Most people, no matter their age, should have a Durable Power of Attorney. This power of attorney lets someone (your agent) manage your financial affairs simultaneously with you. Depending on where you live (I'm only familar with Texas), this power of attorney may be designed to go into effect immediately or not until you are unable to make decisions (a springing power of attorney). In Texas, you may make the decision as to when your power of attorney goes into effect. However, if you do not trust the person you designate to have this power while you are able to manage your affairs, why would you let them do so if you are unable to manage your financial affairs? Also, with a springing power of attorney, there must be additional paperwork to accompany it to show that you are incapacitated (a doctor's statement, etc.). This makes it less likely that the power of attorney will be honored. In Texas, financial institutions sometimes refuse to honor such documents. My preference is a power of attorney that goes into effect immediately.
If it is likely that someone will have to manage your affairs, then it may be better to give your agent signature rights on your financial accounts. This is especially true if the agent is a close relative. Even if you do this, you still need the durable power of attorney. The term durable is used to indicate that within this document there is a statement that says that the power of attorney remains in effect even if you are incapacitated.
A copy of this document should be kept with a copy of your medical power of attorney to take with you if you are hospitalized. In some states, these two documents may be combined into one. The durable power of attorney may be needed so your agent can sign admitting documents, etc. Remember the durable power of attorney is only effective when you are alive.
Because a durable power of attorney is so powerful, I recommend that you discuss its implications with an attorney before executing one. If you choose to do one without an attorney, then just remember that anything you can do with your financial resources, your agent can do, too.
Showing posts with label Advance directives. Show all posts
Showing posts with label Advance directives. Show all posts
Wednesday, January 16, 2008
Monday, January 14, 2008
Ethics of Dying: HIPAA Release
One document that I now recommend everyone have is a HIPAA release. HIPAA is the Health Insurance Portability and Accountability Act. More information on the privacy aspects of HIPAA is available at privacy rights.org. The HIPAA release allows the person designated by the release access to your medical records. Usually, this is the same person that is designated as your agent in your medical power of attorney. The form I have seen also gives access to your medical records to other people designated in powers of attorney for financial affairs, trustees, etc.
Because HIPAA regulates the release of medical information, there is concern that unless specifically mentioned, medical records might not be open to your agent. A medical power of attorney should allow your appointee access, but there are always concerns about an overzealous privacy officer withholding access. So to be safe, if you are having end-of-life documents prepared by an attorney, ask that a HIPAA release be included.
Because HIPAA regulates the release of medical information, there is concern that unless specifically mentioned, medical records might not be open to your agent. A medical power of attorney should allow your appointee access, but there are always concerns about an overzealous privacy officer withholding access. So to be safe, if you are having end-of-life documents prepared by an attorney, ask that a HIPAA release be included.
Saturday, January 12, 2008
Ethics of Dying: Do Not Resuscitate
I do not recommend that "Do Not Resuscitate" orders be made routinely outside a hospital setting. If someone is in hospice care then DNRs are appropriate at home. In a hospital setting, DNRs are very useful.
Having a DNR will keep extraordinary means from being used. One thing to remember, especially in the elderlty, is that CPR may well break bones which in turn can cause other complications. Most hospitals will allow some mild efforts to be made to keep you alive, such as administration of drugs that stimulate the heart even with a DNR in place, but that must be specified in the order. These are issues to be discussed with your physician, the earlier the better.
I do not recommend DNRs at home because if you are able to live at home and do not have hospice care, then I believe that there are too many variables to decide that no matter what you will not be resuscitated. It is far better to have the person that holds your medical power of attorney make that decision based on the circumstances at the time. Again, this is a personal decision and there is no correct answer, only what you want.
DNRs are only useful if those taking care of you know that you have one. In the hospital, this is not a problem usually. You must have the DNR at hand, if it is to be used at home. If emergency services are summoned to your home, their job is to keep you alive. Whether or not they will honor a DNR will depend on the law of your state. Many in hospice are told not to call emergency services in a crisis, but instead call hospice. This avoids the issue entirely.
