Ways to Plan Ahead for Medical Care and Treatment

Let's face it. We never know when we might need medical care and treatment. For some people, deciding the issues and tackling the choices at the time care or treatment is needed is a sufficient way of handling matters. For many other people, there may be a desire to plan ahead of time through different types of advance directives.

Advance Directives

An advance directive is a document that is used to tell your physicians what kind of care you would like to have if you become unable to make medical decisions for yourself, such as if you are in a coma. Advance directives can provide direction on what you will allow your physicians to do in caring for you, and they can also state what types of treatment you would not like to have. In addition, they can declare that you want a certain type of treatment, no matter how ill you are.

Once a doctor receives a properly executed advance directive, he or she is under a duty to either honor its instructions or to transfer your care to a physician who will honor the instructions if he or she is unable or unwilling to do so.

  • Living Wills

A living will is a type of advance directive that comes into effect, in some states, only when you are terminally ill. In other states, a living will may be called upon whenever you are unable to make decisions for yourself.

Note: In most situations, being terminally ill means that you have less than six months to live.

While a living will allows for you to describe in advance the kind of treatment you want to receive as your terminal condition progresses or while you are unable to make decisions for yourself, it does not allow for you to appoint a person to make medical decisions on your behalf.

Note: In some areas, a living will may be called a Directive to Physicians or a Healthcare Directive.

  • Durable Power of Attorney for Health Care

A durable power of attorney for health care (or "healthcare proxy") is much like a living will. It allows you to make decisions as to what type of care you would like to receive in the future. A durable power of attorney for health care becomes active any time that you are either unconscious or unable to make medical decisions for yourself. In addition, with a durable power of attorney for health care, you can select a family member or friend to make medical decisions on your behalf if you are unable to make such decisions. You can give a person with a durable power of attorney as much power, or as little, as you wish and you can provide guidance to the decision-maker as to what types of treatment you would or would not prefer.

Example: Your durable power of attorney for health care can state that the designated person has the power to decide when treatment should be stopped. Or, you can state that the person only has the power to determine the types of treatments you receive, but cannot stop those treatments once they have begun.

  • Make sure that the person you appoint will respect your wishes, although he or she may not agree with them. Make sure, also, that the person you appoint has a strong personality. He or she will need to be sensitive to the feelings of others who may not agree with your plans, but also assertive enough to carry out your wishes.

Note: In some states, you are prohibited from nominating certain people as your decision-maker. In most states, your doctor may not be able to be your decision-maker.

  • If possible, an alternative decision-maker should be named in the document in case the primary decision-maker is unable to serve your interests because he or she becomes incompetent, dies or is otherwise unavailable.

  • Do Not Resuscitate Orders

Do Not Resuscitate Orders, or DNRs, are advance requests not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. DNRs are important for individuals who do not want to have this potentially life-saving measure taken because, unless given contrary instructions, hospital staff will try to revive non-responding patients.

To create a DNR, you can either use an advance directive form or you can clearly tell your doctor that you do not wish to have CPR performed. In the former case, your doctor should make a conspicuous note in your medical chart. It is important, however, that a DNR created in this way be made at a time early in your hospitalization when your competency is not in question.

Benefits of Advance Directives

  • With an advance directive, you may experience a sense of relief knowing that you will not be subjected to unnecessary or personally objectionable treatment.

  • Without an advance directive, you may have to rely on the discretion of your physician to make decisions for you about your health care.

  • Having an advance directive may save your loved ones anxiety, concern, and arguments.

Example: John is in a car accident, and ends up in a coma and on a respirator. He had no advance directive in place, and his physician has just expressed concern that John may never "wake up." John's wife, four adult children, two of their spouses, plus five adult grandchildren are all arguing with each other about what John "would have wanted."

Doesn't sound like a very good situation, does it? If John had an advance directive, there would be no question what his wishes. While some loved ones may have trouble accepting decisions in an advance directives, they will be the patient's own decisions, not what someone else might think was wanted.

  • Advance directives can give you the power to choose who can make decisions on your behalf. This can benefit those with a very strong relationship with a friend, or unmarried partners. Such individuals, although important to you, would in other circumstances most likely be barred from participation.

