ADVANCED DIRECTIVES

Facts About Advance Directives

What are advance directives?
"Advance directive" is a general term that refers to your oral and written instructions about your future medical care, in the event that you become unable to speak for yourself. Each state regulates the use of advance directives differently. There are two types of advance directives: a living will and a medical power of attorney.

What is a living will?
A living will is a type of advance directive in which you put in writing your wishes about medical treatment should you be unable to communicate at the end of life. Your state law may define when the living will goes into effect, and may limit the treatments to which the living will applies. Your right to accept or refuse treatment is protected by constitutional and common law.

What is a medical power of attorney?
A medical power of attorney is a document that enables you to appoint someone you trust to make decisions about your medical care if you cannot make those decisions yourself. This type of advance directive may also be called a "health care proxy" or "appointment of a health care agent." The person you appoint may be called your health care agent, surrogate, attorney-in-fact, or proxy. In many states, the person you appoint through a medical power of attorney is authorized to speak for you any time you are unable to make your own medical decisions, not only at the end of life.

Why do I need an advance directive?
Advance directives give you a voice in decisions about your medical care when you are unconscious or too ill to communicate. As long as you are able to express your own decisions, your advance directives will not be used and you can accept or refuse any medical treatment. But if you become seriously ill, you may lose the ability to participate in decisions about your own treatment.

What laws govern the use of advance directives?
Both federal and state laws govern the use of advance directives. The federal law, the Patient Self-Determination Act, requires health care facilities that receive Medicaid and Medicare funds to inform patients of their rights to execute advance directives. All 50 states and the District of Columbia have laws recognizing the use of advance directives. The booklet, "Questions and Answers: Advance Directives and End-of-Life Decisions," available from Partnership for Caring, offers more information about advance directives.

Background
An estimated 15% of surgical patients have an active do-not-resuscitate or do-not- intubate clause that reflects the elderly or chronically ill patient's considered preference for a "dignified death" without artificial life support.

Palliative treatment, or comfort care or emergency events might require anesthesia and surgery. These interventions stress physiologic function, suppress consciousness- and precipitate transient, reversible decreases in cardiac and respiratory function, but are not associated with natural evolutions toward the patient's death.

Applying endotracheal intubation and/or mechanical ventilation to support pulmonary function and medications or electric countershock to promote cardiac output are often specifically restricted in an advance directive document. The patient and family may not be aware that these are usual interventions to support vital organ function during the perianesthesia period.

Ethically, ignoring the issue, assuming the patient's wishes or applying a facility policy or medical decision that automatically suspends any patient's DNR/DNI directive during the perioperative period denies the patient's right to self- determination and to autonomous, informed choices.

A patient whose advance directive specifies no life sustaining measures may be unaware that cardiac or respiratory arrest are always potential yet usually reversible outcomes associated with anesthesia. The SurgiCenter of Baltimore asks that at the time of surgery and prior to receiving any anesthetic medication, a patient with an active do-not-resuscitate advance directive reconsider this designation and reclarify wishes about resuscitation during the perianesthetic period.