Healthcare directive

What Is a Healthcare Directive?

A healthcare directive is a legally recognized document that allows an individual to communicate their wishes regarding medical treatment and care, especially in situations where they are unable to make or express decisions for themselves due to illness or incapacity. This critical component of estate planning falls under the broader category of personal finance, as it ensures an individual's preferences for their well-being and assets are managed according to their desires. A healthcare directive empowers individuals to maintain patient autonomy over their medical future. It covers various aspects of medical care, including preferences for life-sustaining treatment, pain management, and the appointment of a surrogate decision-maker.

History and Origin

The concept of expressing future medical wishes gained prominence in the 1960s. Luis Kutner, a human rights attorney, is widely credited with proposing the original "living will" in 1967, advocating for a document that would allow individuals to express their desires regarding life-sustaining medical treatments when nearing death. This groundbreaking idea aimed to ensure a patient's control over their medical care even when unable to communicate.²⁴

Inspired by Kutner's work, legislative efforts began, though they faced initial setbacks. Dr. Walter F. Sackett introduced an unsuccessful bill in Florida in 1968 and again in 1973.²³ However, a pivotal moment occurred in California in 1976 when it became the first state to legally sanction living wills, spurred by Senator Barry Keene's personal experience with his terminally ill mother's inability to limit end-of-life treatment despite having a power of attorney.²²,²¹ By the early 1990s, all 50 U.S. states and the District of Columbia recognized living wills as legal documents.²⁰ Federal legislation, specifically the Patient Self-Determination Act (PSDA) of 1990, further reinforced the importance of these documents by requiring healthcare providers to inform patients of their right to make advance directives.¹⁹

Key Takeaways

• A healthcare directive outlines an individual's medical treatment preferences in advance, activated when they cannot communicate.
• It ensures personal wishes are honored, reducing the burden on family members and healthcare providers.
• Common forms include living wills and medical power of attorney.
• Healthcare directives are crucial for anyone over the age of 18, not just the elderly or terminally ill, as unexpected incapacitation can occur at any age.
• Regular review and updates are vital to ensure the directive reflects current wishes and medical advancements.

Interpreting the Healthcare Directive

A healthcare directive serves as a personal guide for medical professionals and chosen decision-makers when an individual cannot speak for themselves. Interpretation focuses on ensuring the care provided aligns with the stated preferences and values. Healthcare providers are legally bound to follow the instructions within a valid healthcare directive to the extent possible, guided by medical standards and the patient's best interests. This document becomes particularly critical in complex medical situations where a patient's wishes might otherwise be unclear. It helps to clarify choices about interventions, comfort care, and specific treatments, providing a clear roadmap for their end-of-life care. Effective implementation relies on clear, unambiguous language within the directive and open communication between the individual, their family, and their healthcare team.

Hypothetical Example

Consider Sarah, a 40-year-old financial analyst, who decides to complete a healthcare directive as part of her financial planning. In her directive, she specifies that should she suffer a severe neurological injury resulting in a persistent vegetative state with no hope of recovery, she wishes for artificial nutrition and hydration to be withheld. She also appoints her sister, Emily, as her healthcare agent to make medical decisions on her behalf if she becomes incapacitated.

Years later, Sarah is involved in a serious accident and falls into a coma. Medical professionals determine she is in a persistent vegetative state as described in her healthcare directive. Emily presents the document to the medical team. Because Sarah clearly outlined her wishes regarding life support and designated Emily as her proxy, Emily is able to confidently communicate Sarah's desire to withhold certain treatments, ensuring Sarah's preferences are honored without undue stress or disagreement among family members.

Practical Applications

Healthcare directives are fundamental legal documents used in various aspects of personal and medical planning. They are commonly integrated into comprehensive asset protection and estate plans, alongside wills and trusts. Hospitals and other healthcare facilities routinely inquire about advance directives upon patient admission, as mandated by the Patient Self-Determination Act.¹⁸,¹⁷ These directives empower individuals to:

• Specify Medical Treatments: Detail preferences for or against specific medical interventions, such as resuscitation, mechanical ventilation, or feeding tubes.
• Appoint a Decision-Maker: Designate a trusted individual (a healthcare agent or healthcare proxy) to make medical decisions if the patient is unable.¹⁶
• Guide End-of-Life Care: Ensure that care aligns with personal values and beliefs, especially regarding comfort and dignity in terminal situations.
• Alleviate Family Burden: Reduce the emotional and ethical dilemmas faced by loved ones during a medical crisis by providing clear instructions.

