Tuesday, April 07, 2009

Healthcare Decisions: Advance Directives, Living Wills, and Healthcare Powers of Attorney

"Why ask about Advance Directives?"

When a patient is admitted to a hospital for surgery or treatment they are asked many, many questions about their past medical history and even their social history. But it can be alarming and confusing when among those initial questions, the patient is asked, "Do you have an advance directive for healthcare? In other words, a living will or health care power of attorney?"

These questions aren't meant to make people nervous, but some patients who know what an advanced directive is widen their eyes at such questions, wondering perhaps, "Why are they asking me this right away, am I dying or (do they think the operation will kill me)?"

Other patients want to explain that they have "a will" in their lawyer's office and "no way are they giving anyone power of attorney." In that case, further explanation is required to help the patient understand that the hospital is only concerned about "living wills" that document a patient's end-of-life preferences for care and intervention. And the health-care power of attorney doesn't give a relative carte blanche to spend the patient's money; it is merely an official appointment of one or more individuals to speak for the patient about their health-care matters if they become incapacitated.

"Everyone has the right to make their own health care decisions . . ."

Everyone does have the right to make their own health care decisions, but unfortunately, illness or injury sometimes takes away one's ability to communicate those wishes. In the event of dementia, coma, stroke or traumatic brain injury, a written record of a person's wishes for care in the event of impending death are respected. (Some patients want no heroic measures, others want everything possible done to keep them alive, many choose "only comfort measures.") If no "power of attorney for healthcare" has been appointed by the patient, the legal next-of-kin assumes this role . . . and that may not always reflect what the patient would want!

The Government Requires Hospitals to Ask . . .

Nearly every healthcare facility in the nation depends upon some reimbursement from Medicare to pay for patients' medical expenses. As a government entity, Medicare makes rules and regulations that hospitals and nursing homes must follow before Medicare will pay those bills. The Federal Patient Self-Determination Act is one of those requirements. In regard to advance directives, all Medicare-participating healthcare facilities are required to:

  1. Provide information about health care decision-making rights.
  2. Ask all patients if they have an advance directive.
  3. Educate their staff and community about advance directives.
  4. Not discriminate against patients based on an advance directive status.
When patients have advance directives, they are asked to bring a copy to the hospital so that a copy can be placed in their permanent medical record.

A few words about heroic measures . . . let it be your own choice

Technology has blessed us with many innovations for prolonging life. Some life-extending procedures and equipment (like feeding tubes and tracheotomies) may be used long-term without compromising quality of life. Again, each individual has the right to decide what degree of artificial measures they are comfortable with. There are even many patients living at home or in nursing facilities who require artificial respirators (ventilators) in order to breathe. Other individuals may not want any artificial means, whatsoever, to prolong their life.

A few years ago the issue of life-sustaining measures claimed center stage for a time. Terry Schiavo, a young woman who sustained a profound brain injury, was receiving nutrition and hydration via a feeding tube. Years after starting tube feedings, Terry's husband and parents bitterly disagreed on whether this long-term treatment was in keeping with Terry's wishes. Ultimately, her husband's wishes to discontinue the feeding tube prevailed, and Terry died from dehydration two weeks later.

National Healthcare Decisions Day is April 16th

April 16, 2009 is the second annual National Health Care Decisions Day. This initiative aims to encourage patients to express their wishes about healthcare and end-of-life decisions (and to reinforce the obligation of healthcare providers and facilities to respect those wishes, whatever they may be.) A number of free resources are available on the NHHD website to provide more information and assistance in creating an advance directive. There are many sponsors supporting this endeavor, and you are likely to be informed about events in your community in support of this campaign through your local media.

My Living Will . . .

Yes, I have one. I'm not (that) old, and I don't have a terminal illness, or even a chronic one that I'm aware of, but I made my Living Will a long time ago while working as an ER nurse . . . I guess I was just exposed to enough drama early in my nursing career to realize the uncertainty of life. And I wanted my family to be guilt-free by knowing they would make healthcare choices that I emphatically approved. My Living Will is very similar to the ones provided free from the Christian Life Resources website.

. . .


Anonymous said...

Thank you for your post of April 7. Advance Health Directives are a fundamental right, yet too often ignored. Please check out my post of September 8. 2008 at clinicalbioethics.com

All the best, Bernard Freedman

Carolyn Cooper, MPH, RN said...

Thanks so much for the link to your post . . . I did read about Dr. DeBakey's experience. It's disheartening that the systems in place (e.g. the ethics committee) didn't act as a patient advocate first and foremost to respect his documented wishes.