ARTICLES / General /
An Advance Directive/
Other ArticlesBy
Marilyn Mitchell
An Advance Directive is a document that is
meant to give health care professionals an
understanding of your medical preferences if you
cannot speak for yourself. It tells them
‘in advance’ of needing treatment what you would
most likely want to have happen. Many
people may know them as "Living Wills," but a
Living Will may only address your treatment
options and not allow you to appoint someone to
speak for you if you are unable to communicate.
Another document that is useful is called a
"Durable Power of Attorney for Health Care" and
it allows a person to designate someone to speak
for them if they are unable to speak for
themselves. The person is sometimes called
a ‘surrogate’ or a ‘proxy’ decision maker.
Many Advance Directive documents combine the
'living will' portion with a portion that is a
Durable Power of Attorney for Health Care.
Here is a link to the VA's Advance Directive,
which is a fine version of the combined
document:
http://www4.va.gov/vaforms/medical/pdf/vha-10-0137-fill.pdf
Only about 20 percent of Americans have an
Advance Directive, but I believe everyone could use
one. Some of the most famous bioethics cases
arose from situations involving young women that had
no Advance Directive (Karen Ann Quinlan, Nancy
Cruzan, Terry Schiavo). These women were young
and had no intention of finding themselves in
persistent vegetative states. Keep in mind,
it's not just a persistent vegetative state that may
make speaking for yourself impossible. There
are a whole host of reasons why someone might be
receiving medical treatment and they would be unable
to speak, including many surgical situations.
Advance Directives have two purposes. One is to
let health professionals know what kinds of
treatments you would find acceptable. Many
people find the thought of being placed on a
mechanical ventilator for long-term existence
unacceptable. Others may find the idea of
living with advanced dementia, dependent on a
surgically placed feeding tube, something they would
like to prevent. Some want every possible
treatment to be attempted, regardless of the
outcome. Often people decide whether they
would like a medical team to attempt resuscitation
(CPR) or to allow for a natural death.
The other critically important thing an Advance
Directive usually does is to appoint someone
specific to make medical decisions on your behalf if
you are unable to make them. It's vital to
speak with that person about your values and
expectations since it is a serious responsibility. All too often in clinical settings, health
professionals ask the person most likely to assist
with decision-making what they think the person
requiring treatment might want and they admit they
have no idea. The person named in the Advance
Directive is meant to make decisions that are
closest to what that person would want if they could
speak for themselves. It's not acceptable for
people to direct the health care team to take
actions based on their own values since those values
may differ from those of the person in need.
Just as unacceptable would be for the health care
team to decide what is best without knowing what the
ill person would want. This is the area where
there seems to be a general lack of understanding.
We are not deciding what we think is best for the
person; we are attempting to imagine what that
person really would want done. What is “best”
is often very subjective in medical situations.
