There may come a time when you or a family member is seriously injured or very ill. In the midst of your shock and grief, you may be asked to make difficult decisions about medical care. You may be asked whether certain life support systems should be provided, not provided or stopped. While advances in medical technology have saved thousands of lives, sometimes the ability of this technology to prolong life raises more questions than it answers. Every competent adult has the right to accept or refuse any recommended medical treatment.
Whether it is you or your family member who is involved, it is usually more difficult to make decisions on complex issues when you are under stress. Because of this, it is important for you to learn about the levels and types of medical care available, and to discuss the kinds of treatment you would feel comfortable with before you or your family is asked to make these decisions. For example, if you or a loved one were in a coma and your doctor said there was very little chance for recovery, would you want—or would you want your loved one—to be kept on life support? These are questions to consider and discuss with your family and physician.
An advance directive is a document written before such a situation has occurred. This document can state a patient’s desires about treatment, or it can name someone else to make such decisions if the patient becomes unable to make decisions.
You are encouraged to read this information and ask your doctor any questions you may have. You may also want to speak with an attorney to make sure the decisions you have already made or plan to make can be legally followed by your doctors, nurses and other health care providers.
Why So Much Interest in Advance Directives?
Questions about medical care at the end of life are of great concern today, partly because of the growing ability of medical technology to prolong life and partly because of highly publicized legal cases involving unconscious or dying patients. The 1990 Patient Self-Determination Act is a federal law that says patients must be informed of their rights under state law to make decisions about their medical care, including the right to accept or refuse medical or surgical treatment and the right to have an advance directive. The advance directive document is a way for you to communicate what kinds of medical care and treatment you do or don’t want if you become unable to make these decisions for yourself.
According to Indiana law, “competent adults have the right to control the decisions relating to their own medical care, including the decision to have medical or surgical means or procedures intended to prolong their lives provided, withheld or withdrawn.”
Under Indiana law, a written advance directive can communicate a competent person’s wishes regarding health care, including life-prolonging treatment. The directive can designate a person who will have the role of making difficult health care decisions for you, if you become unable to state your wishes. A formal advance directive can be in the form of a living will, a life-prolonging procedures declaration, an appointment of a health care representative, or an appointment of a power-of-attorney for health care (Indiana Code IC 16-8-11). You have a right to make an advance directive if you want to, but you are not required to do so.
Psychiatric Advance Directive
Any person may make a psychiatric advance directive if he/she has legal capacity. This written document expresses your preferences and consent to treatment for a specific diagnosis. The directive sets forth the care and treatment of a mental illness during periods of incapacity. This directive requires certain items for the directive to be valid. Indiana Code 16-36-1.7 provides the requirements for this type of advance directive.
What Is a Living Will?
A living will is an advance directive that allows you to specify or limit the kinds of life-prolonging procedures you wish to receive if you become terminally ill and unable to make medical decisions.
A living will does not become effective until three conditions are met:
1. The patient has been diagnosed with an incurable injury, disease or illness.
2. A physician has certified in writing that the patient is in terminal condition—meaning that there can be no recovery, and death will occur within a short period of time.
3. That life-prolonging procedures would only prolong the dying process.
A living will is a voluntarily executed document put into writing and signed by the person making the declaration. If that person is unable to sign the document, he or she may ask another individual to sign it, but it must be done in the presence of the person whose name appears on the declaration. It must be dated and signed in the presence of at least two witnesses.
A witness may not be the individual signing on behalf of the person; a parent, spouse or child of the person; entitled to any part of the person’s estate; or directly and/or financially responsible for the person’s medical care.
A living will indicates the person’s desire to either withhold or withdraw life-prolonging procedures that would artificially prolong the dying process. Appropriate nutrition and hydration, medication to ease pain, and comfort care will be provided.
In the instance that the patient is pregnant, a living will is not valid.
A living will may be revoked at any time by a signed and dated revocation, physical cancellation such as destroying the living will, or by telling others that it is being revoked. If the living will is revoked, the physician must be told.
Steps in completing a living will:
Obtain the form appropriate for Indiana. A copy may be obtained by contacting a personal attorney, the Indiana Bar Association, the Society for the Right to Die/Concern for Dying or the American Association of Retired Persons.
