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The legal forms
There are several forms that are used to express your wishes should you be unconscious or unable to participate in decision-making. Two of them you can fill out yourself. Together they are called an “advance directive”. You do not need an attorney to complete them, and you can revise them at any time. You can download these forms from this page and get started.
A Health Care Power of Attorney is a document in which you give another person the power to make decisions related to your health care in the event you are unable to speak for yourself. This tells your doctor, and your family members, who you want to make decisions. You should appoint a person you trust and who knows how you feel about medical procedures at the end of life.
A Living Will is a document that gives instructions to help your Health Care Power of Attorney understand your wishes. If there are certain situations where you would prefer to be allowed to die a natural death and not be kept alive by medical treatment, heroic measures, or artificial means, the Living Will is where you describe those preferences. For instance, if you are in a persistent vegetative state, you might want different treatment than if you were simply unconscious. There is space on the form to where you can write out instructions about all kinds of care: resuscitation, ventilators, tube feeding, etc. (The rest of this article can help you sort out those decisions based on your own values and beliefs.)
Remember, this document will only be used if you are no longer able to make decisions for yourself. It can be changed or canceled at any time, as long as you are still competent and able change it.
On June 12, 1991, South Carolina adopted a new Living Will form. The old form does not say anything about permanent unconsciousness and does not allow tube feedings to be withheld in most situations. If you signed a Living Will in South Carolina prior to June 12, 1991, it is still valid. However, you may want to review your Living Will and consider signing a new one.
Mercy Hospice, like most institutions, will honor your Advance Directive and support your rights as a patient to voice your health care decisions. If you are a patient at Mercy, please inform us if you execute or change any of these documents during the course of your care.
A Do Not Resuscitate (DNR) order is a specific set of instructions from your physician NOT to start cardiopulmonary resuscitation (CPR). This means no attempts would be made to try and restart your heart after it has stopped beating. Typically these forms are used only if you are on hospice care. If you have a terminal condition and your desire is to allow a natural death, you will want your doctor to complete a DNR.
Your physician will not create a DNR unless he or she has received instructions from you, or your Health Care Power of Attorney (if you are unable to speak for yourself). The DNR is a separate order from the Living Will because it is considered instructions directed specifically to medical personnel. Like a prescription, it is on a special form and needs to be documented in your medical records. You many change your wishes regarding DNR status at any time.
There are two (2) types of DNR orders. One is signed by your physician expressing your wishes while you are in your home. The second DNR order applies to the event in which you may be in an ambulance for transfer to a hospital emergency room, physician office or nursing home. Without these forms, medical personnel will be obligated to perform CPR if your heart stops beating. If you want a natural death and agree to a DNR, please display the notice prominently in your home and be certain that everyone knows of your desire not to be resuscitated.
Please contact Mercy Hospice and Palliative Care if you have any questions or wish to complete an Advance Directive. Our number is 843-347-5500.
You may also call:
- Horry County Council on Aging at 1-800-868-9095 or
- The Long-term Care Ombudsman Division in Columbia, South Carolina at 1-803-898-2850.
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How do I decide about life-supporting
measures?
The most difficult decisions a health representative must make involve those that may extend life when in the natural course of events the person would die. Decisions may have to be made about machinery or procedures that assist with breathing, digestion, or circulation. If a person has a curable condition, these procedures can be implemented temporarily until the body can manage on its own again. In the context of a terminal illness, however, they often prolong life and simply postpone a death that is inevitable. At this stage, the patient is usually unable to make his or her preferences known. Decisions to use or not use life support are difficult for family members to make on behalf of someone they love. Planning ahead and making your wishes known will help everyone involved.
As you make plans about specific forms of life support, gather the facts you need to make an informed decision. In particular, you must understand the benefits as well as the risks and alternatives that any treatment may include. A treatment may be beneficial if it relieves suffering, prompts the body to return to full functioning, or enhances quality of life. The same treatment may be considered burdensome if it causes pain, prolongs the inevitable dying process, or subtracts from quality of life. Facts about commonly used life-support measures are described in the next section of this article. They may sound rather grim and extremely final, but remember, you are considering these matters not in the context of the present moment, but in the context of the final days of life.
In addition to helping you investigate and understand the facts, making end-of-life decisions asks you to draw upon your values and ethics and any religious beliefs you may have. Some people find it difficult to put these considerations together and translate them into practical decisions. To help you, we have included in italics the thoughts of individuals who have made decisions regarding when to stop life support. We don’t promote or discourage any one position; we simply provide these statements as a springboard to perspective and a way to help you clarify your own desires concerning various life-support measures. For example, read the following passage and see how you respond:
"If there is a chance that life support will actually get me back to where I was when I was healthy and enjoying life, then it would be OK for a limited time, say ten days. If I am so sick and miserable, and there is no reasonable chance of recovery to a quality of life I would accept, then I would like to have vigorous comfort measures but would not want my life extended beyond what my body will support on its own."
