The Importance of Having an Advance Health Care Directive
By Shahed Hasan

The Terry Schiavo case has raised a variety of legal and moral issues about when a person can be allowed to die. But an advance health care directive spelling out her wishes could have prevented the family’s battle over her care. While the Schiavo case has received widespread attention, thousands of other families face the same life or death decision every day.

What is an “Advance Health Care Directive”?
An “advance health care directive” or “advance directive” is a document in which you give instructions about your health care if, in the future, you cannot speak for yourself. You can give someone you name (your “agent”) the power to make health care decisions for you. You can also give instructions about the kind of health care you do or do not want.

Why is it useful?
In a traditional “living will,” you state your wishes about life-sustaining medical treatments if you are terminally ill. Unlike most living wills, an advance directive is not limited to cases of terminal illness. If you cannot make or communicate decisions because of a temporary or permanent illness or injury, an advance directive helps you keep control over health care decisions that are important to you. In your advance directive, you state your wishes about any aspect of your health care, including decisions about life-sustaining treatment, and choose a person to make and communicate these decisions for you.
It is particularly important to appoint an agent. When a decision needs to be made, your agent can participate in discussions and weigh the pros and cons of treatment based on your wishes. Your agent can decide for you whenever you cannot decide for yourself, even if your decision-making ability is temporarily limited. If you do not formally appoint someone to decide for you, many health care providers and institutions will make critical decisions that might not be based on your wishes. In some situations, a court may have to appoint a guardian unless you have an advance directive. An advance directive can also relieve family stress. By expressing your wishes in advance, you help your family or friends who might otherwise struggle to decide on their own what you would want to be done.

What does an Advance Directive say?
An advance directive normally contains two parts. The first part is the appointment of an agent for you if you cannot decide for yourself. You can define how much or how little authority you want your agent to have. You can also name persons to act as alternate agents if your primary agent is unavailable, and disqualify specific persons whom you do not want to make decisions for you. If there is no one whom you trust fully to serve as your agent, then you should not name an agent. Instead, you can rely on the second part of the advance directive to make your wishes known.
The second part of the advance directive contains specific instructions about your health care treatment. If you choose, you can also include a statement about donating your organs. Your instructions in the second part provide evidence of your wishes that your agent, or anyone providing you with medical care, should follow.
You can cancel or change your advance directive by telling your agent or health care provider in writing of your decision to do so. Destroying all copies of the old one and creating a new one is the best way. Be sure to give a copy of the new one to your physician and anyone else who received the old one.

What happens if you do not have an Advance Directive?
If you do not have an advance directive and you cannot make health care decision, some state laws give decision-making power to default decision-makers or “surrogates.” These surrogates, who are usually family members in order of kinship, can make some or all health care decisions. Some states authorize a “close friend” to make decisions, but usually only when family members are unavailable.
Even without such laws, most doctors and health facilities routinely consider family, as long as there are close family members available and there is no disagreement. However, problems can arise because family members may not know what the patient would want in a given situation. They also may disagree on the best course of action. Disagreement can also undermine family consent. A hospital physician or specialist who does not know you well may become your decision-maker, or a court proceeding may be necessary to resolve a disagreement.
In these situations, decisions about your health care may not reflect your wishes or may be made by persons you would not choose. Family members and persons close to you may go through needless agony in making life and death decisions without your guidance. It is far better to make your wishes known and appoint an agent ahead of time through an Advance Directive.

The importance of advanced planning
Too few of us do advanced planning. It’s important for all adults, not just for old people. Indeed, the young in many ways have more at stake because serious medical decisions can have consequences that last decades. Don’t fall into thinking that planning for the worst makes the worst happen. That’s not true. Planning now for future health care decisions is a priceless gift to your loved ones and to yourself. There is no choice in the matter when it comes to death, but there is a choice about how you can die, and that can be a good thing.

Editor: Akhtar M. Faruqui
2004 . All Rights Reserved.