Advance directives allow persons to make decisions about medical treatment prior to the onset of circumstances that might precipitate these decisions and in the event of incapacitating illness.
Directives to Physicians and Durable Powers of Attorney for Health Care
A directive to physicians, or living will, allows you to tell your doctor that you do not wish to receive life-supporting measures if this treatment will not help you recover from your illness. A living will is a means of communicating your wishes to your physician or other physicians who may be treating you.
A Durable Power of Attorney for Health Care allows you to name a person to make medical decisions for you if you cannot make these decisions for yourself. You may specify the scope of this decision-making capacity.
The state of Texas requires the use of state statutory forms for advance directives, which may be obtained from your local medical society, bar association or area agency on aging. Hospitals also make these forms available to patients.
Advance Directives do not:
- Keep others from trying to save your life. EMS and Emergency Room personnel are required to attempt to resuscitate you and provide treatment.
- Automatically prohibit medical treatment. Doctors must determine that you are terminally ill and that your condition is hopeless before an advance directive takes effect.
- Keep you from making decisions for yourself about your treatment. You may revoke an advance directive at any time, regardless of your mental state.
- Mean that you will not receive comfort measures if you are terminally ill.
- Make you a candidate for euthanasia.
- Mean that you will receive less care and attention from medical personnel than patients without an advance directive.
Why Use an Advance Directive?
Advance directives help to avoid many problems related to end-of-life medical care. The following hypothetical case illustrates some of the real-life dilemmas faced in treating the terminally ill:
Mrs. Smith discovered her eighty-four-year-old husband in his easy chair unconscious and barely breathing. Panic-stricken, she attempted mouth-to-mouth resuscitation and called 911. Within minutes, an ambulance with EMS technicians arrived and found that Mr. Smith was no longer breathing and had no pulse. After administering CPR and defibrillating electric shocks, Mr. Smith’s heart began beating again, and he was transported to the local Emergency Room. Mr. Smith had suffered a massive heart attack. Doctors offered little hope for recovery.
At the hospital admitting desk, Mrs. Smith was asked many questions, such as address, next of kin, insurance coverage and religious affiliation. She was also asked a question required by law, “Does your husband have an advance directive?”
Hours later, Mr. Smith lay in the ICU. A breathing machine attached to a tube in his windpipe, breathed for him. Drugs prompted his heart to continue beating. He was comatose. During the night his heart stopped again, and more electric shocks were required to regain a heartbeat. An external pace maker was used to help maintain heart rhythm. Over the next two days, his condition worsened. His heart once again stopped beating and could not be restarted, even with fifteen minutes of chest compressions, additional drugs and electrical shocks.
Would you want to be kept alive by a breathing machine, potent drugs or electric shocks if your condition were hopeless? If not, an advance directive may inform medical providers to stop using these drastic measures after it becomes obvious they will no longer help you recover. If Mr. Smith had an advance directive, his medical treatment would likely have changed early on from aggressive rescue measures to comfort care.
Between Life and Death
Because of technological advances in medical care, persons are no longer considered dead just because their hearts have stopped beating or breathing has ceased. CPR and other forms of medical treatment can sometimes get a stalled heart beating again. Ventilators can breathe for us. Renal dialysis replaces the function of failed kidneys. An intra-aortic counter pulse balloon pump and drugs can help maintain blood pressure. These and other techniques have rescued many acutely ill patients from the brink of death.
What then is the brink of death? Health care professionals may conclude that a person has reached the point of no return when no amount of treatment can restore life. Such diagnoses; however, are not always clear-cut. Patients and families are sometimes placed in the difficult place of deciding when it is futile to attempt heroic medical treatment.
As dazzling as they are, all the wondrous medical resources in the world cannot preserve life forever. Studies have shown CPR to revive only thirty-seven percent of the ICU patients for whom this treatment was indicated. Of those who were resuscitated in this way, only seventeen percent lived to be discharged.
Before the advent of these new life-support technologies, an ICU was seen as a way to save lives and relieve the suffering of seriously ill or injured patients. Some are now questioning how humane this intense technology is when used to prolong the suffering of the dying.
