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Living Wills and Advanced Directives
PULSSE introduction
to Living Wills
Recommended
Form for a Living Will
Living Wills,
Assisted Suicide, DNR Policies and Euthanasia
Colorado
Joint House Resolution on Assisted Suicide
PULSSE strongly
recommends that you study this part of our website. It concerns advanced
directives. Before you acquire a living will, or if you ever have an end
of life decision to make for a loved one, please investigate for yourself
your options; do not depend on anyone else to do it for you. The laws of
most states prescribe the basic content of living wills. While most people
assume that they will prevent the futile indignity of being kept alive
artificially when there is no hope of recovery, a living will may also
be used by health care providers to justify Do Not Resuscitate orders.
A diagnosis that a patient is imminently terminal may not always be correct,
but it becomes a self-fulfilling prophecy if no life-sustaining treatment
is provided. Life is too precious to give doctors the power to decide when
it cannot be sustained without even trying to sustain it. The decision
to turn off a patient's respirator is very difficult, but that should not
be used as an excuse to withhold a respirator
completely.
ARM (Association for Responsible Medicine)and PULSSE suggest that patients who want a living will should insist on wording similar to that shown below. If you have a living will, we strongly suggest that you change it or cancel it. Living wills should only be signed by people who know they have a terminal condition and are ready to die. Otherwise, they may offer a cost-conscious health care provider a tempting alternative to providing the kind of care that may lead to recovery. However, with possible legislation on the horizon for legalized euthanasia, eventually it may be imperative that all have living wills to protect us from cost-conscious physicians "recommending" to our surrogates that we have no chance of recovery without appropriate testing. We strongly recommend that you study the website of The Coma Recovery Association before you decide to declare a living will or advanced directive. Please pay special attention to this article: NACD ARTICLES - COMA. Whether or not you have a living will, be sure this information is entered into your records when you go into a hospital and that you discuss it with your doctors and nurses. For more commentary on this subject see Raging For Life: A Commentary in the Association for Responsible Medicine website.
Recommended
Form for a Living Will (courtesy of Association For Responsible
Medicine).
Patient-Protective
Wording for Living Wills.
I, ___________________________,
willfully and voluntarily make known my desire that my dying not be artificially
prolonged under the circumstances set forth below, and I do hereby declare:
If at any time I have a terminal condition and if my attending or treating
physician and another consulting doctor have determined that there is no
medical probability of my recovery from such condition and that my death
is imminent, and they have certified in writing that they have made this
determination, I authorize the treating doctor to take the following steps:
1) Inform me (if I am conscious) and my surrogate designated below and obtain our written consent. If there is no surrogate, then written consent of the proxy established by law must be obtained unless it is certified in writing that no proxy is reasonably available.
2) Continue to provide all life sustaining treatment possible for a period of no less than seven and no more than ____ days.
3) After this time, if I have not shown improvement, remove all treatment except comfort care and food and water (___), remove all treatment except comfort care (___). The following person is authorized to act as my surrogate: (Provide name, address and phone number).
(PULSSE strongly
recommends that you have two or three alternate surrogates
listed for
extra
protection.)
Information on Living Wills, Assisted Suicide, DNR Policies and Euthanasia (courtesy of Association For Responsible Medicine).
On June 12, 1998 an article appeared through Reuters that claimed that "Doctors and families are often forced to make difficult decisions about continuing or withdrawing life support systems based on diagnostic tests which are not always accurate." The article goes on to say that: "43 percent of patients were wrongly diagnosed as being in a vegetative state. In addition, half of post-traumatic VS patients may recover within one year of the injury". The Coma Recovery Association's website also has detailed accounts that back up these statements. End of life decision-making is indeed a slippery slope; in an age of managed care we must know all there is to know about our true chances of recovery. Here is the article, please read it carefully:
"MRI scans may help predict coma patient recovery" by Patricia Reaney
LONDON, June 12 (Reuters) - Detailed brain scans of coma patients with
severe brain injuries could help doctors better predict their chances of
recovery, Austrian doctors said on Friday. Patients in a vegetative state
(VS), who show no emotion and do not react to what is happening around
them, are difficult to treat because doctors do not know who will respond
to treatment and regain consciousness. Doctors and families are often forced
to make difficult decisions about continuing or withdrawing life support
systems based on diagnostic tests which are not always accurate. But Dr
Andreas Kampfl, a neurologist at the University Hospital in Innsbruck,
Austria, and colleagues believe using magnetic resonance imaging (MRI)
to assess the extent of brain damage could remove some of the guesswork.
