How you live can respect your choices, even at the end.

More important to your family than how to distribute your belongings and wealth after death is how they should be clearly directed, not just informed, of your wishes should you become incapacitated. If you don’t have a will you might feel embarrassed; if you don’t have a living will you might be terrified.
Consider this:
- In recent surveys only two in five adults age 45 or older had a living will.
- Worse, fewer than two in five had a durable power of attorney for health care decisions.
- An article in the Archives of Internal Medicine cited a study where doctors were asked to consider six hypothetical medical cases.
Overall, 65% of the decisions the doctors made were contrary to patients’ advance directives.

The Good

Living Wills are a good place to start but they can never cover all the complexities and gray areas that arise when you become incapacitated.
And the likelihood that you will become incapacitated and die is 90% and 100% respectively. Sobering and somber to be sure; awkward to discuss and
therefore shuffled to the bottom of the “ought to do” list, but one of the kindest considerations you can show to your family is to deal clearly with these
decisions before the time arises.

The Bad

There is no lack of examples of what you likely don’t want to have happen:
A woman who made clear that she didn’t want to be put on a ventilator to help her breathe. The woman’s daughter however wanted her to continue with treatment. The woman had severe dementia but was expected to recover and the hospital gave greater weight to her prognosis and her daughter’s wishes and decided to put the woman on a ventilator. She did recover and lived, severely demented, for another two years.

The point

The point is very simple: while living wills are necessary because they communicate to your family what kind of life is worth living to you, and they are critical when family members don’t agree on your treatment, doctors know that the more important decision is creating a health-care-proxy or power-of-attorney document.
Select carefully, but absolutely do select this individual. He or she may be very respectful of your wishes while you are lucid and capable of discussing them, yet become freaked out, irresolute, and useless when the time arises. No one gets used to witnessing suffering and dying and even more so of family or friends; decisions to withhold supportive or heroic measures are difficult for most individuals. You must select someone who you not only trust, but that you are confident has the character to execute (so to speak) your directives. Grey areas and complexities are the rule rather than the exception. Family members can threaten whomever you select; physicians and hospital employees, however well intended, may argue for continuing support of a situation you absolutely would not wish to maintain. The more you detail and document your desires the easier it will be for your designee to carry out your wishes.

Before signing documents it is reasonable to check with state laws, and with your attorney. You may have religious considerations or organ donation directives (hopefully) that might not be reflected in generic forms. Some people have specific requests such as personal grooming, flowers in the room, music to be played, or wish to become part of experimental programs to help with research.

Be sure that your agent (the one who has durable power of attorney) has authorization to have complete access to your medical records. Otherwise they may become restricted under the Health Insurance Portability and Accountability Act (HIPAA).
Once the documents are signed, give copies to your doctor, the hospital you are most likely to access, your agent, AND your backup agent. Please give
copies to first degree family members and anyone you think might get involved, constructively or otherwise, in your end-of-life affairs.

Periodically review your directives, and keep tabs on your health care proxy. If they get sick or die or move away you will need to designate someone else. Finally, you living will needs to take into account medical advances that can turn what was once a terminal or irreversible condition into something treatable.

Every Tuesday you can listen live to Dr. Kiessling’s medical radio talk show, “Just a G.P.” on 650 KENI at 12:30 pm (Alaska time). You can call in with your questions, or tweet into the show live. Follow at @DrKiesslingPCA and use #JustGP on all your tweets during the show. ‘Like’ Primary Care Associates on Facebook for Podcasts of the show, online exclusives, and the latest and greatest in Healthcare news.

(much of the above an update of: WSJ Health Journal D1, 3/22/2005 )

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