Writing an Advance Directive
An Advance Directive (also called a Living Will) is your best guess as to what you would want done in certain medical situations. The major question is whether you want everything done to keep you alive in any and every medical situation. If not, then you need to make decisions about your medical care.
Remember that your Advance Directive is only invoked if you are unable to speak for yourself. So, as long as you are able to communicate, your spoken direction, not your written document, will determine what medical treatments you allow. Furthermore, your Advance Directive can be changed as often as you wish.
Here is an exercise to help you begin making decisions for your living will:
Consider scenario 1 and go through the list below (a-j) and decide whether each medical intervention is something you would want to do, would not want to do or is something you are undecided on. Then repeat the process with scenario 2 and scenario 3.
If you are confused or want to learn more about any of these medical interventions, scroll down; we have included more information on many of them below.
Scenario 1: If I become acutely ill and unable to express my wishes but, in the opinion of my physicians, there is reasonable hope that I can return to my previous state of health.
Scenario 2: If I become acutely ill and unable to express my wishes and, in the opinion of my physicians, there is little or no reasonable chance that I can return to my previous state of health.
Scenario 3: If l become acutely ill and unable to express my wishes and, in the opinion of my physicians, I have severe permanent brain damage that would make me unable to recognize people or make rational decisions.
List of Medical Interventions to Consider:
- Cardiopulmonary resuscitation (CPR): the use of artificial means to start the heart beating
- Mechanical breathing via use of a ventilator
- Artificial nutrition: nutrition and feeding given through a tube in the vein, nose, or stomach
- Major surgery with potential complications and discomfort
- Kidney dialysis
- Minor surgery or invasive diagnostic tests, such as removing some tissue or using a flexible tube to look in the stomach with potential discomfort
- Simple diagnostic tests, such as X-rays, which have little potential for complications or discomfort
- Pain medications, which may indirectly hasten my death
Below are some of the common invasive procedures used as an adjunct to medical treatment. The links provided will help guide you in completing your Advance Directive or can help your health care representative if your directive has not spelled out your specific wishes.
Peripherally Inserted Central Catheter (PICC):
A PICC line gives your doctor access to the large central veins near the heart. It's generally used to give medications or liquid nutrition. A PICC line can help avoid the pain of frequent needle pricks and reduce the risk of irritation to the smaller veins in your arms.
A PICC line requires careful care and monitoring for complications, including infection and blood clots.
Before agreeing to a PICC line, you or your health care representative should very clearly understand the purpose of the PICC line, the expected duration of need, and whether you will be allowed to request its removal if you no longer want it.
Mechanical ventilators are machines that act as bellows to move air in and out of your lungs. Your respiratory therapist and doctor set the ventilator to control how often it pushes air into your lungs and how much air you get.
You may be fitted with a mask to get air from the ventilator into your lungs. Or you may need a breathing tube if your breathing problem is more serious.
Before agreeing to a ventilator, you or your heath care representative should understand why it is being recommended, whether it is likely you will eventually be able to breathe without the ventilator, and whether you can request its removal even if this means you will not survive.
For a detailed discussion of ventilators and related issues, click the link below:
CPR and DNR:
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions, often combined with artificial ventilation, in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. It is recommended in those who are unresponsive, with either no breathing or abnormal breathing; for example, agonal respiration.
A do-not-resuscitate order (DNR) is a legally binding order signed by a physician and a patient, surrogate, or by a family's request. Its purpose is to let medical professionals know you do not want to be resuscitated if you suddenly go into cardiac arrest or stop breathing.
CPR saves many lives. But for individuals who are already severely ill, CPR may prolong suffering while extending life without quality, enjoyment, or meaning.
The link below provides a very detailed analysis of CPR and when a DNR may be appropriate. Because each situation is so different, you or your health care representative will want to have a full discussion with your doctor before making a decision to have a DNR.
Advanced directive next steps:
1. Make sure you have filled out the forms correctly and completely. If witnesses are required, get their signatures. If the form states that you need a notary public, take the form, along with your identification, to any place that provides notary service.
2. Make sure your doctor, health care representative, and loved ones have copies. You want these documents to be available if needed.
3. Review your directive as time passes to make sure it reflects your current preferences. As your life and circumstances change, so may your outlook on medical options. Whenever you review your directive, initial and date it to show that it still reflects your preferences.
4. Be proud! You have taken an empowering step towards control of your medical treatment. Encourage others to do the same.