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David Fisher, MD, MPH: The document that is more important than a living will

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Sunday, August 2, 2009

The document that is more important than a living will

Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn't it? What they don't mention is that these documents are already available for free, and you don't even need a lawyer in order to complete them.

The most important advance care planning document, and the one everyone should have regardless of age, is the Durable Power of Attorney for Health Care (DPAHC). This is the document that names someone to make decisions on your behalf if you ever are in a situation where you cannot express your own wishes. Most people, when asked, know immediately which person they would trust in that situation. It is important to name this person in writing, because state laws vary, and without the proper paperwork, it is possible that someone other than the person you want would have authority over your health care if you could not express yourself. For example, I recently admitted a patient to the nursing home whose granddaughter cared for her at home for many years. The patient had become very ill and could no longer express her own wishes, but she had expressed her wishes to her granddaughter during previous conversations. Unfortunately, they never completed a Power of Attorney for Health Care. The patient's estranged son arrived on the scene and began to demand a course of management that went against the patient's wishes. In spite of the granddaughter's protests, the nursing home was obligated by law to follow the wishes of the son, because Illinois law gives adult children priority over grandchildren for decision making authority when there are no papers. Such a scenario could have been avoided had my patient completed her DPAHC and named her granddaughter.

If you live in my home state of Illinois, the official DPAHC form can be downloaded for free here. Most other states make their forms available as well, and you can find them by doing a web search for "(your_state) power of attorney for health care". Once you have the form, you simply need to identify your person of choice, fill in their name and contact information, and sign the form. In Illinois, you will need one witness to also sign the form. You don't need an attorney, and you don't need a notary public. You don't even have to have your decision-maker sign the form. I still recommend this, because the person you choose needs to know of the important responsibility you have given them.

There are other sections of the form that allow you to express specific wishes, such as a procedure you definitely would or would not want, or specific organs you would want donated. It is not necessary to fill out these portions, though it may be helpful for your decision making agent to know this information. However, he or she is not obligated to follow what is written there. That is why the best approach is to have a conversation about your wishes with the person you trust. This will give them the opportunity to ask you questions and to see and hear directly from you what is most important about your individual wishes.

Another advance directive is the living will, which gives you the opportunity to state that you would not want to be kept alive artificially if you contracted a terminal illness and doctors believed you had no hope of recovery. This document also gives you the opportunity to define specific courses of action. I have run into problems with this document and I do not find it as useful as the Power of Attorney. One problem with the document is that you can fill it out and never tell anyone. If you were to become very ill, unless someone has a copy of your living will, it may never be followed. It is much more powerful to have a living, breathing advocate (your Power of Attorney for Health Care) who understands your wishes and can help guide your doctor through the myriad of possible scenarios that can occur if and when you become ill. I do not have a living will, but I do have a Power of Attorney for Health Care. I know the President told us recently that he and his wife have a living will, and that it is important to have one, but I think it is far more important to have your Power of Attorney for Health Care.

Once you have filled out your advance directive, keep a copy for yourself, give a copy to your decision maker, and give a copy to your doctor. There is a movement to standardize these documents and make them more accessible across health care systems. In Chicago, a large coalition called Someone to Trust is working to accomplish this goal for the first time in a large, multiethnic city. Google Health recently added a section where you can scan and store these documents so you can authorize your agent or doctor to access them in time of need. If you feel comfortable using this service it is a good resource.

For more information on Advance Care Planning, visit the website for National Health Care Decisions Day.

1 comment:

hospicephysician said...

I agree 100%! I tell my patients and families over and over that choosing a health care proxy is very important and should not be taken lightly. It really should be someone that knows you well and has had an open discussion about your wishes. As palliative care physicians we know that every scenario cannot be accounted for in the advanced directive, but a trusted Health Care Proxy can help the physician understand what was important to that patient, what quality of life means to that person etc. Also, guilt is a HUGE issue if the health care proxy was named casually, never discussed end of life issues with the patient and now faces difficult decisions. Also, patients put too much confidence in their physicians. They have a false belief that the physician will assess the situation and make the best decision for them during these difficult times. TRUST ME, physicians don't want to touch this with a 10 foot pole and I've heard them say over and over that they don't want to make decisions about life and death for patients. Anyway, I could go on and on, great post.