Background

• There was a time when the physician made all of the medical decisions for her patients. Patients currently demand autonomy when making decisions that affect their health and welfare--a desire that the courts have termed "informed consent." Most people want to make their own decisions concerning end of life medical care, and they want to base those decisions on complete, accurate and up-to-date information. There are two different, but similar, advance directives. One is called a living will and the other is called the healthcare power of attorney.
  
  

Living Will

• The purpose of a living will is to convey a person's desires for life-saving or life-sustaining medical treatments, and the conditions under which the treatments will or will not be accepted. The document is called a living will because it takes effect when the person named in the will is still alive. A set of laws that many states offer essentially boil down to a narrowly focused form of a living will are called Do Not Resuscitate laws. These laws allow patients to refuse cardiopulmonary resuscitation if their heart stops. These laws also protect healthcare providers when following the wishes of the patient.
  
  

Healthcare Power of Attorney

• Also known as a durable power of attorney, a healthcare power of attorney is a document that allows someone else (a spouse, close friend or significant other) to make medical decisions for the person named in the document. It is used for all forms of medical treatment--not just life-saving or life-sustaining treatments. The person does not have to be terminally ill or in a vegetative state for the healthcare power of attorney to be in effect. But the healthcare power of attorney does not deal with life-saving or life-sustaining treatments. So it is a good idea to have both documents ready to go in the event of a health crisis. Consult your state's laws (termed Natural Death Acts) for further instructions.
  
  

Advance Directive Limitations

• An advance directive cannot be complied with if it is either not known about, or if there is only one copy of it that is stashed away in a safe or a safe deposit box somewhere. Hospitals may not place a copy of an advance directive in the person's chart, or the care-providing doctor may not be aware of its presence in the person's chart. Uncertainties, or terms and phrases that can be interpreted in many ways, may also exist in the executed advance directive. A person's desires may also change after an advance directive is finished.
  
  It is true that some doctors do not follow an advance directive even though they are aware of the contents of the document. This happens because of pressure from the family, fear of being sued, and because of an unclear directive. These findings are supported by one of the largest clinical studies on the subject called the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment, or the Support study.
  
  

Needed Improvements

• There are many improvements that can be made to make an advance directive more effective in its purpose. Some suggestions include providing a values history describing the person's religious, spiritual and moral beliefs; providing information about general treatment goals; and stating whether or nor artificial hydration and feedings are desired.
  
  Doctors are typically unprepared to deal with the death of their patients, and the American Medical Association has involved itself in physician education to this end. Extreme proposals to get doctors to follow the desires of their patients include fines, professional sanctions, legal actions to recover damages, among others. Some states already provide laws requiring doctors to follow advance directives, but they are rarely, if ever, enforced.