using standard forms. The durable power of attorney for health care document must be witnessed by two adults or notarized. Such documents and procedures vary by state.
Can more than one durable power of attorney be named?
Only one person can serve at a time, but other individuals can be named as successor agents if the first individual named as the agent is not able or is unwilling to serve.
Can a durable power of attorney for health care be revoked?
The patient can revoke a durable power of attorney for health care at any time and in any manner by simply tearing up the durable power of attorney for health care document, expressing orally to witnesses the desire to revoke the document, or in writing. Health care professionals who witness such revocations should document them in the medical record.
How are the living will and durable power of attorney for health care implemented?
Both documents, called advance directives, require that two doctors determine that the patient has lost the capacity to make health care decisions. A living will has the additional requirement that the patient must be suffering from a terminal condition or is in an irreversible coma.
What are some other differences between the durable power of attorney for health care and the living will?
The living will simply requires the withholding or withdrawal of life-prolonging treatment, whereas the durable power of attorney for health care names a specific person who is authorized to make decisions for the patient. Specific instructions may be given in the durable power of attorney for health care, but they are not required.
How do health professionals know if a patient has an advance directive?
Many hospitals and clinics will ask the patient or family upon admission about the existence of advance directives when they are admitted to the hospital. The existence of an advance directive is documented prominently in the medical chart. Also, health professionals should document the content of discussions about the patient's end-of-life desires or any expression of treatment preferences.
Physicians and health care providers are immune from civil, criminal, and disciplinary action if they follow the advance directive statute in good faith and meet its provisions.
Do Not Resuscitate (DNR) Orders
Advance directives are not DNR orders. DNR orders are written by doctors to indicate that a patient should not be resuscitated. The order may be written to reflect a patient's or surrogate's expressed wishes about resuscitation, or because the patient will not benefit from resuscitation. For example, for someone with a living will or durable power of attorney for health care, CPR may be appropriate if they are suffering from an acute life-threatening condition. Patients with advance directives may want aggressive treatment for potentially reversible conditions.
Points to Remember
Advance directives only take effect when the patient loses the ability to make his or her own decisions. Before that time, the patient's current expressed wishes should be followed. Advance directives do not replace active communication with patients and their families.
Patients and families should be provided appropriate and sufficient information to make informed health care decisions. Patients' expressed preferences about health care treatments should be documented as they evolve in the course of treatment.
Assessing and attending to patients' spiritual needs are important in quality end-of-life care and should be a routine part of patient care.
Quality medical care also includes providing patients with a supportive atmosphere in which to reflect on end-of-life choices and to allow their wishes to be communicated to their health care providers and to their families.