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 Dying. Show all posts
Showing posts with label Dying. 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.
Wednesday, January 2, 2008
Ethics of Dying: Medical Power of Attorney
I made end of life decisions for both my grandmothers and my mother. My paternal grandmother died from stomach cancer back in the seventies. She did not have any of the legal documents available today. Everything was done on the basis of her wishes in a tacit agreement with her doctor and the hospital. There were no extraordinary measures taken, but everything was done to keep her comfortable. My mother and I were able to keep her at home until the last few weeks. My mother changed to a night shift (I worked days), so my grandmother was alone each day for only a couple of hours. While my grandmother was weak, her mind was clear until the end. The last days were difficult as she needed more and more pain medication. She turned the decision-making over to me, so I opted for her comfort even if it shortened her life by a few days. My mother and I were both with her when she died.
When my maternal grandmother came to live with us many years later, I knew she needed legal documents if I was to make decisions for her. She met with an attorney and had the necessary documents executed. I was designated as her agent in her medical power of attorney. Over the next seven years she lived with us, I would use that medical power of attorney several times including her final illness. In Texas, a medical power of attorney is only effective if the person who executed it is unable to make their own decisions. My grandmother ws competent, if stubborn, most of the time. However, she had several procedures that involved sedation or mild anesthesia. At those times, I took over the decision-making.
At age 96, she had major surgery from which she never recovered. After the surgery, she never really regained consciousness, so I made her choices as to treatment. I acted under the medical power of attorney. All seven of her children were able to visit her before she died. One aunt strongly objected to some of my decisions, but all she did was tell me of her disagreement. She could have done much more. Any legal document can be challenged including living wills and medical powers of attorney. While the courts usually follow the wishes of the person who executed the documents, court disputes can delay end of life decisions. The best way to avoid courtroom showdowns is to make sure your end of life decisions are known to all your immediate family and that these choices are clearly spelled out in the proper documents.
My mother had Parkinson's disease (PD), and after sixteen years PD killed her. I made the decision to keep her comfortable, but nothing more. I am an only child, so there was no one to object. Nevertheless, it was easier to act because I had her medical power of attorney. Friends and family stayed with her in the morning; I stayed every night. I held her while died early one morning. Even as my brain knew I had made the correct decision, my heart told me I had let her go too soon. Only knowing that she did not want machines provided solace.
I believe everyone should execute a medical power of attorney if there is someone that you would trust with your life. I think it is wrong to execute a medical power of attorney unless thought has been given to who will make decisions. Do not wait until you are in the hospital facing life and death decisions. You also need to consider what actions you want your agent to take in different situations and tell whoever holds the medical power of attorney your exact wishes. Do you want artifical nutrition, artificial hydration, a respirator, heroic mesasures to keep your hear going even though some procedures might break ribs? Talk to someone who has used a medical power of attorney. Find out what they faced. Above all, discuss these issues with those around you.
When my maternal grandmother came to live with us many years later, I knew she needed legal documents if I was to make decisions for her. She met with an attorney and had the necessary documents executed. I was designated as her agent in her medical power of attorney. Over the next seven years she lived with us, I would use that medical power of attorney several times including her final illness. In Texas, a medical power of attorney is only effective if the person who executed it is unable to make their own decisions. My grandmother ws competent, if stubborn, most of the time. However, she had several procedures that involved sedation or mild anesthesia. At those times, I took over the decision-making.
At age 96, she had major surgery from which she never recovered. After the surgery, she never really regained consciousness, so I made her choices as to treatment. I acted under the medical power of attorney. All seven of her children were able to visit her before she died. One aunt strongly objected to some of my decisions, but all she did was tell me of her disagreement. She could have done much more. Any legal document can be challenged including living wills and medical powers of attorney. While the courts usually follow the wishes of the person who executed the documents, court disputes can delay end of life decisions. The best way to avoid courtroom showdowns is to make sure your end of life decisions are known to all your immediate family and that these choices are clearly spelled out in the proper documents.
My mother had Parkinson's disease (PD), and after sixteen years PD killed her. I made the decision to keep her comfortable, but nothing more. I am an only child, so there was no one to object. Nevertheless, it was easier to act because I had her medical power of attorney. Friends and family stayed with her in the morning; I stayed every night. I held her while died early one morning. Even as my brain knew I had made the correct decision, my heart told me I had let her go too soon. Only knowing that she did not want machines provided solace.
