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An Advance Directive
By Marilyn Mitchell

(Page 1 of 2)

An Advance Directive is a document that is meant to give health care professionals an understanding of your medical preferences if you cannot speak for yourself.  It tells them ‘in advance’ of needing treatment what you would most likely want to have happen.  Many people may know them as "Living Wills," but a Living Will may only address your treatment options and not allow you to appoint someone to speak for you if you are unable to communicate.  Another document that is useful is called a "Durable Power of Attorney for Health Care" and it allows a person to designate someone to speak for them if they are unable to speak for themselves.  The person is sometimes called a ‘surrogate’ or a ‘proxy’ decision maker.  Many Advance Directive documents combine the 'living will' portion with a portion that is a Durable Power of Attorney for Health Care.  Here is a link to the VA's Advance Directive, which is a fine version of the combined document.

Only about 20 percent of Americans have an Advance Directive, but I believe everyone could use one.  Some of the most famous bioethics cases arose from situations involving young women that had no Advance Directive (Karen Ann Quinlan, Nancy Cruzan, Terry Schiavo).  These women were young and had no intention of finding themselves in persistent vegetative states.  Keep in mind, it's not just a persistent vegetative state that may make speaking for yourself impossible.  There are a whole host of reasons why someone might be receiving medical treatment and they would be unable to speak, including many surgical situations.

Advance Directives have two purposes. One is to let health professionals know what kinds of treatments you would find acceptable. Many people find the thought of being placed on a mechanical ventilator for long-term existence unacceptable.  Others may find the idea of living with advanced dementia, dependent on a surgically placed feeding tube, something they would like to prevent. Some want every possible treatment to be attempted, regardless of the outcome. Often people decide whether they would like a medical team to attempt resuscitation (CPR) or to allow for a natural death.

The other critically important thing an Advance Directive usually does is to appoint someone specific to make medical decisions on your behalf if you are unable to make them. It's vital to speak with that person about your values and expectations since it is a serious responsibility. All too often in clinical settings, health professionals ask the person most likely to assist with decision-making what they think the person requiring treatment might want and they admit they have no idea. The person named in the Advance Directive is meant to make decisions that are closest to what that person would want if they could speak for themselves. It's not acceptable for people to direct the health care team to take actions based on their own values since those values may differ from those of the person in need. Just as unacceptable would be for the health care team to decide what is best without knowing what the ill person would want.  This is the area where there seems to be a general lack of understanding.  We are not deciding what we think is best for the person; we are attempting to imagine what that person really would want done.  What is “best” is often very subjective in medical situations.

In emergencies, the default option is to do everything to save the person's life.  But there are situations in which doing that would not necessarily be in the best interest of the person experiencing the emergency situation. For instance, an elderly person had requested hospice care and was nearing the end of their life.  The relative living with them panicked and instead of calling their hospice nurse, called 911. The elderly person was unsuccessfully resuscitated, which caused pain from having their ribs broken during the chest compressions and unnecessary stress at the end of their life. They did not survive. They did have an Advance Directive, but their relative did not follow their wishes to die a natural death. It is very important to choose someone you think will commit to following your desires.


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