living will

For more information on living will, visit Britannica.com.

Definition

A living will is a legal document in which patients instruct health-care providers about their wishes with respect to medical procedures should they become incapacitated. The living will and the durable medical power of attorney are two federally mandated parts of what is known as advanced medical directives.

Purpose

Advanced medical directives are legal mechanisms to assure that patients' wishes with respect to a number of medical procedures are carried out in their final days or when they are incapacitated. The documents reflect patients' rights of consent and medical choice under conditions whereby patients can no longer choose for themselves what medical interventions they wish to undergo.

In 1990, recognizing the importance of patient treatment wishes at the end of life, Congress enacted the Patient Self-Determination Act (PSDA). This federal law ensures that patients admitted to hospitals, nursing homes, home health agencies, HMOs, and hospices be informed of their rights under state law to prepare advance health care directives and have the documents entered into their medical record. Each state has different requirements for the living will and the power of attorney. It is important to research medical directives before an accident or illness make that an impossibility. Living wills have become customary in many parts of the country and are broadly respected by health care providers. However, a high percentage of Americans do not have a living will and/or a power of attorney to ensure its compliance.

Description

The living will can be a very broad or a very narrow document, according to the wishes of the patient. It is the patient's declaration, a written statement of what he or she wants to occur in the event of serious accident or illness. It is primarily directed to medical personnel about the type of care the patient wishes to have, or wishes not to have, under situations of terminal illness or incapacitation.

The document commonly includes the kinds of medical procedures that are usually administered to patients who are seriously ill. These may include:

• transfusions of blood and blood products
• cardiopulmonary resuscitation (CPR)
• diagnostic tests
• dialysis
• administration of drugs
• tissue and organ donation
• use of a respirator
• surgery

The living will declaration can also include issues of pain medication, food, and water. Most states recognize that relief from pain and discomfort are procedures that most people wish to have and these are not considered life-prolonging treatments. In some states, however, food and water may be considered life prolonging. and the consideration to forego them may fall within the rights of the patient to refuse. What may be included in the living will depends upon the state.

The living will—in some states called instructions, directive to physicians, or declaration—does not require a surrogate (an appointed person) to make decisions for the patient. Most states include these types of instructions in their medical durable power of attorney forms. Not all states, however, recognize separate living wills as legally binding; California, for instance, does not.

Preparation

The living will should be given careful thought, and be talked about with the patient's family, physician, and care providers. It is highly recommended that discussion of patient wishes occurs before medical treatment is necessary, because the living will involves both the patient's family and loved ones, who are expected to assist in its implementation. It should be researched for the state in which the patient is most likely to receive medical care, and be dated and signed before two witnesses.

The living will may be drafted on standardized forms, with or without the assistance of an attorney. The document may be revoked in writing, or orally, by either the patient (the person making the advance directive) or by a designated proxy (a surrogate) at any time. If the patient does not specify in the living will a particular element of treatment or treatment withdrawal, then it is not included. It is very important that living wills be as specific and detailed as possible.

Most hospitals offer a medical directives resource, commonly in the religious office attached to the hospital. Coupled with a durable medical power of attorney (a person chosen to make medical decisions on the patient's behalf if the patient cannot make his or her own decisions), the living will ensures in advance that patient wishes about the quality of death are respected.

Normal Results

The living will, whether prepared prior to hospitalization or prepared once the patient is admitted, is placed in the patient's medical chart along with other documents such as the medical power of attorney declaration. Providers are required by federal law to honor this declaration of the patient's wishes. The document serves as a statement of intentions on the part of the patient and can be very important to family members, health care providers, and patient proxy during a very distressful and disconcerting time.

See also Do not resuscitate order.

Resources

Periodicals

Matousek, M. "Start the Conversation: The Modern Maturity Guide to End-of-Life Care." "The Last Taboo." Modern Maturity (September-October 2000).