Example: George is suffering from end-stage pancreatic cancer, and has named his long-time same-sex partner to have durable power of attorney. The two men discussed George's condition, and George's partner knows that George is ready to die. George's parents have never approved of his lifestyle or partner, and they have now shown up at the hospital demanding that drastic measures be taken to save George's life. While in normal situations, the parents may have had a voice, George's durable power of attorney clearly states that his partner, is the only one allowed to make medical care decisions on George's behalf in accordance with George's wishes.

  • In some situations, fights between family members or between family and friends or partners can end up in court. What follows is usually a costly, emotional battle over how the patient should be treated. If you have an advance directive that is properly executed, this eventuality can be avoided.

Some Considerations

  • In drafting an advance directive, realize that medical choices and treatments available today may be unavailable in the future. You will either need to update your directive as new developments in medical technology and treatment become available, or you will need to draft your directive in such a way that newly developed treatments are not excluded.

  • Most state law presume that people want relief from pain, so those items are not included in the definition of "life-prolonging treatment." If you do not want to receive pain medications, you should make that clear in your directive. The same goes for food and water in some states.

Note: There is a lot of controversy regarding withholding of food and water. If you want food and water withheld-or provided-be certain to mention it in your advance directive.

  • Have you thought carefully about your wishes and preferences? Making sure that your advance directive protects your wishes is the most difficult task. For example, have you thought about whether you want life-prolonging treatments, no matter what your quality of life might be? Would you rather not have treatment if it means it could keep you alive, but in a permanent coma? What if you couldn't feed yourself? Breathe on your own? Would you want to have life-saving treatments for a short period of time, or not at all?

Example: What if there was a chance you would have to be placed on a respirator, but you would only need it for four days, and then you would most likely be healthy enough to be taken off of it? Would you want to be placed on the respirator in that situation?

  • Have you discussed your wishes with your healthcare provider? In many situations, including your physician or healthcare provider in the process of discussing your treatment wishes is a good idea. If you have a terminal illness, your physician can review your diagnosis with you and can provide essential advice on what types of treatment you are likely to need, and the effect those treatments might have.

Note: Even if you don't have a terminal condition, discussing your values, fears, and desires with your healthcare providers can be beneficial. With these discussions, your healthcare providers will obtain a better idea of how you would like to be cared for and treated in the future.

Legal Requirements

  • In most states you must be least 18 to make a valid directive, although a few states do allow for parents to make directives on behalf of their minor children.

  • You must be capable of understanding what the document means, what it contains, and how and when it applies.

  • The directive must be signed in the presence of either a witness, a notary public, or both, depending upon the law of your state.

  • You can change your mind about the matters discussed in an advance directives, but you should destroy all copies of any old directives and write a new one instead of trying to "amend" or "add to" the original directive. That way, you can avoid questions and arguments over the version to apply.

How An Advance Directive Should Be Written

  • Ask your doctor if he or she has an advance directive form.

  • If you have a terminal or serious illness, check with national and local organizations or groups devoted to that condition. For example, if you have AIDS or cancer, you may want to ask a local or national AIDS or cancer support group for advance directive information or forms.

  • Write your wishes down on your own, making sure that you have researched and followed any state laws that apply to you.

  • Check the Internet, or a computer store, for software on drafting advance directives, again making sure that you follow your state's laws.

  • Call a lawyer and ask for assistance in drafting an advance directive.

Note: Some states have laws that require that specific, approved forms be used for advance directives. Check your state laws, or ask your physician or attorney. If it is, you must use an approved form so there will be no question that it is enforceable. An "approved" advance directive will stand up much better in court should it, unfortunately, come to that.

Note: No matter what method is utilized for drafting an advance directive, the final document should be signed, dated, witnessed and/or notarized as required by state laws. A copy should be kept for your own records, a copy should be given to your physician or physicians, a copy should be given to your attorney if you have one, and a copy should be given to a family member or trusted friend.

Next Steps

Contact a qualified health care attorney to help navigate legal issues around your health care.

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