Nearly 80% of Americans die in a hospital or other care facility.
The doctors who work in these facilities are generally charged with
preserving a patient's life through whatever means are available.
This may or may not be what you would like in the way of treatment.
Healthcare directives give you the opportunity to write out your
wishes in advance and ensure some legal respect for them if ever you
are unable to speak for yourself.
What is a living will?A living will, known in most states
as a Directive to Physicians or Healthcare Directive, sets out your
wishes about what extended medical treatment should be withheld or
provided if you become unable to communicate those wishes. The
directive creates a contract with the attending doctor. Once the
doctor receives a properly signed and witnessed directive, he or she
is under a duty either to honor its instructions or to make sure you
are transferred to the care of another doctor who will.
Many people mistakenly believe that healthcare directives are
used only to instruct doctors to withhold life prolonging
treatments. In fact, some people want to reinforce that they would
like to receive all medical treatment that is available -- and a
healthcare directive is the proper place to say so.
What is a durable power of attorney for healthcare? Doesn't that
do the same thing as a living will?
A durable power of attorney for healthcare -- called a healthcare
proxy in some states -- gives another person authority to make
medical decisions for you if you are unable to make them for
yourself. Unlike a healthcare directive, this document doesn't
necessarily state what type of treatment you want to receive. You
can leave those decisions to your proxy if you feel comfortable
doing so. Ideally, however, the two documents will work together.
For example, your healthcare directive may contain a clause
appointing a proxy (sometimes called an attorney-in-fact, agent or
representative) to be certain your wishes are carried out as you've
directed. Or you may create two separate documents, a directive
explaining the treatment you wish to receive and a durable power of
attorney appointing someone to oversee your directive.
If you do not know anyone you trust to name as your healthcare
proxy, it is still important to complete and finalize a healthcare
directive recording your wishes. That way, your doctors will still
be obligated to give you the medical care you want.
What happens if I don't have any healthcare documents?If
you have not completed either a formal document such as a healthcare
directive to express your wishes, or a durable power of attorney to
appoint someone to make healthcare decisions on your behalf, the
doctors who attend you will use their own discretion in deciding
what kind of medical care you will receive.
When a question arises about whether surgery or some other
serious procedure is authorized, doctors may turn for consent to a
close relative -- spouse, parent or adult child. Friends and
unmarried partners, although they may be most familiar with your
wishes for your medical treatment, are rarely consulted, or are
purposefully left out of the decision-making process.
Problems arise where partners and family members disagree about
what treatment is proper. In the most complicated scenarios, these
battles over medical care wind up in court, where a judge, who
usually has little medical knowledge and no familiarity with you, is
called upon to decide the future of your treatment. Such legal
battles -- which are costly, time-consuming and usually painful to
those involved -- are unnecessary if you have the care and foresight
to use a formal document to express your wishes for your
When does my healthcare directive take effect?
Your healthcare directive becomes effective when three things
- you are diagnosed to be close to death from a terminal
condition or to be permanently comatose
- you cannot communicate your own wishes for your medical care
-- orally, in writing or through gestures, and
- the medical personnel attending you are notified of your
written directions for your medical care.
In most instances, you can ensure that your directive becomes
part of your medical record when you are admitted to a hospital or
other care facility. But to ensure that your wishes will be followed
if your need for care arises unexpectedly or while you are out of
your home state or country, it is best to give copies of your
completed documents to several people, including your regular
physician, your healthcare proxy and another trusted friend.
Who should I choose as a healthcare proxy?
The person you name as your healthcare proxy should be someone
you trust -- and someone with whom you feel confident discussing
your wishes. While your proxy need not agree with your wishes for
your medical care, you should believe that he or she respects your
right to get the kind of medical care you want.
The person you appoint to oversee your healthcare wishes could be
a spouse or partner, relative or close friend. Keep in mind that
your proxy may have to fight to assert your wishes in the face of a
stubborn medical establishment -- and against the wishes of family
members who may be driven by their own beliefs and interests, rather
than yours. If you foresee the possibility of a conflict in
enforcing your wishes, be sure to choose a proxy who is
strong-willed and assertive.