Organizations

Partnership for Caring. 1620 Eye St., NW, Suite 202, Washington, DC 20006. (202) 296-8071. Fax: (202) 296-8352. Toll-free hotline: (800) 989-9455 www.partnershipforcaring.org/.

U.S. Living Will Registry. 523 Westfield Ave., P.O. Box 2789, Westfield, NJ 07091-2789. Toll-free: (800) LIV-WILL or (800) 548-9455). www.uslivingwillregistry.com/.

Other

Living Wills And Other Advance Directives.wwww.intelihealth.com.

What You Can Cover in Your Healthcare Directives. Nolo Law for All. wwww.nolo.com/lawcenter/ency

— Nancy McKenzie, PhD

A legal document that sets out the medical care an individual, or the principal, wants or does not want in the event that he or she becomes incapable of communicating his or her wishes.

Investopedia Says:
A living will is used by people whose wishes will be met should they reach a point when they are no longer able to make the decisions for themselves. For example, if a person sustained life-threatening injuries, or was incapacitated as a result of some terminal illness, the decisions about his or her health care will be his/hers as long as there is a living will. Without one, the decision becomes the responsibility of spouses, family members or other third parties.

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Still with life. This is a life insurance term used to describe the living benefits available under a life insurance policy such as a monthly retirement payment to an insured.

A document that details one’s wishes regarding the degree and amount of health care desired if one becomes mentally incapacitated.

A written document that allows a patient to give explicit instructions about medical treatment to be administered when the patient is terminally ill or permanently unconscious; also called an advance directive.

With improvements in modern medicine, the life of persons who are terminally ill or permanently unconscious can be prolonged. For increasing numbers of persons, the decision of whether to prolong life is being made in the form of a written document called a living will. The living will is one type of advance directive that may be used by a person before incapacitation to outline a full range of treatment preferences or, most often, to reject treatment.

A living will extends the principle of consent, whereby patients must agree to any medical intervention before doctors can proceed. It allows the patient to guide health care for the future when she may be too ill to make decisions concerning care. It can be revoked by the patient at any time. For many the living will preserves personal control and eases the decision-making burden of a family.

Forty-two states and the District of Columbia have living-will statutes that make a properly executed living will legally binding. In states that do not have a statute, living wills stand as a clear expression of the patient's wishes. Living-will statutes require that the person be legally competent to execute the will and that the will be witnessed by at least one disinterested person. Once a person who has a valid living will is terminally ill, the attending physician and a second physician must certify in writing that there is no reasonable expectation for improvement in the patient's condition and that death will occur as a result of the incurable disease, illness, or injury.

Upon this certification the doctor is obligated to follow the instructions contained in the living will. This typically means the patient does not want any medical procedures that serve only to prolong but not prevent the dying process. Therefore, if the patient is unable to breathe, the doctor is not required to connect the patient to a respirator. A patient may state in a living will that he does not want a feeding tube if unable to swallow food. Another common directive is to forbid resuscitation if the patient's heart stops beating.

Living wills have been criticized because they are usually limited to the withholding or withdrawing of "life-sustaining" procedures from a patient with a "terminal condition" or "terminal illness," and thus do not accurately reflect the broad legal right to refuse treatment. In addition, by their very nature, living wills reduce the patient's wishes to writing, and thus may be too rigid (or too vague) to adapt to changing interests or anticipate future circumstances.

To overcome these problems, many states have enacted statutes that permit a competent adult to designate a surrogate decision maker (also termed a health care proxy or agent) to make health care decisions for her in the event of incapacitation. The proxy's authority is usually not limited to decisions about life-sustaining treatment. A proxy can supplement a living will.

All fifty states have durable-power-of-attorney statutes that permit an individual (the principal) to designate another person (the attorney in fact) to perform specific tasks during any period of incapacity. Though most of these statutes do not expressly refer to medical care decisions, no court has ruled that they preclude the delegation of medical decision-making authority to the attorney in fact.

See: Death and Dying; Health Care Law; Organ Donation Law; Patients' Rights; Physicians and Surgeons.