Focus has shifted from the right to live to the right to die. After all, what is living? Is it merely breathing, or does quality of life include personal independence, meaningful relationships and relative freedom from discomfort? As Paul said in Phil. 1:23-24, “I am torn between the two: I desire to depart and be with Christ, which is better by far; but it is more necessary for you that I remain in the body” (NIV) .
To understand the need for an advance directive, it is important to know that in the hospital setting all medical treatment (or the withdrawal of treatment) is carried out upon the order of a physician. A Do-Not-Resuscitate order (DNR) is an order by a physician for medical personnel not to perform CPR on a dying patient when resuscitation is unlikely to accomplish long-term good. A copy of the advance directive in the medical record can be very helpful in communicating your wishes to the physician who is considering a DNR order. If an advance directive is not available, the doctor may seek the opinion of your next-of-kin or other substitute decision-maker. The more unclear the situation, the more likely it is that the physician will order every possible means to keep you “alive” as long as possible.
It is your and your family’s responsibility to make sure that physicians who treat you know about your advance directive. Communication can break down in a number of ways. When someone calls 911, paramedics are dispatched to the scene. EMS technicians and ER doctors may not know about a patient’s advance directive and are therefore obligated to do all they can to sustain life. As a result, persons who have gone to great lengths to sign advance directives may still end up connected to life support devices when taken to a local hospital in a hopelessly dying condition. The family may then be required to decide whether or not to remove life-sustaining treatment. Few health care decisions are more difficult to make, but an advance directive can provide guidance in a highly stressful time.
Even for non-emergency hospital admissions, you will be asked by law if you have an advance directive. It is up to you or your loved ones to make sure a copy of the directive is placed in your records.
Another critical transition on the advance directive paper trail occurs when a patient is transferred from a nursing home to a hospital for acute care. Some studies indicate that hospital personnel are informed of a patient’s advance directive during such a transfer in only one out of four cases.
Finally, when the doctor approaches your family for a discussion of life-support measures, family dynamics and grief will come into play. Some families pull together in their sorrow; others have difficulty coming to consensus. Realistically speaking, a physician may comply with a patient’s living will if the family is opposed to it. It is important that you share your wishes concerning life-maintaining medical treatment with your loved ones. A living will can help you do this. If you feel that your family may disagree with you or with each other about your living will, you may wish to use a Durable Power of Attorney for Health Care. If it is the physician who disagrees with the wishes of the patient, he or she is ethically and legally obligated to withdraw from the case if an understanding cannot be reached.
Ethical and Theological Convictions
Bioethics, or the study of ethical decision making in the healthcare setting, evolved out of respect for rights of human beings involved in experiments. Informed consent emerged as one of the first patient rights. This right to individual choice while dependent on healthcare services is the substance of self-determination.
Advance directives are expressions of self-determination at the end of life. The directive to physicians is a communication between patient, family, the health care team, and the larger community that when death becomes imminent, the patient does not wish dying to be artificially prolonged. The Durable Power of Attorney for Health Care identifies the person whom the patient trusts to be consulted when the patient is unable to make his or her own healthcare decisions. By utilizing these documents patients express the profound desire to remain active, responsible participants in all health care decisions, including those at the end of life. Since the end of life may bring periods when the patient is not able to make clear decisions, the patient decides in advance so that others can act in the patient’s behalf.
Because Baptists have long honored the principles of soul competency and the priesthood of the believer, we can deeply appreciate the principle of self-determination. By including these principles among our theological convictions, we affirm the individual Christian’s ability to seek God’s will and to respond to the leadership of the Holy Spirit.
In Christian thought, human beings are understood in terms of our relationship with God. We are dependent, creaturely, limited, as well as purposeful, free to participate and capable of love. To be human is to be relational. To be relational is to be accountable for one’s perceptions, powers and activities to others. Denying this accountability in favor of a life devoted to self-interest and exploration is sin. Affirming our interdependence expresses the willingness to be responsible in our interactions with neighbors and the rest of creation. Interdependence is the shared recognition that our choices impact the lives of others (including future generations) and the subsequent commitment to respect others in ways pleasing to God.
