17 Advance Directives: When Are They Necessary?
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Dynamic Chiropractic – May 5, 1997, Vol. 15, Issue 10

Advance Directives: When Are They Necessary?

By Barbara Zapotocky-Cook, DC
If you were in a motor vehicle accident that put you into a coma, who would make health care decisions for you? Value check! Do you want to live as long as possible, regardless of the quality of life that you'd experience, or do you want to preserve a "reasonably good" quality of life, even though it means you may not live as long? If you chose to be kept alive indefinitely, how long would a reasonable length of time be? Also, if you were so incapacitated, who would you prefer to make these decisions for you? And does this person know what your wishes are?

Advance directives are oral or written statements made by individuals that state personal wishes regarding specific medical circumstances.

These statements determine the preferences of the individual regarding types of medical care the person wishes to accept or reject, and also determine who should make the health care decisions for the individual. The purpose of advance directives is to eliminate the possibility of uncertainty, misinterpretation or confusion at the time of the event.1 The most commonly used instruments are:

Living will: a declaration that allows a person to direct that life-sustaining medical therapies be withdrawn or withheld in the future if the person is terminally ill and no longer able to make decisions.

Durable power of attorney: gives someone you designate the legal authority to make decisions on your behalf. A regular "power of attorney" is only in effect if the person is competent. The "durable" part designates that someone may act for you should you become incompetent.

Durable power of attorney for health care: delegates authority to another person to make decisions only about health care.

Proxy: the person selected to serve as agent of the durable power of attorney. (Neither the living will nor the durable power of attorney for health care requires the services of an attorney).

Aided by the highly publicized case of Nancy Cruzan, the Patient Self-Determination Act (PSDA) was put into effect in late 1991. Nancy Cruzan was a woman in her twenties who had been injured in an automobile accident and had been kept alive in a persistently vegetative state for six years. The PSDA requires that all hospitals, nursing homes, home health agencies, hospices and health maintenance organizations that receive Medicare or Medicaid funding provide patients with a written statement of their rights under state law to accept or refuse treatment. The act also requires these institutions to ask patients if they have signed advanced directives.

If the patient has completed these directives, the facility is supposed to gain a copy of the document and place it in the patient's file. If the patient has not signed a directive, the facility is supposed to supply the patient with information and forms discussing living wills and durable powers of attorney. The idea behind the PSDA is to encourage people to make their choices and arrangements before they become patients. As you might guess, merely providing people with information does not necessarily promote action.

There are a number of considerations that affect a person's choice when considering writing advance directives. A 1991 study conducted at the Sanders-Brown Center on Aging at the University of Kentucky found that older adults with families prefer to use informal arrangements based on conversations with spouses or adult children regarding personal preferences in end-of-life decision making. Many had an aversion to actually writing out formal arrangements and depended on the family to know what was best. But this begs the question: Do family members know the preferences of the older adult?

In contrast, older adults with no family were very interested in using advance directive instruments and appointing friends or physicians as proxies to make their health care decisions for them.2 This initiative was taken as a result of having to make their own health care decisions throughout life.

Advance directives are a choice for people who wish to exercise their autonomy as long as possible. They provide clarity of direction for the people chosen to act as surrogates and remove the burden of guilt. Following are two organizations that have information and packets on advance directives. States differ in their requirements, and the organization Choice in Dying offers specific state packets.

To find out more contact:

Choice in Dying
200 Varick St.
New York, N.Y. 10014
(212) 366-5540
Fax: (212)366-5337
E-mail:

American Association of Retired Persons
601 E. St. N.W.
Washington, DC. 20049
Publication # PF5302(795) D15803

Barbara Zapotocky, DC, MA
Honolulu, Hawaii

References

  1. Doukas DJ & Reichel W. Planning for uncertainty: A guide to living wills and other advance directives for health care. 1993. Baltimore: The Johns Hopkins Press.
  2. High DM. Who will make health care decisions for me when I can't? Journal of Aging and Health, 2(3). 1990. New York: Sage. p. 291-309.

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