I believe everyone should execute a medical power of attorney if there is someone that you would trust with your life. I think it is wrong to execute a medical power of attorney unless thought has been given to who will make decisions. Do not wait until you are in the hospital facing life and death decisions. You also need to consider what actions you want your agent to take in different situations and tell whoever holds the medical power of attorney your exact wishes. Do you want artifical nutrition, artificial hydration, a respirator, heroic mesasures to keep your hear going even though some procedures might break ribs? Talk to someone who has used a medical power of attorney. Find out what they faced. Above all, discuss these issues with those around you.
Tuesday, January 1, 2008
Ethics of Dying: Why me?
I give talks on various topics. One is the Ethics of Dying. One reason I was originally asked to speak on this topic is that I have made end of life decisions for both my grandmothers and my mother. I was with each of them when they died. Intellectually, I can tell you that I have absolutely no problems with the decisions I made in each case. Emotionally, these decisions still have the power to make me second-guess what I did. This is true, even though, I knew the wishes of each of my loved ones.
My maternal grandmother had seven children, but she chose me to make her end of life decisions. I think she understood that her children would never agree and that would create ill feelings. As the oldest grandchild, I knew the dynamics of the family and believe she made the correct choice. One of my aunts did not agree with my choices, but she knew I followed her mother's wishes and did not object. She would have opted for keeping her mother alive by any means as long as possible.
That is my message today. You must communicate with your loved ones. If someone is legally empowered to make these decisions for you, they must know your wishes. If you are to make these decisions for someone else, ask them what they want. This does not mean a simple: "let me die." Modern science can provide a host of options as death nears. Some involve the use of machinery to keep you alive. Do you want to be on a respirator? Think about that now while you are healthy and tell your loved ones. Better yet, put it in writing. A living will is one way to communicate your wishes.
The biggest decisions involve food and water or as I prefer to say: artificial nutrition and artificial hydration. This is a highly personal decision that I believe only the individual can make. I do know that deprived of artificial nutrition and artificial hydration, the body stops fighting and chemicals are released that ease the end. So if I am dying, I do not want artificial hydration or artifical nutrition. How can you expect someone to make these decisions if they have not discussed it with you?
Do you want hospice care? Deciding to use hospice, usually means ending the fight to stay alive. Comfort is the primary goal. Again, something to think about and discuss.
I have seen the decision to administer artificial nutrition and artificial made both ways. I have made it both ways for my loved ones depending on their wishes and the circumstances. I have second guessed myself either way, even though I know I honored their wishes. For this reason. I urge everyone to communicate their end of life desires.
I believe the best way to communicate is by executing the proper legal documents as designated by your state. Most hospitals can supply forms for this and you can always seek an attorney's advice. Other organizations such memorial and burial societies ( http://www.funerals.org) can provide assistance. Just realize that some of these documents are specific to each state. Use those designed for where you live. If you later move, they will be honored, but it is always better to execute those specific to your home state. If nothing else, put your wishes in writing in your own words.
My maternal grandmother had seven children, but she chose me to make her end of life decisions. I think she understood that her children would never agree and that would create ill feelings. As the oldest grandchild, I knew the dynamics of the family and believe she made the correct choice. One of my aunts did not agree with my choices, but she knew I followed her mother's wishes and did not object. She would have opted for keeping her mother alive by any means as long as possible.
That is my message today. You must communicate with your loved ones. If someone is legally empowered to make these decisions for you, they must know your wishes. If you are to make these decisions for someone else, ask them what they want. This does not mean a simple: "let me die." Modern science can provide a host of options as death nears. Some involve the use of machinery to keep you alive. Do you want to be on a respirator? Think about that now while you are healthy and tell your loved ones. Better yet, put it in writing. A living will is one way to communicate your wishes.
The biggest decisions involve food and water or as I prefer to say: artificial nutrition and artificial hydration. This is a highly personal decision that I believe only the individual can make. I do know that deprived of artificial nutrition and artificial hydration, the body stops fighting and chemicals are released that ease the end. So if I am dying, I do not want artificial hydration or artifical nutrition. How can you expect someone to make these decisions if they have not discussed it with you?
Do you want hospice care? Deciding to use hospice, usually means ending the fight to stay alive. Comfort is the primary goal. Again, something to think about and discuss.
I have seen the decision to administer artificial nutrition and artificial made both ways. I have made it both ways for my loved ones depending on their wishes and the circumstances. I have second guessed myself either way, even though I know I honored their wishes. For this reason. I urge everyone to communicate their end of life desires.
I believe the best way to communicate is by executing the proper legal documents as designated by your state. Most hospitals can supply forms for this and you can always seek an attorney's advice. Other organizations such memorial and burial societies ( http://www.funerals.org) can provide assistance. Just realize that some of these documents are specific to each state. Use those designed for where you live. If you later move, they will be honored, but it is always better to execute those specific to your home state. If nothing else, put your wishes in writing in your own words.
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