Finally, life support can be removed. Even if you do not have a DNR or it has not been used or it has been ignored, you can make the decision to withdraw life support, or if you are not capable of making decisions, the person that holds your medical power of attorney can make that decision.
Having a DNR will keep extraordinary means from being used. One thing to remember, especially in the elderlty, is that CPR may well break bones which in turn can cause other complications. Most hospitals will allow some mild efforts to be made to keep you alive, such as administration of drugs that stimulate the heart even with a DNR in place, but that must be specified in the order. These are issues to be discussed with your physician, the earlier the better.
I do not recommend DNRs at home because if you are able to live at home and do not have hospice care, then I believe that there are too many variables to decide that no matter what you will not be resuscitated. It is far better to have the person that holds your medical power of attorney make that decision based on the circumstances at the time. Again, this is a personal decision and there is no correct answer, only what you want.
DNRs are only useful if those taking care of you know that you have one. In the hospital, this is not a problem usually. You must have the DNR at hand, if it is to be used at home. If emergency services are summoned to your home, their job is to keep you alive. Whether or not they will honor a DNR will depend on the law of your state. Many in hospice are told not to call emergency services in a crisis, but instead call hospice. This avoids the issue entirely.
Finally, life support can be removed. Even if you do not have a DNR or it has not been used or it has been ignored, you can make the decision to withdraw life support, or if you are not capable of making decisions, the person that holds your medical power of attorney can make that decision.
Thursday, January 10, 2008
Ethics of Dying: Advance Directives
Advance directives, living wills, medical powers of attorney, HIPAA releases, Do-Not-Resuscitate orders, etc. have limits. These are written documents that cannot express all your wishes. The best of them, the medical power of attorney, appoints someone to make your decisions if you are not able to make them. All of them can be fought in court. However, if you have chosen the proper person for you medical power of attorney, that person will stand up for you and make sure your wishes are followed.
If there is disagreement within your family about end-of-life decisions, then frank discussions of your wishes are imperative. You do not seek to change the mind of those opposed to your decisions, only that they will honor them. If, in the worst case, it is clear that your wishes will not be followed, then I would put something in writing to the effect that this person is to be excluded from any health care decision pertaining to me. Be sure to sign, have it witnessed and better yet, notarized. Depending on how serious the conflict, this might be an issue to discuss with an attorney.
Advance directives only work if the hospital and the doctors have them. I recommend that a copy be made of each document and kept in a plastic bag in a readily accessible spot, e.g. taped to the door of the refrigerator, in the refrigerator freezer, in the top drawer of your desk, etc. The person with your medical power of attorney should have a copy of all documents and know where the originals are kept. Don't keep originals in a safety deposit box unless the person who holds your medical power of attorney has access to that box. Even then, I think is is better to keep these documents in a safe place in your residence.
Each time you go to the hospital, even if you were recently hospitalized in the same one, have copies of your documents to be put in your chart or records. Make sure that all your doctors are aware you have executed these documents, and most importantly, communicate your wishes directly to the doctor. Doctors will honor your oral directives if at all possible.
Advance directives work if they have not been done in a vacuum, that is, done on paper but never discussed. I have used directives to make decisions about the end of life successfully. The lack of advance directives can make a difficult time even more horrendous. Ease your loved ones burden and have these documents done.
If there is disagreement within your family about end-of-life decisions, then frank discussions of your wishes are imperative. You do not seek to change the mind of those opposed to your decisions, only that they will honor them. If, in the worst case, it is clear that your wishes will not be followed, then I would put something in writing to the effect that this person is to be excluded from any health care decision pertaining to me. Be sure to sign, have it witnessed and better yet, notarized. Depending on how serious the conflict, this might be an issue to discuss with an attorney.
Advance directives only work if the hospital and the doctors have them. I recommend that a copy be made of each document and kept in a plastic bag in a readily accessible spot, e.g. taped to the door of the refrigerator, in the refrigerator freezer, in the top drawer of your desk, etc. The person with your medical power of attorney should have a copy of all documents and know where the originals are kept. Don't keep originals in a safety deposit box unless the person who holds your medical power of attorney has access to that box. Even then, I think is is better to keep these documents in a safe place in your residence.