MRI is a method of obtaining detailed images of the inside of the body.
Though widely used in the diagnosis of cancer and other illnesses, it has
not been used until now to predict the recovery of brain injury patients.
"Our data suggest that cerebral MRI may assist in early prediction of outcome
from a post-traumatic VS," Kampfl said in a report in The Lancet medical
journal. The estimated number of adult patients in a persistent vegetative
state in the United States alone ranges from 10,000 to 25,000. In 1996
the cost of their medical care was in excess of $1 billion. The Austrian
study coincided with a British court case that highlighted the dilemmas
faced by the families and doctors of VS patients. Catherine Roberts, a
26-year-old from Bournemouth in southern England, accepted a 100,000 pound
($162,000) out-of-court settlement from a British hospital accused of failing
to properly diagnose and treat her after she suffered a brain hemorrhage
six years ago. After two months in a coma, doctors had told her parents
she would not recover and should be allowed to die. They had already stopped
feeding her and were about to remove her breathing tube when she responded
to her mother's voice. "We accepted what the doctors told us," her mother
told a British newspaper. "When they say your child is going to be a vegetable
you do not think they can make a mistake." But Kampfl said a 1996 study
showed that 43 percent of patients were wrongly diagnosed as being in a
vegetative state. In addition, half of post-traumatic VS patients may recover
within one year of the injury. The Austrian researchers took MRI scans
of 80 adult patients. Most of the participants were men, and the most common
cause of their head injuries was a car accident. MRI scans were done six
to eight weeks after the injury. Three neurologists reviewed the images
for the number, size and location of the injuries and assessed the patients
at roughly three-month intervals for one year. At the end of 12 months,
38 patients had recovered consciousness and 42 remained in a vegetative
state. The scans showed that the patients who recovered had injuries in
fewer areas of the brain. The patients who did not recover also had a more
damage to specific areas of the brain. "Our findings indicate that lesions
of the corpus callosum and the dorsolateral upper brainstem are predictive
of a patient not recovering," the researchers added, referring to the interior
of the brain and the top of the brainstem. Dr Keith Andrews, of the Royal
Hospital for Neurodisability in London, said any test that helps in decision-making
is valuable but the results of the Austrian study were not precise enough
for dealing with day-to-day practice with individuals. "Until neurophysiological
tests can give precise results, their role in this complex neurological
disorder remains supportive rather than diagnostic," he said in a commentary
in The Lancet..11:34 06-11-98 Copyright 1998 Reuters Limited. All rights
reserved. Republication or redistribution of Reuters content, including
by framing or similar means, is expressly prohibited without the prior
written consent of Reuters. Reuters shall not be liable for any errors
or delays in the content, or for any actions taken in reliance thereon.
All active hyperlinks have been inserted by AOL.
This is another reason for our deep concern with this issue: the
following Joint House Resolution died in committee in March of 1998, but
we are sure it will be back:
Assisted Suicide in Colorado Second Regular Session Sixty-first General
Assembly LLS NO. R980182.01 JGG STATE OF COLORADO BY REPRESENTATIVE Morrison
HOUSE JOINT RESOLUTION 98-1005 WHEREAS, Numerous people suffer from intractable
and untreatable pain and terminal illness; and WHEREAS, Many of these people
are of sound mind and wish to direct the withholding of lifesustaining
nutrition and hydration that artificially preserves their lives; and WHEREAS,
Others suffering from pain and terminal illness, or their relatives who
witness their loved ones' pain and suffering, desire to take a more active
approach to end the person's suffering; and WHEREAS, Physicians treating
patients with intractable pain and terminal illness are faced with the
ethical dilemma of preserving human life and obeying the law while respecting
the wishes of their patients; and WHEREAS, The debate concerning the appropriate
societal policy on euthanasia and physicianassisted suicide continues to
be a significant and emotional issue throughout the nation; and WHEREAS,
The United States Supreme Court has recently ruled that certain state legislation
prohibiting assisted suicide
does not violate the Due Process or Equal Protection Clauses of
the United States Constitution while at the same time the 1994 Oregon law
authorizing physicianassisted suicide was reaffirmed by the Oregon voters
on November 4, 1997; and WHEREAS, The Colorado Medical Society has elected
to address the controversial issue of assisted suicide and has adopted
the following sensitive and comprehensive policy on euthanasia to guide
physicians:
I. Euthanasia means a good death. Only the competent patient or the authentic proxy of the incompetent patient may decide what for each patient constitutes a good death.
