Advance Directives  

The importance of advance directives in maintaining patient autonomy during end-of-life health care decisions

Dean Myers

Ethics & Compliance in the Healthcare Industry; BU 560

Dr. Mark Emerson

August 7, 2007


Societal attitudes regarding death and dying have changed substantially over the past 20 years.  Once a topic of limited conversation even among medical providers and ethicists, a vast majority of Americans currently express a genuine level of comfort discussing these types of issues.  According to an American Medical Association study in 1988, only 15 percent of adults completed an advance directive (AD) and outlined their wishes with a friend or family member.  A contrasting study in 2004 noted an obvious shift with 90 percent of Americans specifically talking with a family member about the death and dying process and 42 percent completing an advance directive (VITAS, 2004, Major Findings §).  With 2.4 million Americans dying each year, we must promote the use of advance directives and consistent communication with our loved ones and physician about the type of medical treatment we desire when faced with a “life limiting condition” to ensure patient autonomy throughout this process (NHPCO, 2004, Intro §).

Advance directives are “written instructions which communicate your wishes about the care and treatment you want to receive if you reach the point where you can no longer speak for yourself” (FCA, 2000).  Ortman (2004, Conclusion §) describes them as “a viable legal option available to patients who choose to protect their right to refuse medical treatment in the event that their mental competency is lost to injury or disease”.  The execution of an advance directive allows an individual to control the medical care they receive in future end-of-life situations, when they become unable to consent to or refuse a specific medical treatment or a course of treatments.  Every state governs the use of advance directives with its own laws so an individual must utilize a state-specific directive to ensure legal execution of the document.  The Idaho Medical Consent and Natural Death Act (2005) codified the use of the directive titled, ‘Living Will and Durable Power of Attorney For Health Care’, in the State of Idaho effective July 1, 2007 (see  for a copy of the form).

Durable Power of Attorney for Health Care

There are generally two types of an advance directive, a durable power of attorney for health care (DPA-HC) and a living will.  The durable power of attorney for health care, also known as the ‘medical power of attorney’, is the most common form and allows an individual to appoint someone to make all decisions for them related to medical care and healthcare providers if they are unable to make them for any reason.  Depending on the state where an individual lives, the designation(s) for this appointed person includes healthcare agent, attorney-in-fact, surrogate, or healthcare proxy.  The agent or proxy is entrusted to make all medical decisions, including the ability to withdraw or withhold life-sustaining procedures as directed.  Many state-specific form documents limit the choices available for life-sustaining care to: 1) All Treatment, Artificial Hydration and Nutrition; 2) Artificial Hydration and/or Nutrition; and 3) Comfort Care Measures (OAG, 2007).  An individual may state specific guidelines for treatment decisions that do not fall within these 3 options as an addendum to the document, including rationale for certain decisions to treat/not treat (e.g. based on religious/cultural/family values).  However, the proxy must have the flexibility and intimate knowledge of the patient to interpret their wishes as medical circumstances change.  A single document cannot account for, nor anticipate every scenario or circumstance possible with complex medical conditions.  To ensure validity as a legal document, a durable power of attorney requires a signature.  In addition, some states require witnesses, enforce specific rules about who can serve as a witness, and may dictate notarization of the document (NHPCO, 2005, Advance Directives §).

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Living Will

The other form of an advance directive is a living will, also called "instructions," "directive to physicians," or "medical declaration" in other states.  The living will provides written instructions about the specific interventions an individual desires to prolong or sustain life.  The document also specifies the person’s preferences regarding unwanted treatment measures and the circumstances in which they want to refuse, limit, or withhold life-sustaining or life-prolonging treatment when the individual loses their mental capacity or becomes unable to communicate. Id.  Life-sustaining treatments include artificial nutrition and hydration, dialysis, antibiotics, mechanical ventilation, cardiac resuscitation, defibrillation, and other invasive ...

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