Living Wills: The Basics
Spelling out End-of-Life Wishes Eases
Worry for Loved One and Caregiver
A living will tells doctors the lengths to take in using respirators and other devices to keep a terminally ill patient alive. In most cases, living wills instruct health care providers not to employ artificial life-prolonging measures. In many states this is also called a "directive to physicians" or "health care directive."
Every state has specific laws governing living wills. Although the laws tend to mirror each other, it is critical to follow your state's procedures to ensure the document's legal validity. Many states also have laws regarding what is called a life-prolonging procedure statement for individuals who want heroic measures taken to keep them alive.
A living will is as important for caregivers as for the dying patient and the doctors providing care. It leaves little doubt about the treatment the patient wants - and doesn't want - when the patient no longer can make or communicate decisions.
If properly executed, a living will relieves caregivers of doubt about the action to take, provides a strong voice for the patient if some family members have other ideas and serves as a legal instruction to doctors. It may also protect from liability the health care providers who honor the living will's instructions.
No, but the two documents work well together and it is useful to have both. Suppose you're caring for an Alzheimer's patient. A living will guides doctors at the end; a durable power of attorney will authorize you or someone else to make health care decisions through the years when the patient is no longer rational but not yet terminally ill.
Without a specific directive to the contrary, doctors may do everything in their power to keep a patient alive. A living will spells out a dying patient's wishes and requires that they be followed. If doctors feel they can't follow a living will's directives because of an ethical or moral conflict, they are obligated to try to find someone else who can follow such instructions.
Three events must happen:
A doctor must certify that a patient is terminal and has a short time to live.
The patient cannot speak, write or otherwise communicate wishes or direction.
Doctors and nurses are given the patient's living will.
Make copies of the document, and keep the original and at least one copy in a fireproof box in your home. The box also should include papers showing the senior's proof of medical insurance and durable power of attorney for health care. Put the box where you can access it quickly and easily, so you can grab those papers in an emergency.
If the senior has been hospitalized or lives in a nursing home, give a copy of the living will to medical staff and ask that it be added to the patient's chart. If the senior lives in a private home and must be rushed to a hospital or treated by emergency medical technicians, show the living will to the emergency staff.
In most states, it is illegal to ignore a living will - but it happens. Paramedics or emergency room staff usually will disregard a living will because they are trained to respond to a medical crisis immediately, leaving no time to read legal documents. If you accompany the patient to an emergency room or are present when 911 is called, be firm with medical personnel and insist that the living will is followed. When the worlds of medicine and law collide in a crisis, this may be the most you can do for the senior.
Under the federal Patient Self-Determination Act, hospitals and nursing homes are required to explain living wills to anyone admitted to the facility, ask whether they already have one and provide the necessary form should patients want one. But living wills, like durable powers of attorney for health care, are best prepared long before they are needed - although many people don't think about them until they're ill.
It's a good idea to involve everyone close to the patient in the discussions. Simple forms are widely available from hospitals, doctors, HMOs, lawyers and organizations dealing with Alzheimer's and other illnesses. Bear in mind, however, that many standard living will forms do not address the complex situations that can arise. Many lawyers advise people to include in their living wills information about their wishes under several different scenarios to offer the most guidance possible.
Once the senior fills out the form in accordance with state requirements, all caregivers should receive copies. Seniors or their caregivers should present the signed living will upon admittance to a health care facility.
Keep in mind that the issues raised by different treatments are complex and need full airing by the patient, caregivers and family members before decisions are made. Among them:
A Do Not Resuscitate order, known as a DNR. This tells the doctor not to give cardiopulmonary resuscitation when the patient's heart stops.
Respirators or ventilators. These machines breathe for patients who no longer can breathe on their own. Short-term, they save lives. Long-term, they can keep a comatose patient with no evidence of brain function technically alive for years.
Surgery. Cancer patients may decide that surgery to remove a spreading tumor will destroy the quality of their last days without significantly boosting their chances of survival.
Chemotherapy. As with surgery, patients may decide that the suffering from side effects of treatment may not be worth the potential benefits.
Food and water. This extremely complicated issue arises most often when a patient is in a vegetative state. Laws in some states regard food and water as special life-prolonging treatments; others don't. If they are considered life-prolonging, it's easier for a doctor to implement a living will that requests them to be withheld. A living will should specifically address the patient's wishes regarding food and water.
Pain medications. It can be difficult for doctors or caregivers to ascertain whether a comatose patient is in pain, so it is useful if a living will specifies whether the patient wants to receive pain-relieving medications.
Doctors will do their best to treat the patient. When they have questions about how to proceed, they most likely will turn to the closest available relative - who may or may not be the primary caregiver, the person who knows the most about the patient's wishes or the person most likely to follow through on the patient's wishes. Serious disputes about treatment options may arise that can hamper doctors' ability to care effectively for patients and may need to be resolved in court - a situation beneficial to no one.