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Understanding Advanced Directives

by Paul T. Campana, LSW

As we watch our loved ones grow older, we tend not to dwell on their inevitable demise. While there are few of us who look forward to the death of those we love, we should take responsibility NOW for making some decisions. This can make the process of death easier, for when competent decisions should be made for our loved one, he or she may be unable to do so. It is now that we should all look deep into our souls and make decisions about the health care for those loved ones we care about. There are legal documents which enable a person to make decisions prior to their incapability. In Massachusetts these documents include a Durable Power of Attorney for Health Care or Health Care Proxy.

A "Health Care Proxy" allows you to choose a person with whom you instruct to fulfill your health care wishes in the event that you are incapacitated, and you are unable to speak for yourself. It is a document that formally designates a relative or significant other to make decisions on your behalf. It is used by someone you trust and have designated to make health care decisions for you if you are not able to make them for yourself. In effect, you assign someone else the authority to perform certain acts as your agent, consistent with your health care wishes, if you become incompetent.

There are also treatments to take under consideration when instructing someone to make decisions for you. They may be, "Do Not Resuscitate" or "DNR", "Artificial Hydration and Nutrition", and "Comfort Measures Only".

A DNR order, may be ordered only by your primary physician per direction of the patient, or the Health Care Proxy. No one has the legal, or ethical right to proceed with CPR (cardiopulmonary resuscitation) without the consent of the person involved. As a Health Care Proxy Agent, you are the legal representative, if the person is unable to express their own direction of health care as deemed so by a physician. CPR, developed in the 1960s, is the act of applying force to the chest with one's hands, compressing the heart and filling the lungs with air. DNR is the act of not performing CPR. This is a very difficult decision for every-one, and more difficult for those who have no direction from their loved one.

Artificial Hydration and Nutrition, or Intravenous (IV) Therapy is a common method of artificial hydration. By the means of a needle inserted most commonly in the arm, a patient can receive fluids and medications. Fluids and medication are artificially given to prolong life. There are arguments that no matter what the By means of a needle inserted most commonly in the arm, a patient can receive fluids and medications. There are arguments that no matter what the prognosis, artificial means of hydration should not be denied. Once again, this is an ethical question that is very difficult for most of us, but can be prevented if a persons desires were pre-instructed to the Health Care Agent prior to this critical time in their life.

Comfort Measures Only is another desire expressed by a person that a primary physician must write an order. Comfort Measures implies that some medical and nursing interventions will not be delivered. Certain medical interventions are clearly intended to provide comfort to a patient and not prolong the dying process. Pain medications or other medicines may be used to obtain comfort for the patient, who may have been opposed to antibiotics to treat an infection. Diagnostic testing would be eliminated if there is to be no active treatment. A feeding tube would not be initiated and IV therapy would be utilized for pain medication only, and not hydration. Surgery and/or any hospitalizations would not be expected, or desired.

We should all look towards filing a Health Care Proxy now when we can act in a positive, proactive role to express our desires. You and your loved one can then find great comfort in knowing your wishes will be fulfilled, and not reacting upon when a critical condition arises. Both the patient and their loved ones may also feel great healing and comfort in moving from attempting to cure the condition, to moving towards a more dignified death.

The American Society of Law, Medicine, and Ethics:
Non-profit educational & research organization devoted to critical thought in health law, medicine, bioethics & patient care. ASLME offers 2 nationally known peer-reviewed journals, as well as national conferences on emerging topics in law & medicine.

Information about Five Wishes:
Five Wishes is a document that helps you express how you want to be treated if you are seriously ill and unable to speak for yourself. It is unique among all other living will and health agent forms because it looks to all of a person's needs: medical, personal, emotional and spiritual. Five Wishes also encourages discussing your wishes with your family and physician.

Five Wishes lets your family and doctors know:

  • Which person you want to make health care decisions for you when you can't make them.
  • The kind of medical treatment you want or don't want.
  • How comfortable you want to be.
  • How you want people to treat you.
  • What you want your loved ones to know.


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