September 25, 2015

Advance Directives: Reducing Costs and Improving Healthcare

With the death of Oliver Sacks, Atul Gawande becomes my favorite doctor/medical writer. He has taken on issues that resonate with me. His recent book Being Mortal describes how doctors, uncomfortable discussing their patients' anxieties about death, fall back on false hopes and treatments that actually shorten lives, not improve them.

Overkill, his most recent article for the New Yorker, carried this subtitle: 
An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?

One of the best things we can do is prepare an advance directive that spells out for doctors and other healthcare providers what we want them to do, and what we don't want them to do. When I read and write about healthcare issues, I'm often frustrated because there's often so little I can do. That's not the case here.

Drafting an Advance Directive
There are two types of advance directives, and it’s important to have both.
  • A living will spells out what types of medical treatment you want at the end of life if you are unable to speak for yourself.
  • A health care power of attorney is someone you appoint to make healthcare decisions on your behalf. That agent (also called an attorney-in-fact or proxy) becomes your spokesman and advocate on all the medical treatments you address in the document.
Many states combine the two forms into one document. Advance directives are legally valid throughout the United States, and you don't need a lawyer to complete one.

One state's advance directive doesn't always work in other states. If you spend significant time in several states, you should complete advance directives for each state.

An advance directive does not expire. It remains in effect until you change or rescind it. If you want to make changes, you should complete a new document.

To download a free advanced directive form for your state, click here.

Health Care Power Of Attorney
Your healthcare agent makes decisions only when you cannot communicate them yourself. If you regain the ability to make decisions, your agent may no longer act on your behalf.

Your  healthcare "attorney" need not be a lawyer. You'll likely name a family member or close friend whom you trust to make serious decisions. That person should clearly understand your wishes and be willing to accept the responsibility for making medical decisions for you.

Living Will
Before your health care proxy can take over and make medical decisions on your behalf, two physicians must certify that:
  • You are unable to make medical decisions, and
  • You are in the medical condition specified in your state's living will law (such as "terminal illness" or "permanent unconsciousness").
Under the DC law, my healthcare attorney can start making medical decisions only when my doctor and one other qualified health professional (either a psychologist or psychiatrist) certify that I lack "sufficient mental capacity to appreciate the nature and implications of a health care decision, make a choice regarding the alternatives presented, or communicate that choice in an unambiguous manner."

The DC law also specifies that my attorney "does not have authority to authorize abortion, sterilization, psycho–surgery, or convulsive therapy or behavior modification involving aversive stimuli, unless authorized by a court."

Will My Directive Be Honored?
As I noted in an earlier post, advance healthcare directives are often not honored for various reasons. At this stage in my life, I'm making an extra effort to guarantee that my directive is honored.

I've already emailed a copy of the draft to my kids, my housemates, and the friend who will become my health care proxy. I checked with my neurologist, who requested a copy of the final directive. I'll make sure my gerontologist receives a copy, too.

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