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Posted on January 20, 2020 at 9:45 AM

Over the past decades, increasing emphasis on individual
autonomy has led to the view that competent adults should decide for themselves
how they want to be treated medically. 
This shift in practice and policy has been accompanied by the adoption
of advance directives that allow competent adults to specify in advance how
they want to be treated, with the goal of extending respect for autonomy into
periods of decisional incapacity.

Advance Directives are written instructions about health care
treatment made by adult patients before they lose decision-making
capacity.  These instructions are
completed ahead of time and only apply when decision-making capacity is
lost.  Examples of an advance directive
are a health care proxy document and living will.  A health care proxy is a document that allows
you to appoint another person as your health care agent to make health care
decisions if you are no longer able to do so. 
You may give your health care agent authority to make decisions for you
in all medical situations if you cannot speak for yourself.  Thus, even in medical situations not
anticipated by you, your agent can make decisions and ensure you are treated
according to your wishes, values and beliefs. 
A living will is a document that contains your health care wishes and is
addressed to unnamed family, friends, hospitals and other health care
facilities.  You may use a living will to
specify your wishes about life-prolonging procedures and other end-of-life care
so that your specific instructions can be read by your caregivers when you are
unable to communicate your wishes.  A
living will cannot be used to designate a health care agent, the health care
proxy document must be used for this designation. 

An advance directive should be considered as a “gift” to a
loved one, giving them peace of mind, minimizing stress, and reducing potential
conflicts among family members.  This all
starts with a conversation with family members and friends who are best likely
to represent a patient’s wishes.  The
conversation should clarify a patient’s values and beliefs, framing medical
wishes around these values and beliefs and addressing questions such as:

v  What’s
important to the patient

v  What
contributes to the quality of life the patient may want

o   What
activities are essential to having this quality of life

v  How does
the patient want to spend their final years, weeks or days

o   What role
does faith play in making these decisions

o   How much
medical care is the patient willing to have to stay alive

o   What kind
of medical risks is the patient willing to take

v  When would the
patient want to shift from treatment to comfort care

The conversation should not end here as it’s impossible to
predict every scenario.  But it is
important to continue to share wishes and preferences; explaining views that
will give loved one’s information to make decisions on behalf of the

One of the challenges this presents is that patients may not
know what treatments they want in the future and many do not complete an
advance directive.  When patients become
unable to make or communicate crucial health care decisions for themselves,
health care providers look to others to speak on behalf of the patient.  A health care agent is someone that has been designated
by the patient to make health care decisions should the patient become unable
to do so for him/herself.  Responsibility
begins when the patient loses capacity (may vary by state).    What if the patient has not designated a
health care agent and loses decision-making capacity?   In New York State, the Family Health Care
Decisions Act (FHCDA) provides a hierarchy/highest priority class from which
the provider must choose the surrogate. 
The role of the surrogate is identical to that of the health care
agent—to represent the patient’s expressed and implied wishes using the
substituted judgment standard or if the patient’s wishes are unknown, using the
best interest standard.  In the ideal
scenario, the agent or surrogate is someone who has a close, loving
relationship with the patient; someone who has intimate knowledge of the
patient’s preferences and values; someone the patient chose or would choose to
make health care decisions on his or her behalf; and someone with whom the
patient had previously discussed preferences for care.

 The most important
take away from this blog is that this all starts with a CONVERSATION.  Discussing with family or a loved one what is
important to you, your values, beliefs, wishes, preferences.  Then frame your medical wishes/preferences
around these values and beliefs. 




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