II. Passive euthanasia means that medical interventions are withheld or withdrawn, allowing a disease process to continue its natural course leading to death. Competent patients have a moral right to seek a good death by refusing treatment if that is their wish. Furthermore, physicians have a moral obligation to honor the wishes of their competent patients or the authentic proxy of their incompetent patients, with respect to withholding and withdrawing undesired medical interventions.
III. Active euthanasia means that an intervention by someone other than the patient is intended directly and immediately to bring about the death of a suffering patient at the patient's request. However, providing treatment or medication with the intention of easing the pain of a dying patient is acceptable treatment and not active euthanasia, even though such treatment or medication may foreseeably hasten the moment of death.
IV. Suicide means that one intentionally terminated one's life. Refusing a treatment which may delay the moment of death is not suicide. However, intentionally taking a lethal dose of medication even when fatally ill would be suicide. A physician who intentionally provides a lethal dose of medication for the purpose of aiding a patient to commit suicide is assisting suicide. This differs from providing an adequate dose of medication for the purpose of pain relief, even though it may foreseeably hasten death.
V. Physicians share with all society a duty to obey the law which currently prohibits both active euthanasia and assisting suicide. Because controversy surrounds these issues, physicians ought to continue to evaluate their responsibility to society regarding these practices.
VI. It is critical that the medical profession redouble its efforts to ensure that dying patients are provided optimal treatment for their pain and other discomfort. The use of more aggressive comfort care measures, including greater reliance on hospice care, can alleviate the physical and emotional suffering that dying patients experience. Evaluation and treatment by a health professional with expertise in the psychiatric aspects of terminal illness can often alleviate the suffering that leads a patient to desire assisted suicide.
VII. Physicians must resist the natural tendency to withdraw physically and emotionally from their terminally ill patients. When the treatment goals for a patient in the end stages of a terminal illness shift from curative efforts to comfort care, the level of physician involvement in the patient's care should in no way decrease.
VIII. Requests for physicianassisted suicide should be a signal to the physician that the patient's needs are unmet and further evaluation to identify the elements contributing to the patient's suffering is necessary. Multidisciplinary intervention, including specialty consultation, pastoral care, family counseling and other modalities, should be sought as clinically indicated.
IX. Further efforts to educate physicians about advanced pain management techniques, both at the undergraduate and graduate levels are necessary to overcome any shortcomings in this area. Physicians should recognize that courts and regulatory bodies readily distinguish between use of narcotic drugs to relieve pain in dying patients and use in other situations.
X. The principle of patient autonomy requires that physicians must respect the decision to forego lifesustaining treatment of a patient who possesses decisionmaking capacity. Lifesustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Lifesustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics and artificial nutrition and hydration.
XI. There is no ethical distinction between withdrawing and withholding lifesustaining treatment.
XII. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death. More research must be pursued examining the degree to which palliative care reduces the requests for euthanasia or assisted suicide.
XIII. Physicianassisted suicide is fundamentally inconsistent with the physician's professional role. Physicians must not perform euthanasia or participate in assisted suicide. A more careful examination of the issue is necessary. Support, comfort, respect for patient autonomy, good communication, and adequate pain control may decrease dramatically the public demand for euthanasia and . In certain carefully defined circumstances, it would be humane to recognize that death is certain and suffering is great. However, the societal risks of involving physicians in medical interventions to cause patients' deaths is too great to condone active euthanasia or physicianassisted suicide. Now, Therefore, Be It Resolved by the House of Representatives of the Sixtyfirst General Assembly of the State of Colorado, the Senate concurring herein: That the policy on euthanasia adopted by the Colorado Medical Society be adopted by the Colorado Board of Medical Examiners and used as a guideline for all medical physicians licensed by the state of Colorado. Be It Further Resolved, That a copy of this resolution be sent to each member of the Colorado Board of Medical Examiners and to each medical physician licensed by the state of Colorado pursuant to article 36 of title 12, Colorado Revised Statutes.
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