Each time you go to the hospital, even if you were recently hospitalized in the same one, have copies of your documents to be put in your chart or records. Make sure that all your doctors are aware you have executed these documents, and most importantly, communicate your wishes directly to the doctor. Doctors will honor your oral directives if at all possible.
Advance directives work if they have not been done in a vacuum, that is, done on paper but never discussed. I have used directives to make decisions about the end of life successfully. The lack of advance directives can make a difficult time even more horrendous. Ease your loved ones burden and have these documents done.
Tuesday, January 8, 2008
Ethics of Dying: Living Will
In Texas, a living will is a "Directive to Physicians and Family or Surrogates" and allows you to put in legal form your end of life decisions. The Directive divides end of life decisions into two categories, one if you are facing eminent death and the other if you are in a persistent vegetative state. No matter where you live, you need to consider these two categories.
What kind of medical treatment do you want if you have a very limited time to live? Do you opt for comfort? Do you choose a last ditch effort at treatment to prolong your life? There is no correct answer. While I would choose comfort and not a life prolonging treatment because I am a Christian and convinced that death is a door to better existence, I do not believe that should be everyone's choice. I fear that too often societal pressures make it seem that we are misusing resources and somehow wrong to fight for every minute of life. I believe this becomes more prevalent as we age, but quality of life, not age, should be the deciding factor. For this reason, I think you have to consider this choice long before you are enmeshed in medicine's clutches.
I know people who have advanced directives that make it clear that they wish to stay alive at all costs. Others I know do not want hospice. However, I believe the vast majority of people who bother to execute a living will do so because they do not want their life prolonged by artificial means including artificial nutrition and artificial hydration. I find that in the absence of a living will or other clear direction, most families opt for all life prolonging measures.
More difficult for me is to decide what you want done if you are in a persistent vegetative state. As I understand this state, you are never expected to regain consciousness, but you will not die if you are given artificial nutrition and artificial hydration and personal care. This is difficult because here we confront the imperfections of science. In extreme cases, there is no doubt that the person will never recover, but we all know cases where there has been a seemingly miraculous recovery. My choice would be no artificial nutrition and no artificial hydration: let me die. I do not think that is the correct choice for everyone. Only an individual can make that choice for themselves. In the absence of a directive or other clear directions, every effort should be made to keep someone in a vegetative state alive. Again, make your wishes known in a living will.
What kind of medical treatment do you want if you have a very limited time to live? Do you opt for comfort? Do you choose a last ditch effort at treatment to prolong your life? There is no correct answer. While I would choose comfort and not a life prolonging treatment because I am a Christian and convinced that death is a door to better existence, I do not believe that should be everyone's choice. I fear that too often societal pressures make it seem that we are misusing resources and somehow wrong to fight for every minute of life. I believe this becomes more prevalent as we age, but quality of life, not age, should be the deciding factor. For this reason, I think you have to consider this choice long before you are enmeshed in medicine's clutches.
I know people who have advanced directives that make it clear that they wish to stay alive at all costs. Others I know do not want hospice. However, I believe the vast majority of people who bother to execute a living will do so because they do not want their life prolonged by artificial means including artificial nutrition and artificial hydration. I find that in the absence of a living will or other clear direction, most families opt for all life prolonging measures.
More difficult for me is to decide what you want done if you are in a persistent vegetative state. As I understand this state, you are never expected to regain consciousness, but you will not die if you are given artificial nutrition and artificial hydration and personal care. This is difficult because here we confront the imperfections of science. In extreme cases, there is no doubt that the person will never recover, but we all know cases where there has been a seemingly miraculous recovery. My choice would be no artificial nutrition and no artificial hydration: let me die. I do not think that is the correct choice for everyone. Only an individual can make that choice for themselves. In the absence of a directive or other clear directions, every effort should be made to keep someone in a vegetative state alive. Again, make your wishes known in a living will.
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