Living Wills and Advance Directives

The medical profession in the United States has experienced a shift in ethics and values over the past 3 decades, from a position of paternalism to an emphasis on patient autonomy. As such, individuals are becoming increasingly involved in their medical care, especially with regard to decision making near the end of life. The desire to “control” the circumstances surrounding one's death has become the norm in the majority culture of the [Page 669]United States, and several practices have evolved to help ensure that this is accomplished. Advance directives and advance care planning are two such concepts that are discussed in this entry.

Terminology

Near the end of life, patients and their families face a number of difficult decisions, such as whether to start or continue a given medical treatment. Advance directives are written documents that state an individual's wishes under specific conditions and in the event that he or she is no longer legally competent to make a decision. There are two general types of advance directives: durable power of attorney and living wills. A durable power of attorney (also known as a “health care proxy”) designates an individual who will make decisions for the dying person when he or she is no longer competent to do so. A living will is a document that specifies in writing what kinds of treatment are and/or are not wanted by the individual under specific conditions.

In addition, there are two types of directives that are specific to certain treatment interventions: the do not resuscitate (DNR) order and the do not hospitalize (DNH) order. The DNR indicates that no resuscitation measures (typically cardiopulmonary resuscitation [CPR]) should be undertaken if the patient goes into cardiac or respiratory arrest. The DNH order states that the person or the responsible party (relative or legal guardian) does not want the person to be hospitalized. DNH orders are typically issued when an individual's pain management, comfort care, and current treatment needs can be met either at the person's home or in a nursing home. This does not mean that the patient can never be hospitalized, but simply that before the decision to hospitalize is made, a discussion needs to occur between the competent patient or patient's family/guardian (if the patient is incompetent) and the attending physician to determine if hospitalization is what is best for the patient.

History of Advance Directives

Although competent adults in the United States have long held the right to refuse life-sustaining medical treatment, individuals who were incompetent at the time a treatment decision was required, and their loved ones, had no option but to follow the decisions of the medical team. Marilyn Webb discussed several significant events that occurred between the late 1960s and the early 1990s and brought the concept of advanced directives to the attention of the public. This concept was introduced in 1967 when Luis Kutner, an attorney and member of the Euthanasia Society of America, proposed the first model of a living will. That same year, the Euthanasia Society began to distribute these model documents out to the public. In 1968 and again in 1973, Dr. Walter F. Sackett introduced a bill allowing patients to express their future desires regarding life-sustaining medical treatment to the Florida state legislature. However, the bill was defeated both times. In 1974, Barry Keene proposed a bill aimed at legalizing living wills called the Natural Death Act, but this too was defeated. It was not until the famous New Jersey Supreme Court ruling in the case of Karen Ann Quinlan in 1976 that proposals for advance directives were able to gain ground.

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