End-Of-Life Decision Making

Several landmark court cases—The Karen Ann Quinlan case in 1975, the Nancy Cruzan case in 1990, and the Terri Schiavo case in 2005—have brought national attention to the significance and importance of having mechanisms in place for implementing care decisions at the end of life. Due to injuries sustained in an accident or unanticipated health events, these women were unable to make their own health care decisions. Because the women did not have written documents that clearly stated their wishes for sustaining life and their close family members disagreed about the type of care they should receive, decisions made about their end-of-life care resulted from lengthy legal battles. To avoid these undesirable situations and assist persons who wish to remain in control of health care decisions after they are unable to articulate their desires, states have enacted laws that allow for the creation of advance directives to help facilitate end-of-life decision making.

Advance directives are legal documents prepared by a competent individual that convey wishes regarding personal health care decisions. Two types of advance directives are the living will and durable power of attorney for health care. A living will enables individuals to express their wishes regarding life-sustaining treatment, such as the use of a feeding tube or ventilator for pulmonary failure. Narrow in scope, a living will authorizes the use or withdrawal of certain life-sustaining procedures only in situations in which individuals are mentally incapacitated and death from a terminal condition is imminent or if they are in a persistent vegetative state. Conversely, durable powers of attorney for health care are not restricted to terminal illnesses or prospectively identified situations. Instead, they give a broader range of authority to a trusted individual (i.e., surrogate) to make health care decisions only when the individual cannot make the decisions. Although any adult can initiate advance directives, the Patient SelfDetermination Act, passed by U.S. Congress in 1990, requires that all federally funded hospitals and nursing homes give patients an opportunity to complete a living will and durable power of attorney for health care upon admission.

The driving force behind advance directive laws is the ethical principle of autonomy, which requires respect for persons' deliberate choices made in accordance with their own values, consciences, and religious convictions. By appointing a surrogate decision maker, the individual attempts to extend the principle of autonomy into situations of personal incompetence. The surrogate decision [Page 408]maker is usually a family member who has sufficient knowledge of the person's values and desires to make the appropriate decisions. Executing advanced directives requires surrogate decision makers to adhere to the ethical principle of substituted judgment, wherein they are to replicate the same decision the person would have made had she or he been capable of making a decision. This standard requires that surrogate decision makers synthesize the person's diverse values, beliefs, practices, and prior statements to reconstruct what she or he would want under the specific circumstances. Surrogates have an implicit duty to follow the individual's presumed instructions by attempting to carry out those reported desires.

...