Living wills and health care proxies
Have you ever thought about what would happen if a serious illness
or medical emergency left you unconscious? How will doctors know what
treatments you want, or don’t want? Who would communicate your
wishes to them?
Unless you have a living will or health care proxy — documents
known as advance caredirectives — important medical
decisions may be left to a physician or others who are unaware of your
values, beliefs, or preferences. That’s why everyone over age 18
should have a living will or health care proxy.
The two types of advance care directives work in different ways. A health
care proxy allows you to appoint someone as your health care agent — a
person who will convey your wishes to medical personnel if you’re
unable to communicate. A living will lets you specify in writing
what you want done in certain circumstances.
People sometimes worry that signing one of these documents means giving
up control over their medical treatment. But that’s not how they
work. As long as you’re able to make and communicate your decisions,
your word supersedes anything you’ve written or said to others.
The health care proxy
In this document, you name a person to make health care choices for
you if you can’t make the decisions yourself. Without a health
care proxy, that job will likely fall to your relatives. For many people,
this isn’t a problem. But unless you feel close to your legal next
of kin, you may not want decisions about your health care in his or her
It’s best not to appoint more than one agent (and in many states
it’s illegal to do so), because all of them would need to agree
on every decision. But do appoint an alternate agent in the event your
first agent is unavailable when needed. You can also instruct your agent
to consult others.
Your health care agent is legally obligated to make decisions that she
or he thinks you would make. That’s why it’s important to
be as specific as possible with your agent about medical treatments you
may or may not want, your religious or spiritual beliefs, and your preferences
in situations that might arise. You can’t anticipate everything,
so make sure you feel absolutely comfortable allowing the person you
choose to decide about matters you haven’t specifically discussed.
What’s in a living will?
If you don’t know anyone who would make a good health care agent
for you, don’t choose one. Filling out a state-specific living
will is better than appointing someone who might not carry out your wishes.
A living will provides a written record that can guide your doctors and
loved ones in caring for you. In many instances, it’s used to determine
how aggressive your medical treatment will be.
Living wills generally ask about the following medical procedures:
Artificial nutrition and hydration (tube feeding): This
procedure involves placing a tube in a vein, the stomach, or the upper
intestine when a person is unable to eat and drink. People who reject
tube feeding often do so because of the discomfort or because tube feeding
may lead to other invasive procedures.
Cardiopulmonary resuscitation (CPR): CPR can
be used in an attempt to save the life of a person who has gone into
cardiac arrest. Toward the end of life, the chance of success is very
low, and CPR can cause injury. Some people with terminal illnesses who
have been resuscitated this way say they wish they hadn’t been.
Defibrillation: An electric shock may restart
the heart when it fails. The shock causes the body to jerk, although
the person is usually unconscious and doesn’t feel it. Some people
who are sick or dying decide to forgo defibrillation because they feel
it’s “too much.”
Mechanical ventilation: A ventilator or respirator
(sometimes called a “breathing machine”) forces air into
the lungs when a patient can’t breathe adequately on her own. A
tube attached to the machine is inserted into the nose, mouth, or throat
and passed into the trachea (windpipe). Because of the extreme discomfort,
a person on a ventilator requires high doses of sedatives and thus is
not fully conscious. People decline this procedure for many reasons.
They may not want their families to see them in an incoherent state,
hooked up to a machine. Many simply don’t want to spend what may
be their last days lying in a hospital bed on life support.
Pressors: These are medications, delivered
through an intravenous tube, that raise blood pressure. Pressors are
generally used only for the sickest patients. Some people feel that if
their condition is that severe, they’d prefer not to have any intervention.
Sharing your health care preferences
After your agent, your doctor is the most important person to talk to
about your living will or health care proxy. She or he can also provide
you with information about how various treatments might affect you. Schedule
an appointment specifically for this purpose, or arrange for extra time
at your next visit. Make sure your doctor is aware of the contents of
your advance care directive and agrees to find a clinician to comply
with any requests that she or he finds problematic. Also, be sure your
physician knows your preferences about pain management.
It’s important to define any terms in your health care proxy or
living will that could be open to interpretation, such as “life-threatening,” “short
period of time,” “severe disease,” “end-stage
condition,” and, especially, “quality of life.” In
a study reported in the November 1, 2003, British Medical Journal, a
group of doctors given a hypothetical living will and patient story came
to very different conclusions about what should be done. Clarifying terms,
the authors suggest, can help everyone involved better understand and
act on patients’ wishes.
Once you’ve completed your advance care directive, keep the original
and ask your doctor to keep a copy in your medical file along with his
or her notes about the conversations you’ve had. If you have a
health care agent, be sure his or her contact information is in the file
and kept current.
July 2005 Update
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