Living wills and other tools to convey medical wishes
The issues surrounding serious illness and death aren’t easy to discuss, but it’s far easier on everyone if you decide which medical care options you’d like to pursue before you’re faced with a serious accident or illness. If you don’t, you may find yourself in a situation in which you’re unable to communicate your wishes regarding the extent of treatment efforts, such as resuscitation and life-support machines.
Living wills are just one part of advance directives — tools that can help you avoid just that kind of situation. Learn more about what these tools are, how to create them and how valuable they can be to both you and your family.
Advance directives: More than just living wills
Advance directives are written instructions regarding your medical care preferences. Your family and medical professionals will turn to these directives if you lose the capacity to make your own health care decisions or you sustain an injury that renders you unable to express your wishes. Any competent individual age 18 or older may prepare an advance directive.
Advance directives primarily include two parts:
- Living will. This written, legal document spells out the types of medical treatments and life-sustaining measures you do and don’t want, such as mechanical respiration and tube feeding. In some states the living will may be known by a different name, such as health care declaration or health care directive.
- Medical power of attorney (POA). Also called a durable power of attorney for health care or a health care agent or proxy, the medical POA form is a legal document that designates an individual to make medical decisions on your behalf in the event you’re unable to do so. The medical POA document is different from the power of attorney form that authorizes someone to make financial transactions for you. If you don’t appoint a medical POA, the decisions about your care default to your spouse. If you aren’t legally married, decisions fall to your adult children or your parents.
Each part has its limitations. For instance, you can’t possibly plan ahead for every situation, so what you include in your living will might not apply in certain instances. Your medical POA isn’t given a set of instructions on what to do in every situation, so you have to trust that this person will make decisions based on what’s best for you.
The best way to lessen those limitations is to combine the two types of advance directives with a conversation with your loved ones. Talk about what’s in your living will and explain how your values shaped your decisions. This gives your loved ones greater insight into what you’d want in medical situations.
| Planning option | What does it do? | Benefits | Limitations |
|---|---|---|---|
| Living will | Details your feelings on certain medical treatments and interventions. | Gives your doctors and loved ones an idea of the care you’d prefer if you can’t speak for yourself. | You can’t possibly plan ahead for all situations. In those instances, your doctor and loved ones would use this as a guide. |
| Talking with your loved ones | Lets you elaborate on your feelings about medical treatment. | Helps your family better understand your wishes. Gives a greater understanding of your approach to each situation. | A conversation isn’t as legally binding as written instructions. |
Choose a decision maker
Carefully choosing and authorizing a person to act for you by naming him or her in a medical POA document is possibly the most important part of your discussion. That person doesn’t necessarily have to be a family member. You may want to have your health care decision maker be different from the person you choose to handle your financial matters. Some people are willing to make health care decisions but not financial decisions, and the reverse may also be true.
You don’t have to choose a health care agent, but it’s usually a good idea to do so, because he or she can make decisions in situations not anticipated in your written advance directive.
“Be sure to avoid picking someone out of feelings of guilt or obligation,” says Paul Takahashi, M.D., a specialist in geriatrics at Mayo Clinic, Rochester, Minn. “You need to feel comfortable that he or she is going to do what you would want.”
When selecting a health care agent, choose someone you trust and who you’re comfortable with. He or she should understand fully your medical care philosophy and wishes. It may be helpful, but not necessary, if this person lived in the same city or state as you do.
“The person should be levelheaded, mature and calm in a crisis,” adds Edward Creagan, M.D., a cancer specialist at Mayo Clinic, Rochester, Minn.
Once you’ve chosen a health care agent, let your family and close friends know.
Treatments to discuss
In determining your wishes, think about your values, such as the importance to you of independence and self-sufficiency and what you feel would make your life not worth living. Is the treatment lifesaving or life sustaining? Does that make any difference to you?
Although an infinite number of medical situations can arise, be sure to discuss the following treatments. It may help to talk with your doctor about these and other issues and terminology.
- Resuscitation. Restarts the heart when it has stopped beating (cardiac death). Determine if and when you would want to be resuscitated by cardiopulmonary resuscitation (CPR) or by a device that delivers an electric shock to stimulate the heart. Would it matter what stage of an illness or injury you were in?