Do you agree? Disagree? You can use these quotes to help clarify your own values and preferences. (Return to list)
Commonly used life-support measures
Tube feeding: Often called "artificial nutrition or hydration," tube
feeding can provide a balanced formula of nutrients in liquid form even if a
person is unable to swallow. A tube either is placed down the nose
and into the stomach or is inserted through a small hole
in the abdomen. This procedure can be a short-term solution to
a sudden illness, or it can be used to help people who are
in a coma or have some other long-term condition that makes eating difficult.
It can provide a quality of life acceptable to some people, but near the end
of life, it often merely prolongs dying. Without tube feeding, a seriously
ill person will die in a matter of days or weeks. However, the
process appears to be painless, and people report that the
sensations of hunger go away after the first 24 hours. (For more information
about artificial feeding, see our article on Nutrition.)
"I personally abhor the idea
of being kept alive with a bunch of tubes sticking out of
me. It strikes too deeply at my dignity. At some point we all need to go. If
I am unconscious or am not eating for some other reason, do not prolong my life
through artificial feeding. Let nature take its course."
Cardiopulmonary resuscitation (CPR): Many of us have seen television dramas in which the health care team uses electric shock or pounding on the chest to stimulate the heart to resume beating. This is definitely a life-saving technique, and in the context of a generally healthy person who suddenly has a heart attack, it can result in years or even decades of healthy, active living. In the context of chronic or terminal illness, however, studies indicate that only about 15 percent of people advanced in age or illness leave the hospital alive after CPR. In other words, 85 percent die in spite of receiving CPR. Those people who do get CPR and survive often suffer from broken ribs as a result of the process. Although CPR could mean the difference between life and death, it is not a gentle procedure and could well be a traumatic way to die if a person is already near the end of life.
"Given the statistics about CPR, I only want it if I have a reasonable chance of recovery to a healthy state. For instance, if I have a sudden heart attack but have been healthy enough to lead a fairly functional life, do CPR. If I am debilitated by cancer, however, and my heart stops, do not do CPR."
Ventilator (breathing machine): A ventilator is a machine that helps the body breathe by pushing air into the lungs through a tube inserted down the throat. A ventilator can keep a person alive when the lungs have stopped breathing on their own. Ventilators are commonly used for a short time after surgeries. They can also be used for long-term chronic conditions, although they severely restrict one’s ability to move or talk. They can be uncomfortable because their breathing rhythm may not be synchronized with a patient’s natural rhythm. Coughing or crying, for instance, is difficult on a ventilator because the machine forces a regular breathing pattern and cannot accommodate variation. The tubes themselves may cause pain or discomfort. Given the alternative, however, some people find that being on a ventilator is an acceptable quality of life. Bear in mind that ventilators used near the end of life rarely contribute to a full recovery. More often, they prolong the moment of death. Choosing this course may be appropriate if family members need time to arrive from far away. Depending on the condition, a person who needs a ventilator but goes without it usually dies within minutes or hours of its removal.
"I would be willing to go on a ventilator for a limited time, say four days, if the doctors felt I just needed a little help, and there was more than an eighty percent chance that I would breathe on my own again. If it’s determined that my body will not breathe independently off the ventilator, I want to be taken off but sedated so I do not have to feel anxious as I stop breathing."
Antibiotics: Antibiotics are drugs that are used to fight infection. They can be given either in pill form or intravenously. Although they are very effective at fighting disease, antibiotics can cause numerous side effects such as rashes and nausea. Certainly if a person has an infection that is causing pain, antibiotics are highly recommended for their ability to give comfort. Depending on a person’s general state of health, antibiotics may help him or her survive an infection. In some cases, without antibiotics a person who is seriously ill could die within a few hours to a few days.
"If I have a terminal illness and get an additional infection that is causing me pain, give me antibiotics. I don’t want them as a means to prolong my life, but as a means to keep me pain free. On the other hand, if I have a terminal illness and also contract pneumonia or some other painless infection, do not give me antibiotics. Pneumonia is a reasonably painless way to die, and since I’m going to die anyway, let me go peacefully."
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For more information
If you would like to read more about advance directives and health care planning, the American Bar Association has an excellent toolkit you can access online:
Consumer's
Tool Kit for Health Care Advance Planning (downloadable
off the web)
Tool 1: How to Select Your Health Care Agent or Proxy
Tool 2: Are Some Conditions Worse Than Death?
Tool 3: How Do You Weigh Odds of Survival?
Tool 4: Personal Priorities and Spiritual Values Important
to Your Medical Decisions
Tool 5: After Death Decisions to Think About Now
Tool 6: Conversation Scripts: Getting Past the Resistance
Tool 7: "Proxy IQ Test" for Family or Physician
Tool 8: What to Do After Signing Your Health Care Advance
Directive
Tool 9: Guide for Health Care Proxies
Tool 10: Resources for Advance Planning for Health Care
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