Advance directives affirm interdependence in two ways. First, they communicate our desire to participate in crucial decisions, which impact not only our own lives, but also those of our families, the health care team, and the larger community. Second, they acknowledge a responsibility to sometimes forego self-interest in an age of scarce healthcare resources. This second point is not a discounting of life’s value; rather, it is an affirmation of the lives of others when death is imminent. At its best, an advance directive can resemble Jesus’ request from the cross that his mother be taken care of and that God would forgive his persecutors. This kind of love transcends immediate self-interest to bless and redeem.
Finitude is the acknowledgment of human limitations. We cannot do everything. We cannot know everything. We cannot live forever. If Scripture is clear about anything, it is that human beings are not gods. There is but one God. Human options and activities; therefore, are limited by our finite nature. In every person’s life, there comes a point when he or she must accept or deny finitude. Often that choice happens in a medical center. When it does, an advance directive can express your affirmation of finitude as part of God’s will and instruct your caregivers to respect that value in an age in which not only death, but also aging are treated as bitter enemies. Countless resources are being exhausted in the pursuit of eternal youth. Christians proclaim Jesus Christ has taken away death’s sting and nothing that happens to us in this earthly existence is the last word in our stories. Advance Directives can express our belief that there are worse things than death. They can concretize in legal and medical terms our faith that death is not final and that the Lord is our Good Shepherd even beyond death.
Advance Directives and Christian Discipleship
For the Christian, death is neither the end of life nor the failure to heal. Because Christ is “the resurrection and the life” (John 11:25), we can face our own finitude and prepare for our own death. Living in the Reign of God, we have already passed from death unto life and rightly regard cessation of physical existence as a form of passage into the fullness of resurrection. We are encouraged in Scripture to comfort one another with this central hope (1 Thess. 4:17-18).
Facing our mortality is not morbid, but an opportunity to exercise good stewardship, just as Jacob blessed his sons and gave instructions to them concerning his burial (Genesis 49:29-33). We do well to follow his example. Some seek the assurance that their estate will not be spent on futile medical care. For others, advance directives embody the desire to be treated with dignity in their final hours.
Sparing families the stress of difficult decisions during a stressful time is another common motivation for signing an advance directive. The Gospel emphasizes the importance of relationships and good communication. While any significant decision contains the seeds of potential conflict, clearly making our wishes known may alleviate difficulty for our family as they try to do what is best for us when we are no longer able to speak for ourselves.
Some may object to advance directives as a form of euthanasia, but there is clearly a fundamental difference between the two concepts. Euthanasia involves causing someone to die. An advance directive is a request that we allow a person to die when the time comes out of respect for the person’s clearly expressed wishes.
Nor is an advance directive a way to facilitate suicide. An advance directive does not take effect unless a person’ death is imminent—when extraordinary life support would only delay the inevitable. Even when death is imminent, an advance directive does not authorize positive actions, which would hasten death.
Some Practical Suggestions
Investigate advance directives for yourself. You can secure copies of standard forms at your local medical center. Read them carefully and discuss them with your family. Pray for God’s wisdom and guidance. If you believe advance directives are worth pursuing, discuss your wishes with your physician. At its best, an advance directive is the beginning of some deeply significant interactions within families and communities.
If you choose to complete one or more of the standard forms, do so before you reach a crisis. Remember that they can be revoked at any time. Once completed, make several copies to be distributed among family members and physicians. Upon each admission you must present your medical center with a copy of these advance directives. The medical center will not keep one on file because of your right to revoke or alter these documents between admissions.
Encourage your fellow church members to engage in discussion groups regarding bioethical issues. Your local medical center or Texas Baptist Christian Life Commission can offer valuable resources in this endeavor.
“Advance Directives” is one of fourteen articles in the Getting Well: Christian Perspectives on Health, Sickness, and Ministry series. Getting Well deals with major health and biomedical issues.
Christian Life Commission