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.

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.