Advanced Directives

The timing of today's post could not be better. I attended a lecture "Legal Issues Affecting a Terminally Ill Patient" presented by Dr. Cowan who is also a lawyer. It was hosted by the Law-Medicine Center of the Case Western Reserve University Law School. The bulk of the presentation discussed advanced directives.

A bit of background on advanced directives and durable power of attorney for health care. The 1991 Patient Self Determination Act (federal law) is where advanced directives got their start. They are legal documents designed to allow a lay person to plainly express their wishes for what they would medically want done or not done for them in the event that they are incapacitated and can't make that decision for themselves. The form is available on line or through many health care providers. The patient must sign the form in front of witnesses and directions are provided. The durable power of attorney for health care is a document that designates a person to make decisions for you if incapacitated. It is also widely available.

The Patient Self Determination Act also requires any providers that participate in the medicare and medicaid programs to ask the patient if they have an advanced directive. If they do not, they are to be offered a form and assistance/education to complete one. It is in the family, patient,and health care providers' interest to have completed one. Lack of advanced directives can result in family turmoil in times of crisis and difficulty for physicians in providing appropriate care. Certainly the most recent famous case involving turmoil with an advanced directive is Terry Sciavo (http://content.nejm.org/cgi/content/full/352/16/1630). Dr. Quill discussed the concept of "substituted judgement" and asks us to listen to the patient's voice as expressed through the family and close friends. "Substituted judgement" is when a person, usually the next of kin is called upon to make a health care decision when the patient is unable to make it. It is assumed that this person knows the wishes of the patient. It could be a close friend if there is no family.

Dr. Quill also tells us that we need to continue to educate the public and some health care providers that dying in a natural way without artificial nutrition and hydration is humane and more comfortable than with intravenous fluids or tube feedings. I will discuss the dying process in a later post.

Next post: Mrs. C and advanced directives