The basic form may be modified or expanded to meet the specific needs or health care desires of an individual. Persons wishing to modify the form are encouraged to speak to an attorney.
Within a hospital environment, a patient should date and sign the living will and have it properly witnessed. Although it is not illegal to do so, health care workers providing care to the patient should not act as witnesses due to the possible conflict of interest.
A copy of the living will should be placed in the patient’s medical record upon admission, and the patient should distribute copies to his/her physician, attorney and close family members.
A copy of the living will should be presented each time the person is admitted to a hospital so that it may be entered into the medical chart for that particular admission.
Hospital personnel are encouraged not to try to answer any questions with legal implications. If questions arise, the patient is encouraged to contact his/her personal attorney. The hospital risk management department is also available for consultation.
What Is a Life-Prolonging Procedures Declaration?
A life-prolonging procedures declaration document is an advance directive that allows you to specify your wish to receive life-prolonging procedures that would extend life if you become terminally ill and unable to make medical decisions. This declaration must be signed and dated and witnessed by two people who are at least 18 years old and who know you well but are not related to you. These witnesses should not be your potential heirs or your health care providers, and they should not hold direct financial responsibility for your health care.
What Is a Health Care Representative?
A health care representative document is an advance directive that allows you to name someone else to make your health care decisions for you should you become unable to make health care decisions. You should tell this person of your wishes about refusing or stopping care, as well as matters of more routine care. This type of advance directive can relate to any medical situation, not just terminal illness.
What Is a Power of Attorney for Health Care?
A power-of-attorney for health care document is another advance directive that allows you to name someone else to make your health care decisions for you if you become unable to make your own health care decisions. Instructions about treatment preferred or treatment to be avoided can also be included. This type of advance directive relates to any medical situation, not just terminal illness.
What Do You Do with an Advance Directive?
Contents of the advance directive should be discussed and shared with your family and physician. For your advance directive to be respected, each time you are hospitalized you should provide a current copy of the document to hospital staff to be placed in your medical record. You should give a copy to your physician. Make sure that someone, such as your attorney or a family member, knows you have an advance directive and knows where it is located.
What If You Change Your Mind?
You can revoke or amend your advance directive at any time. You should inform your physician, attorney, nurse or relative of your decision to make changes in any of these documents.
Advance Directive Policies at Deaconess
Deaconess is committed to saving lives and minimizing suffering. If a patient’s heart stops or the patient is no longer breathing, an emergency message (code) calls physicians and specially trained hospital staff to the patient. The physicians and staff will make every effort to revive the patient unless a decision not to resuscitate (to revive from apparent death) has been previously made. This is called a “do not resuscitate” order and is made only after thoughtful discussion among the physician, the competent adult patient, family members and any others involved in the decision-making process.
The 1990 Patient Self-Determination Act requires that all adult inpatients be asked when they are admitted to the hospital whether they have an advance directive. Whether you do or do not have an advance directive will not change in any way our commitment to provide you with the highest quality of care. If your advance directive includes instructions or requests that the health care staff at Deaconess are unable to honor, you will be notified. Each adult inpatient, on admission, is given information about advance directives.
It is difficult for people to make decisions when they are under great stress or emotional strain. It can be even more difficult when there are no clear-cut answers as to what is best for the patient. These matters often require discussion and careful thought.
If you experience difficulty in making a decision, the hospital has an Ethics Committee, made up of health care professionals and community members, to review specific case situations. This committee is there to help you understand treatment options without requiring you to follow its recommendations. Your physician or nurse can help you contact an Ethics Committee representative.
For More Information
The information is presented in the hope that you will discuss advance directives with your physician, attorney and family members.
If you would like to discuss advance directives further, or if you are interested in receiving a copy of the advance directives discussed, contact your Care Coordinator
How Do I Create an Advance Directive?
Deaconess Hospital offers sample forms below. Ideally, you should seek legal counsel when creating an Advance Directive. An attorney can provide detailed information about the types of Advance Directives you may wish to create and the issues you should address in each document. Your Advance Directives must be signed, dated and witnessed by two people who know you well and are at least 18 years old.
Witnesses should not be related to you, be potential heirs, hold direct financial responsibility for your health care, or be your personal health care provider.
For more information, refer to the Put It In Writing Web site offered by the American Hospital Association.