September 24, 2015

The Addendum to My Advance Directive: Palliative Care, not Life-Sustaining Procedures

In yesterday's post, I provided the text of the basic advance healthcare directive I'll attach to my revised will. It's fairly standard.

My directive first provides for the appointment of "my durable power of attorney for health care." This individual (also the executor of my will) is empowered to make decisions about my healthcare if there comes a time when I cannot make those decisions myself.

I want to know there is someone who can respond fluidly as my medical situation changes, someone who can deal with situations I can't foresee. I'll add instructions above and beyond what is detailed in the standard directive, to help my healthcare attorney/agent carry out my wishes.

I want to clarify these key preferences in most health care crises: 
  • for palliative care, not life-sustaining procedures, and 
  • for hospice, not hospital.

Questions have been raised about the legality of a provision, like the one I have here, that authorizes my agent to arrange for VSED (voluntarily stopping eating and drinking) in the event I have dementia. I discussed this issue in an earlier post

I'll wrap up this series on advance directives tomorrow.

Here are the additional instructions I'll add to the standard directive:

I direct that my healthcare providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the following:

(A) I direct that no life-sustaining procedures be started and, if started, that they be withdrawn if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, (3) I undergo a marked lessening of my cognitive powers due to dementia, Alzheimer’s disease, stroke or a sudden and permanent brain injury, or (4) my Agent believes the likely risks and burdens of treatment will outweigh the benefits.

(B) My body has been seriously weakened by a progressive disease. If life-sustaining treatment of any kind is not expected to return me to the physical, emotional, and mental competence needed for me to live independently, then I direct that such treatment not be given or be withdrawn. I do not wish to be resuscitated.

(C) If pain medications fail to relieve all pain; major weight loss occurs; lack of appetite appears to herald cachexia or anorexia; break-through abdominal pain or delirium occur; or I fail to recognize medical staff or friends, for example, I direct my Agent to withdraw all life-sustaining treatment and, further, to ensure that I do not receive any fluid or food, whether by IV, tube feeding, or otherwise. I wish to die by voluntarily stopping eating and drinking (VSED).

(D) If any of the conditions described in (A) or (B) or (C) above is present, I direct that I not be given CPR, blood or platelet transfusion(s), artificial nutrition whether enteral or parenteral, dialysis, surgery, resuscitation or any other life-giving or life-sustaining treatment and that I not be placed on a ventilator or given intrustive diagnostic tests, including those requiring drawing my blood. My wish is that I be allowed to die quietly
by voluntarily stopping eating and drinking (VSED).

(E) Treatment for alleviation of pain or discomfort is to be provided at all times, even if it hastens my death or makes me lose consciousness.

(F) I wish to be kept fresh, clean and warm at all times. I direct that my Agent consult with a palliative care physician and that all recommended palliative procedures to ease my physical and emotional suffering be instituted. These include frequent position changes and meticulous oral, nasal, and conjunctival hygiene. In this respect, insertion of a urinary catheter should be considered by my physician. I do not wish to be provided oxygen except as a palliative measure.

(G) If I am in a hospital, I direct my Agent to transfer me to a private room in a palliative care wing. If I am not in a hospital or if transfer to the palliative care wing is not possible, I direct my Agent to transfer me to a private room in a skilled nursing facility that agrees to follow these instructions.

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