For individuals seeking to create a healthcare directive, resources are available through organizations like the National Council on Aging, which provides forms and guidance on advance care planning.¹⁵

Limitations and Criticisms

Despite their critical role, healthcare directives face several limitations and criticisms. One significant challenge is the potential for documents to be too vague or inflexible, making interpretation difficult in unforeseen medical scenarios.¹⁴,¹³ A directive written years in advance may not accurately reflect a person's wishes if their health status or values change over time, and updates are often neglected.¹²

Another barrier to effective implementation is the low rate of completion and discussion. Many individuals do not complete a healthcare directive, and even when they do, discussions about its contents with family and healthcare providers are often insufficient.¹¹,¹⁰ This lack of communication can lead to situations where directives are not readily available or understood during a crisis. Physicians themselves may face challenges in initiating these sensitive conversations due to time constraints, lack of training, or discomfort discussing end-of-life issues.⁹,⁸ Some research suggests that focusing solely on the legalistic completion of an advance directive may even hinder ongoing, meaningful conversations about a patient's goals of care.⁷ Furthermore, while generally legally recognized, the exact requirements and enforceability of a healthcare directive can vary by state, and some medical situations may arise where a healthcare provider might not follow wishes precisely, particularly if medical consensus deems the requested treatment outside of reasonable practice or if there are conflicts of interpretation.⁶,⁵,⁴

Healthcare Directive vs. Living Will

The terms "healthcare directive" and "living will" are often used interchangeably, leading to some confusion. However, a key distinction exists:

• Healthcare Directive: This is a broad term encompassing any legal document that outlines an individual's wishes for medical care and treatment in the event they cannot make decisions for themselves. It can include various components.
• Living Will: This is a type of healthcare directive. Specifically, a living will is a written statement detailing an individual's desires regarding life-sustaining treatment and other medical interventions if they become terminally ill, permanently unconscious, or otherwise unable to communicate. It primarily focuses on the medical treatments to be accepted or refused in specific critical conditions.³,,²

While a living will explicitly states treatment preferences, a healthcare directive might also include the appointment of a healthcare agent (also known as a medical power of attorney or healthcare surrogate), outlining who can make medical decisions on the individual's behalf. Thus, a living will is a specific instruction set, while a healthcare directive is the overarching category that may include both specific instructions and the designation of a decision-maker.

FAQs

Q: Who needs a healthcare directive?

A: Any competent adult aged 18 or older should consider having a healthcare directive. Unexpected illness or injury can occur at any age, making it crucial to have these documents in place to ensure your wishes are known and respected.

Q: Do I need a lawyer to create a healthcare directive?

A: While a lawyer can help ensure the document is legally sound and tailored to your specific needs, it is generally not a legal requirement to use one. Many states provide free, easy-to-use forms. Organizations like the National Council on Aging also offer programs to guide individuals through the process.¹

Q: Can I change or revoke my healthcare directive?

A: Yes, you can change or revoke your healthcare directive at any time, as long as you are mentally competent. It is crucial to review your directive periodically, especially after significant life events (e.g., marriage, divorce, diagnosis of a serious illness, or the death of a designated beneficiary or agent), to ensure it still reflects your current wishes. If you make changes, ensure all old copies are destroyed and new copies are distributed to your healthcare agent, family, and medical providers.

Q: What happens if I don't have a healthcare directive?

A: If you don't have a healthcare directive and become unable to make medical decisions, state laws will typically determine who can make decisions on your behalf. This is often a spouse, adult children, parents, or other close relatives, or potentially a court-appointed guardian. Without your written wishes, these individuals may face difficult choices and potential disagreements, and your preferences might not be fully known or honored.