Keeping Control When Major Illness Strikes

Using Living Wills And Appointing Medical 'Surrogates'

By Geanne Perlman Rosenberg
Investor's Business Daily, October 16, 1995, pp 1-2
When it comes to life-and-death decisions - and it's your life - you don't want to be out of the loop.
Yet an estimated 75% of adult patients have made no provision for how they should be treated if and when a medical catastrophe strikes. Those who fail to plan ahead risk treatment contrary to their wishes. And they may burden their loved ones with agonizing choices - choices that often add guilt to grief.
Who should have a living will or other written document with instructions in case of a devastating medical condition?
Anyone over the age of 50 and any other adult with a potentially incapacitating illness, experts say. Some experts take it even further, advising that every adult plan for the possibility of an incapacitating accident or illness.
Dr. Linda Emanuel, an internist and medical ethicist at Massachusetts General Hospital in Boston and an expert in living wills, routinely discusses patients' living wills, routinely discusses patients' wishes concerning medical intervention, regardless of their age.
She says that when patients are asked initially about catastrophic medical illness, they will sometimes say, "Don't get me stuck on a machine."
But she says such a superficial instruction isn't helpful. If the patient comes into the emergency room with pneumonia, he probably does want to be hooked up to a machine if it will save his life and lead to a complete recovery.
Here are some factors you should consider as you plan ahead:

Traditional living wills don't go far enough. According to John J. Lombard, an attorney specializing in health-care decision making at Morgan, Lewis & Bockius in Philadelphia, traditional living wills tend to be too general.
These wills may state that doctors should refrain from taking heroic measures to prolong the patient's life in the event of terminal illness or a persistent vegetative state. But such a vague message fails to anticipate the many situations that can arise and can leave family members and doctors guessing as to the patient's wishes.
You can tailor treatment to your personal medical situation with "substantive advance directives." These vehicles anticipate the kinds of medical crises that can come up and what treatments you would or would not want.
Major issues include whether you would want a feeding tube in case of a persistent vegetative state and how you feel about life-prolonging measures in case of mental or physical incapacity.
A trusted family member, friend or colleague should be chosen to act as a "surrogate." He or she can make medical decisions in the event you are incapacitated.
Patents also should have backup surrogates in case the original appointee is unavailable. Make sure friends and family know the identities of your surrogates to avoid any challenge to their authority.
If you don't appoint surrogates, you might be stuck with someone you don't want making your medical decisions. Many states are adopting a statutory pecking order for who may make medical decisions in case a patient is incapacitated and has failed to appoint anyone himself.
Surrogates can be given broad powers. Lombard advises that surrogates be given the authority to make health-care decisions, access medical records, disclose medical records to others, hire and fire doctors. consent to or decline medical procedures and hospital admissions and sign consents and releases.
Experts agree that patients should have both surrogates and advance directives detailing their views on treatment. Both devices should be recorded in signed writings in a manner enforceable under state law. In Minnesota, living wills are only valid once they've been given to a health-care worker.
Make sure your living will is placed in the right hands. Don't draft a living will or advance directive and lock it in a safe. Multiple copies should be distributed to your docotrs. including your internist and any treating physicians.
In addition, copies should be placed in your patient and hospital files and should be given to your attorney, family members, surrogates and loved ones. Everyone who may participate in medical decisions should know the game plan.

Emanuel and her colleagues have developed a "medical directive" that patients and their physicians can use to devise and document their wishes in case of incapacitating illness. This work sheet, designed to be a "gold standard advisory document," addresses issues such as how much intervention a patient would want in the event of extreme intellectual impairment or while in a persistent vegetative state.

The American Association of Retired Persons in Washington is disseminating an advance-directives work sheet developed by the American Medical Association and the American Bar Association. Contact your local AARP chapter for further information.