While you need not name someone who lives in the same state as
you do, proximity should be one factor you consider. The reality is
that the person you name may be called upon to spend weeks or months
near your bedside, making sure medical personnel abide by your
wishes for your healthcare.
You should not choose your doctor, or an employee of a hospital
or nursing home where you are receiving treatment. In fact, the laws
in many states prevent you from naming such a person. In a few
instances, this legal constraint may frustrate your wishes. For
example, you may wish to name your spouse or partner as your
representative, but if he or she also works as a hospital employee,
that alone may bar you from naming that person. If the law in your
state bans your first choice, you will have to name another person
What if I really don't know anyone I trust to supervise my
medical care if I become unable to on my own?
Naming a healthcare proxy is an optional part of completing your
healthcare directive. It is better not to name anyone than to name
someone who is not comfortable with the directions you leave -- or
who is not likely to assert your wishes strongly.
Medical personnel are still technically bound to follow your
written wishes for your healthcare -- or to find someone who will
care for you in the way you have directed. It is far better to put
your wishes for final healthcare in writing than to let the lack of
a representative stand in the way.
What types of medical care should I consider when completing my
healthcare documents?Technological advances mean that currently
unfathomable procedures and treatments will become available and
treatments that are now common will become obsolete. Also, the
treatments that are available vary drastically with region,
depending on the sophistication and funding levels of local medical
While putting together your healthcare directive, the best that
you can do is to become familiar with the kinds of medical
procedures that are most commonly administered to patients who are
terminally ill or permanently comatose. Those most commonly
- blood and blood products
- cardio-pulmonary resuscitation (CPR)
- diagnostic tests
- respirators, and
Can I provide instructions in my healthcare documents about
whether I want pain medication, or food and water?The laws of
most states assume that people want relief from pain and discomfort
and specifically exclude pain-relieving procedures from definitions
of life-prolonging treatments that may be withheld. Some states also
exclude food and water (commonly called nutrition and hydration)
from their definitions of life-prolonging treatments. But there is
some controversy about whether providing food and water, or drugs to
make a person comfortable, will also have the effect of prolonging
life. Some people are so adamant about not having their lives
prolonged when they are comatose or likely to die soon that they
choose to direct that all food, water and pain relief be withheld,
even if the doctor thinks those procedures are necessary. Under the
U.S. Constitution, you are allowed to leave these instructions even
if your state's law is restrictive; your doctors are legally bound
to follow your wishes.
On the other hand, some people feel concerned about how much pain
or discomfort they may experience during a final illness; these
people are willing to have their lives prolonged rather than face
the possibility that discomfort or pain would go untreated.
Obviously, it's a very personal choice; you're free to leave the
instructions that feel right for you.
How can I be sure my healthcare documents are legal?
There are a few requirements you must meet to make a valid
healthcare directive. In most states, you must be 18 years old,
though a few states allow parents to make healthcare directives for
their minor children. All states require that the person making a
healthcare directive be able to understand what the document means,
what it contains and how it works.
Also, every state requires that you sign your documents. If you
are physically unable to sign them yourself, you can direct another
person to sign them for you.
You must sign your documents, or have them signed for you, in the
presence of witnesses or a notary public -- sometimes both,
depending on your state's law. The purpose of this additional
formality is so that there is at least one other person who can
confirm that you were of sound mind and of legal age when you made
Where can I get a healthcare directive -- and who can help
complete it?Many people first realize the need for healthcare
documents when they're being admitted to a hospital. But hospital
admission time is probably not the best time to learn about your
options in directing healthcare or to reflect on your wishes. It's
better to get information and complete your documents when you're
under less stress.
Local senior centers may be good resources for help. Many of them
have trained healthcare staff on hand who will be willing to discuss
your healthcare options. The patient representative at a local
hospital may also be a good person to contact for help. And if you
have a regular physician, you can discuss your concerns with him or
Local special interest groups and clinics may provide help in
obtaining and filling out healthcare directives -- particularly
organizations set up to meet the needs of the severely ill such as
AIDS groups or cancer organizations. Check your telephone book for a
local listing -- or call one of the group's hotlines for more
information or a possible referral.
There are also a number of seminars offered to help people with
their healthcare documents. Beware of groups that offer such
seminars for a hefty fee, however. Hospitals and senior centers
often provide them free of charge.