- Mechanical ventilation. Takes over your breathing if you’re unable to do so. Consider if, when and for how long you would want to be placed on a mechanical ventilator. Would it matter what your prognosis was or if your condition was improving?
- Nutritional and hydration assistance. Supplies the body with nutrients and fluids intravenously or via a tube in the stomach. Decide if, when and for how long you would want to be fed in this manner. Would it matter what your prognosis was or if your condition was improving?
- Dialysis. Removes waste from your blood and manages fluid levels if your kidneys no longer function. Determine if, when and for how long you would want to receive this treatment. Would it matter whether the treatment would be permanent rather than temporary?
- Treatments in the end stages of life. Examples include but are not limited to antibiotics, pain medication and mechanical ventilation. Would you want to receive these as comfort (palliative) care if your prognosis was that it would only delay imminent death?
In general, these types of medical interventions can be helpful in temporary situations — situations you’re expected to recover from. But in end-of-life situations, medical interventions may only prolong discomfort. Many situations fall somewhere in between — where your chances for recovery are unknown or unclear. It’s these gray areas that are difficult to plan for.
| Treatment | What does it do? | When it might be considered | Benefits | Limitations | What happens if it’s not used? |
|---|---|---|---|---|---|
| CPR | Restarts heart and breathing | Heart attack | For younger, healthier people, revives heart and breathing | Not effective in older adults and the terminally ill, may only temporar- ily prolong life |
Coma leading to death within five to 10 minutes |
| Tube feeding | Adminis- ters nutrition in a vein or through a tube in stomach |
Injury or illness that prevents swallowing | For a temporary condition, alleviates hunger and confusion from dehydration | For terminally ill, may not extend life, but prolongs dying | Coma leading to death in one to three weeks |
Also determine whether you’d like to donate your organs, eyes and tissues for transplantation or your body for scientific study. If you wish to donate your body for scientific study, contact the medical school closest to your home for details.
Fill out the forms for your state
Put everything in writing. Each state has its own laws regarding advance directives. Your doctor can give you the proper forms. Or, state-specific forms are available from a variety of Web sites. The National Hospice and Palliative Care Organization offers free forms on its Web site.
Though not necessary, you may consider consulting an attorney about this process. “This can be wise, especially if you move to a different state,” says Dr. Creagan.
Once you’ve filled out the forms, give copies to your doctor, the person you’ve chosen as your medical POA, and other friends and family members. Your instinct might be to put your advance directives away somewhere safe, like a safe deposit box, but that will only make it difficult for your loved ones to find the forms when they need them.
“Advance directives can be very powerful,” says Dr. Takahashi. “It’s important to make sure they’re both accessible and utilized.”
Revisit and revise your wishes from time to time
As your health changes or your perspective on life changes, you might reconsider some of your advance directives. Read over your advance directive forms from time to time to see if you need to revise any of the instructions. You can change your mind about your advance directives at any time.
You’ll follow the same steps to revise your advance directives as you did when you first wrote them. Get new advance directive forms to fill out. Discuss your changes with your friends and family and your doctor. Then distribute copies of your new advance directives and ask your loved ones to destroy their earlier version.
If there isn’t time to redo the paperwork, you can always cancel your advance directive by telling your doctor and your family. As long as you’re able to understand your health condition, weigh the risks and benefits of treatment and communicate your wishes, you’re in charge of what happens to you.
How to talk about end-of-life issues
Injury, illness and death aren’t easy subjects to talk about. But the bottom line is that by planning ahead you can ensure you receive the type of medical care you want.
The best approach to discussing the subject is probably to be matter-of-fact and reassuring. If you want an advanced directive for yourself, explain to your family, friends and your doctor what your medical care philosophy is and what you’d want done in specific instances. If your family is morally opposed to some of your wishes or is divided over the issue, you might consider choosing someone more in keeping with your personal philosophy as your medical POA.
If you’re approaching parents or other family members with the suggestion that they create an advance directive, explain that it’s important for you and the family to know what they’d want done.
“Without advance directives, families can be torn apart trying to decide what is best for you,” says Dr. Creagan. “Discussing and deciding what you want in advance can take the burden off your family, who would otherwise have to guess at what you’d want done. And no one wants a court to decide his or her fate.”