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Who Will Make Your Health Care Decisions?
Jan L. Warner & Jan Collins

Question: My father is 86 and has lived with my husband and me since my mother died six years ago. My sister lives more than 1,000 miles away and has little input into anything substantive about Dad. Although we want to help him prepare for the inevitable, Dad has refused to sign a living will. My concern is that since he is going into the hospital and they have asked for his living will, not having one could change the treatment he receives. How can we convince him this is the best thing to do?

Answer: While we heartily endorse the execution of appropriate advance directives, we don’t know if signing a living will is the appropriate decision. By “advance directives”, we mean documents that say now how you want to be treated medically if, in the future, you are unable to express your wishes. As one expert said, we sign advance directives when we are vertical to deal with future medical issues when we are horizontal.

A living will is one of several documents that fall under the general heading “advance health care directives” or “advance directives.” A “living will” is more limited and restrictive than most advance directives because it becomes effective when we are either terminally ill or in a “persistent vegetative state” – that is, have no brain waves – and, in either case, are incapable of making appropriate decisions about our health care. By signing a living will, we are forced to decide today that life-sustaining medical measures, hydration, and nutrition be withheld or withdrawn at some future date without regard to advances in medical technology that we may not know about at the time we sign the document.

By contrast, the health care power of attorney, in our view, is a more flexible document by which we can appoint a trusted family member or friend to make health care decisions should we be unable to do so ourselves. But unlike the living will, our agent can be mandated to discuss our condition with our physician and then make an appropriate decision based upon the circumstances that exist at the time the decision is made, rather than those that were in effect when we signed the document. And unlike living wills, our agent’s authority to make our health care decisions is not limited to end of life, but extends to any time we are unable to speak for ourselves – for example, while we are under anesthesia.

Most deaths follow a very personal decision made near the end of life. Most people die in institutions after an extended and deteriorating illness or acute injury. Today, most people would like to be able to determine in advance both the quality and quantity of their end-of-life experience. Establishing the desired parameters and budgeting resources should be done in advance of a catastrophe. However, because of a lack of appropriate training and understanding of the issues, we believe that many hospitals, physicians, and lawyers artificially limit the kinds of advance directives available in each state. Your father should be fully advised about the health care power of attorney. Not to do so restricts the decision-making process that should be available to all citizens.

Question: Why do hospitals ask us if we have living wills when we are pre-admitted?

Answer: Seeing that more than 30 percent of the Medicare budget was being spent on 1.2 million recipients who died each year in acute care facilities, Congress began practicing health care cost containment on December 1, 1991 when the Patient Self-Determination Act became law. Through this law, Congress required that hospitals, HMO’s, nursing homes, and other health care providers inform patients -- and the community -- about advance health care directives as a condition of continuing to participate in the Medicare and Medicaid programs. But Congress did not fund the necessary educational programs even though statistics tell us that the average cost of medical treatment for a patient who dies without an advance directive is approximately three times higher than for a person who has signed advance directives. For more information, keep reviewing our site.

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Planning Your Future with 20-20 Vision™

Today, more than 36 million Americans are age 65 or over. There are more than 22 million family-member caregivers. Then there are the Baby Boomers. All are grappling with the major decisions that accompany the latter stages of life. This book is for them. Written by two experts with decades of experience between them, it is a comprehensive guide that instructs readers about how to create a plan to deal with all aspects of aging, helps maximize options and ensure wishes are carried out.

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