Medical Alerts Systems and advanced directives do not usually coexist well together. That said, for those in need, both are very important to have. We are sometimes asked to make a note in our subscribers medical history that an advanced directive has been prepared OR that the subscribers wishes are that they are not to be resuscitated OR that no extraordinary measures are to be taken to save their lives. When this comes up, we politely tell them that we cannot make that part of their medical notes because we ultimately have no control as to whether the responding authorities will follow those directions. However, we do think the topic of advanced directives should be addressed.
An advanced directive is the fancy term for a living will. It most often, is in the form of a written document that clearly defines what you would want done for you, in a medical setting, if you were unable to communicate. These documents mostly pertain to end of life decisions but they are not limited just to end of life issues. The concept of this document is to give directions to your loved ones and your medical team, after careful prior (hence the term “advanced”) consideration … as to the medical procedures or the withholding of medical procedures that you would want carried out if you were too injured or ill to give those directions on your own.
The purpose(s) of a living will or advanced directive may vary from individual to individual. One reason to have an advanced directive is to remove the burden of such decisions from your families’ shoulders. By communicating, in advance, what your wishes are regarding end of life issues, you can reduce the stress, guilt and upset that may be caused if your loved ones have to guess what you might want. Advanced directives also help reduce the likelihood of intra family squabbles. For instance, your husband may want to keep you alive by any and all means available … while your kids may think it more appropriate to keep your pain to a minimum but doing nothing more to prolong your life other than pain relief. By putting a living will in place … all of the people in your life that love you … have been made aware of your wishes in advance. Aside from the family issues that this document addresses … it also gives direction to your medical team as to what you want. An advanced directive allows the treating doctors to take actions or withhold treatments according to your specific wishes. In most cases the underlying presumption is that your death is inevitable and coming sooner rather than later and the likelihood of a meaningful recovery is almost non existent. Below you will find some of the common medical issues that advanced directives address.
- Do you want pain medications administered to keep you free of pain, even if those medications might hasten your death?
- Do you want to be kept hydrated with intravenous fluids even if these fluids will prolong your life knowing that your death is imminent?
- Do you want to have a ventilation tube to keep you breathing if you cannot breath on your own?
- Do you want to be fed via a gastric tube that will supply you with nutrition?
- Should you acquire an infection, do you want to have antibiotics administered?
- Should your kidneys fail, do you want to be put on dialysis?
- If you stop breathing, do you want to be resuscitated?
- If your heart stops beating, do you want the medical team to try to get your heart beating again?
- Have you appointed, in writing, some person to make any other medical decisions for you that have not been addresses in your advanced directive? The document that handles this particular issue is called a Durable Power of Attorney for health care decisions. With this document in place, the person acting as your Durable Power of Attorney will now have the legal authority to make health care choices on your behalf.
Even if an advanced directive is prepared and in effect, there are still some issues that can be problematic. These issues are being put in the form of questions but they are questions that are very difficult to answer … hence the ethical dilemma.
- What a conflict occurs between the power of attorney and a family member about treatment or withholding of treatment?
- Simply because an advanced directive has been created, does the family member in question get ignored?
- What if the medical team decides to “put on hold” the advanced directive until there is unanimous consent amongst the members of the family?
- What if there is an ethical conflict between the medical team and the wishes of the patient based on religious values of the medical team?
- What if the hospital is run by a religious institution that holds the sanctity of life above all else?
- What role does the religious values of the hospital play relative to your clearly stated wishes?
It varies from state to state, but in theory the advanced directive should trump all other considerations. It is a legal document that is recognized in every state. This document along with a duly appointed and legally competent durable power of attorney should be the controlling forces during this very stressful time. However, sometimes it does not quite work out that way. Consider implementing some of the ideas listed below that might give added strength to the document itself and the person who has been appointed as the Power of Attorney ((POA) for health care decisions.
- Call a family meeting when everybody is healthy and it seems like a conversation about end of life matters is simply academic. This is the time when this kind of conversation is much easier to have.
- At this meeting, clearly express your wishes regarding these issues and tell all concerned parties that your wishes have been documented in a living will.
- Make sure all concerned parties have copies of your living will.
- Tell all of the concerned parties who will be your legally appointed POA and this also has been put in writing.
- Appoint an alternate POA, in the event your first choice is either unable or unwilling to take on this job.
- Consider making a video of this meeting and/or a video of yourself speaking your wishes directly into the camera.
While there may be some discomfort surrounding these matters, but by putting the proper procedures in place now … you will probably avoid much confusion and upset later.
Advanced directives are designed to address a relatively thin slice of medical issues. For the most part, these documents are designed to address end of life matters only when the person involved is not capable of making these decisions. For those times when there is a terminally ill patient who is communicative and capable … that patient’ contemporaneous spoken wishes override any previous written directives. In other words the advanced directive does not matter if the patient in question is still capable of speaking for themselves … even if their present wishes contradict what they expressed in the written document. Furthermore, the POA has no authority in decision making provided the patient is communicative and considered legally capable. Another consideration is timing. Very often these documents are prepared years, if not decades before they may actually be needed. What one may want when they are forty five years old may be very different when they are eighty five years old. Like many things in life, we evolve in our thinking as we grow older. With regard to advanced directives, it is probably a good idea to review this document on an infrequent but regular schedule. This way, should changes need to be made …. They can be made prior to the time of need. The frequency for the review of living wills is obviously a very personal matter. That said, there are some life cycle events that should give reason for such review. Events, like the death of a spouse, family tumult, unavailability of the POA or change in health would be reasons to review an advance directive.
It has often been said that conversations about religion and politics should be kept amongst our inner circles. When it comes to end of life matters religious and spiritual beliefs inform our decisions about what should and should not be done for us as we approach death. With regard to living wills and ones religious beliefs and affiliation, it might be a good idea to consult with your priest, rabbi, pastor, imam or some other spiritual advisor during the time that your are preparing this advanced directive. It might also be a good time to make clear to your family how your spiritual beliefs helped shape your living will. In matters such as this, your clear verbal and written communication to those that you love will greatly reduce the chance of disquiet during a very stressful time. Below you will find, what seems to be the view of some religions on end of life matters.
- Both Orthodox Christians and Orthodox Jews seem to be very clear about their position. That position can probably best be stated that the sanctity of life trumps all else. According to these faiths, life is in God’s hands and it is not meant to be interfered with by us. These views would override the wishes of the person, their family members or doctors. Other factors such as likely outcome and finances do not matter in the eyes of religious orthodoxy.
- Many other religions like some Protestant faiths, Conservative Jews, Buddhists and some Islamic sects are more subtle in their position. With these religious affiliations there seems to be more room for choices regarding a end of life choices.
We are making no values judgments here as to whether one of the above is right or wrong. Our attempt is merely to shed light on the varying positions, different religions take on end of life matters.