fundamentals
Advance Directives
Living Will
A living will is a limited document that expresses a person’s preferences for future medical care. In many states, the document is more formally called a medical directive to doctors or a declaration. The focus of a living will is usually end-of-life care, but it can include instructions about any aspect of care or treatment. For example, increasingly, people often complete specialized psychiatric advance directives focused on mental health treatment. Living wills become effective only when the person has lost capacity to make health care decisions and the person has a particular condition defined by state law—usually a terminal condition or permanent unconsciousness. Some states recognize additional conditions such as an end-stage condition (for example, advanced Alzheimer Disease ) or any condition specified in the living will. Many people believe that death is preferable to being perpetually dependent on medical equipment or having no hope of returning to a certain quality of life. Others feel just as strongly that extreme heroic measures and technology should be used to extend life as long as possible, regardless of the degree of medical intervention required or the quality of life that results. A living will allows a person to express either of these preferences (or any intermediate measure that the person finds acceptable). Including information in a living will about core values relating to Introduction to Death and Dying , personal priorities, and goals of care can be just as helpful, if not more so, than specific treatment wishes, because most specific treatment decisions are unforeseeable. To be legally valid, a living will must comply with state law requirements such as those regarding how the document is signed and witnessed or notarized or what must be included in the text of the document. Many states have specific forms available for people to use if they choose. People can usually find examples of acceptable forms from hospitals and other health care professionals, local offices on aging, or law (bar) association web sites. Typically, living wills address the issue of when the goals of treatment should change from aggressive, curative efforts to efforts that primarily provide comfort care and allow a natural death. Everyone draws this line somewhat differently depending on their values, beliefs, and goals. In their living will, some people give mainly general guidance, whereas others also give instructions about particular treatments, such as artificial nutrition and hydration ( Tube Feeding ), Everyone's situation and wishes are unique and complex. Thus, the brief examples of living will language included here are provided simply to help illustrate the wide variety of issues. For example, to indicate a preference for full aggressive medical treatment, the document might state: "I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery, the burdens of the treatment, or the cost of the procedures." It should be noted, however, that the person’s choice has certain limits. For example, health care professionals are not required to provide treatments that are medically inappropriate or clearly futile. To prevent heroic attempts to extend life, the document might state: "If I have a terminal condition or am in a Vegetative State from which I am not expected to recover, and life support will only delay the moment of my death, I do not want my life to be prolonged, and I do not want life-sustaining treatment (including artificial feeding and hydration) to be provided or continued.” Still others may draw this line differently. For example, they might want the document to state: “If I have permanent and severe brain damage (for example, I can open my eyes, but I cannot speak or understand) and I am not expected to get better, I do not want my life to be prolonged, and I do not want life-sustaining treatment (including artificial feeding and hydration) to be provided or continued.” In all cases when people refuse care through an advance directive, health care professionals are nonetheless always required to provide comfort measures as needed for the person’s condition. Living wills have substantial limitations. For example, they generally address only a narrow range of end-of-life decisions, they cannot realistically anticipate all the serious medical circumstances the person may face in the future, and the written document may not be available at the time and place needed. Also, peoples' preferences often change as they develop a progressive illness or as their values or priorities change over time. Living wills are often done long before serious decisions actually need to be made, so highly specific directions may not have been intended for new and unforeseen circumstances. Nevertheless, a living will can provide general guidance to health care professionals and the person’s surrogate decision makers in the face of serious illness. A health care power of attorney can apply to all medical decisions for the person lacking capacity, and it allows the person chosen as the surrogate decision maker to respond to changing medical information and circumstances. In contrast, a living will generally addresses only a narrow range of end-of-life decisions. 