End-of-life planning helps patient, family

3/4/2012

Whether a patient is facing a life-or-death medical emergency or a routine procedure, one question is virtually always asked before treatment: Do you have a living will?

Thanks to a series of court cases dating to the 1980s and advances in medical science, the once-taboo topics of end-of-life planning, living wills, and durable health-care power of attorney have been routine since 1991. Those documents allow an individual to spell out in advance who can make medical decisions on their behalf and whether they want life-sustaining treatment if they are gravely ill and cannot speak for themselves. When people don't formally make their wishes known, families facing a medical crisis can find themselves trying to make weighty decisions while in the middle of an intensely stressful situation.

Just recall the decades-old, widely debated cases that surrounded Karen Ann Quinlan in the 1970s, Nancy Cruzan in the 1980s, and Terri Schaivo several years ago. Though each case was different, the public had front-row seats as raging battles played out in the courts over those women being on artificial life-sustaining machinery.

The advance directives of living wills and durable health-care power of attorney became more prevalent as a result of 25-year-old Ms. Cruzan, whose parents wanted artificial feeding and hydration removed.

Their legal battle reached the Supreme Court, which in 1990 sided with her parents and said they had the right to discontinue the feeding and hydration.

"After that landmark case, the Patient Self Determination Act that became law in 1991 directed health-care organizations to ask whether patients had advance directives," said Laura Phillipps, of Hospice of Northwest Ohio.

Education

One way to ease the anxiety is to plan ahead. The Advance Care Planning Coalition of Greater Toledo is available to help individuals and families with the details.

It's common that someone in most families will have to make life-or-death and health-related decisions on someone's behalf. If patients did not have the directives, health facilities educate them on their right to complete the forms.

"It was our federal government's way of trying to improve care at the end of life so that people's wishes would be respected," said Ms. Phillipps, a coalition volunteer.

She explains the difference between the documents:

● A durable health-care power of attorney allows people to identify as many as three people each to make medical decisions for them in the event they are unconscious or not able to speak.

● A living will lets people establish the type of care they want in the event they become permanently unconscious or are certified as terminally ill and are not able to express their wishes. A living will lets people decide if they want life-sustaining treatment withheld or withdrawn in favor of comfort care and pain relief.

Each state has its own forms for the two documents. Elder care attorney Dean Horrigan in Maumee said the documents can be obtained from Lucas County Probate Court, the Lucas County Bar Association, and online. They are also easily obtained by plugging "advance directives" into an online search engine. One Web site is http://bit.ly/wPV97B.

Mr. Horrigan, also a volunteer with the coalition, said the most recent version of the form is from 2009.

"Try to find the most recent version. The older version is still effective, but the forms change subtly over time," he added.

The documents also have an organ donor registry that allows people to say whether they want their organs used to save lives or for research.

Thinking ahead

In the years after the law became effective, the health-care profession learned that it was important to encourage families to talk about end-of-life care. That made a difference toward respecting a person's choice should they be faced with an end-of-life decision.

"In other words, the documents didn't really improve care. What really helped to improve care and to help make decisions of improved care was supporting people having conversations," Ms. Phillipps said. "If you don't have the documents and don't talk to your family, the family is basically sitting in the driver's seat" in a medical crisis.

Relatives might pursue a course that is contrary to a patient's wishes if the person has the documents, but never verbalized the wishes with relatives.

"You may document what you want, but in the moment of that medical crisis, a lot of emotions can come into play, and if you haven't had discussions with loved ones, they may make decisions in opposition to your choices," she said. "When making out forms, sit down with two or three people who are designated to make decisions for you. Tell them what you want so they can speak for you."

Mr. Horrigan doesn't charge for living wills. They are free online, and cost should not be a deterrent.

"What we do as lawyers is put health-care power of attorney and living will as part of an estate plan," he said.

"The goal is to explain to people the availability of these documents that are at no cost. People don't have to pay a lawyer to do it."

Talking about the documents with loved ones is vital.

"Have conversations with the individual or individuals you have appointed," Mr. Horrigan said. "I want my son to know what my wishes and needs are. That's an important element of estate planning and directives."

His clients either already have a living will or are ready to obtain one.

"They understand that this is the time in their lives where they are capable and competent to express their wishes," Mr. Horrigan said. "It provides peace of mind and clarity to their loved ones who are forced to express their wishes, and they can rely on the document versus making an assumption. It's a way to control our own destiny in this situation when we are unable to speak about it later."

Contact Rose Russell at rrussell@theblade.com or 419-724-6178.