Decisions: How to Make Your Health Care Decisions Known

What Are Your Wishes?

Beginning the process of creating an advance directive can seem daunting. What should go in it? How detailed should it be? There are so many scenarios to consider that it can be overwhelming. Rather than trying to think of everything that could happen, focus on specific situations. Begin by asking yourself some questions and write down your thoughts about each.

• Are there basic functions you believe you must have in order to feel that you would want to continue to live? Do you feel you must be able to recognize loved ones or to respond to others?

• Do your spiritual or religious beliefs affect your attitudes about a terminal illness, treatment decisions, or death and dying? Do you believe life-sustaining treatments should never be withheld or withdrawn? Or do you believe that when there is no hope of recovery, death should be allowed?

• Are there specific kinds of life-sustaining treatment you would want to have if you were diagnosed with a terminal condition? If you could not eat or drink, would you want a feeding tube?

• Are there specific life-sustaining treatments you would not want to have if you were diagnosed with a terminal condition?

• Is there a particular doctor you want to help your family make decisions about your care?

• Is there anyone you do not want involved in your health care decisions? Example: specific family members, friends, or professionals

• If given a choice, where would you prefer to die?

(Adapted from documents produced by Oregon State University)

Many states' living will forms mention at least two scenarios, permanent unconsciousness and terminal illness. They make it easy for you to state whether or not you would want continued life support under those circumstances. Some forms mention two or three more prototypical scenes. You can cross out and initial any of the scenarios you don't wish to include in your choice to accept or reject life support.

In addition to the choices on the forms, it's important to include your considerations in making your choice. In an increasing number of states, the law presumes you would want to be fed and hydrated artificially, unless you have a written instruction that specifically rejects this treatment and overrides the presumption. Also keep in mind that you will be fed as long you have the ability to chew and swallow, even if you have lost all cognitive abilities. If such a situation is a concern, you might want to refuse spoon feeding in your living will.

Your living will is very helpful to your physician, family, and your health care agent when they must make choices on your behalf. It is important to understand that these documents alone do not guarantee enforcement. The more you can do to prevent conflicting opinions about your wishes, the greater the likelihood those wishes will be followed.

For more information on the decisions you can make see "Your Wishes" in this issue.

Who Will You Appoint?

In your durable power of attorney for health care, you appoint a health care agent to carry out your wishes. This legal document gives the person you appoint the right to direct your health care if you are unable to make or communicate decisions. Your agent can be anyone you choose who is at least 18 years of age -- your next of kin or another family member, or someone outside the family.

To prevent conflicts of interest, avoid choosing your primary care physician or any other health care practitioner involved in your care. Many states will prohibit you from doing this, unless the practitioner is related to you by blood, marriage or adoption.

You will also want to name an alternative agent, and cover the same questions with that person. The alternative agent will step in if your first choice is unavailable or otherwise unable to act. If you have designated a spouse and subsequently are divorced, many states will not recognize that person as a legitimate health care representative.

Remember, your health care agent(s) can make your decisions only if you are incapable of doing so. For example, your health care agent might make decisions while you are unconscious, but once you are conscious again, you will make your own decisions.

As you consider potential agents, ask yourself, "Are they assertive? Do they live nearby? Are they comfortable talking about death? Will they respect my values?"

In any case, your family should know and understand how you have instructed your agent and whom you have appointed as your agent. Whatever you say, make sure to explain things in detail. Many people complete advance directives too hastily, without considering all options and without describing fully their wishes for end-of-life treatment.

During these conversations, tell your agent just what you think about "extreme measures" doctors might use to prolong your life. Do you want every treatment available, no matter how limited the benefit might be? Or would you rather forego treatment once it becomes clear that death is inevitable?

There may be instances when a person has no one appropriate to serve as their agent. If this is your situation, please contact our Client Support Program at 800.247.7421. We may be able to suggest some resources to assist you. There are still effective means of expressing your wishes.

What Should You Do Next?

Experience tells us that advance directives, when easily accessible, carefully prepared and appropriately communicated, can go a long way toward making sure you get the type of care you want.

Talking to family members about your wishes is the single most important step in this process. A frequent problem is disagreement among loved ones. If physicians hear of such disagreement, they could be justified in continuing life-sustaining treatment, to avoid a possible lawsuit or licensing complaint.

Conversations with loved ones about your wishes and feelings about end-of-life care can be difficult, but there are sensitive ways to broach the conversation. If you can have this conversation when all or most of your loved ones are gathered together it will help ensure a common understanding of your wishes. You might begin the discussions with:

"I want to make sure that I get the best care possible and the type of care that I want, so there are things we should talk about ..."

"Since none of us knows what the future will bring, there are some things that I think we should all talk about ..."

"If you are ever in a position where you need to make health care decisions for me, it will be most helpful to you if you know what I really want..."

Unlike speaking to your family about your wishes, making your advance directive accessible is an easy thing to do. Give copies to your agent, your alternative agent and your doctor.

It is very important to find a doctor whom you trust and who will take the time to listen to you and your family. Consider the following when discussing your advance directive with your physician.

• Make an appointment to discuss your wishes.

• Bring your agent with you to this appointment.

• Tell them what matters to you most.

• If you are concerned about suffering, talk to them about your concerns.