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End of Life Care: Should I sign a ‘living will’?

If you or a loved one have entered a health care facility in the last few years, chances are you’ve been asked to sign some sort of “Living Will.” This document, which supposedly enhances a person’s power to refuse unwanted medical intervention at the end of life, isn’t the “safe and simple” legal solution its proponents make it out to be.

Before signing a Living Will, you need to know some important facts–facts that could mean the difference between life and death.

Euthanasia advocates formulated the Living Will

The Living Will was suggested at a meeting of the Euthanasia Society of America (now called Choice in Dying) in the late 1960s. By the mid-1970s, the Society’s educational arm had distributed three quarters of a million copies. Euthanasia advocates publicly admit that the Living Will was instrumental in promoting societal acceptance of euthanasia.(1)

Living Wills are vague and oversimplified

Although proponents claim that these documents allow patients more decision-making power, Living Wills, because of their vague language, actually give that power to doctors. These doctors may not know the patient or the patient’s medical history–let alone his/her specific wishes regarding end-of-life care.

Most Living Wills contain a statement such as: “If I should have a terminal illness and I am unable to make medical decisions, I direct my attending physician to withhold or withdraw medical treatment that prolongs the dying process and is not necessary to my comfort or to alleviate my pain.”

On the surface this statement may sound clear. However, it leaves many questions unanswered such as: What is a “terminal illness”? Who is an “attending physician”? What is “medical treatment”? All of these crucial terms are open to wide interpretation.

“Terminal illness” may be defined as one that, with or without treatment, will cause death. Is the time-frame for this terminal condition one month? One year? Two years?

One definition within Veterans Administration guidelines defined terminal illness as a “debilitating condition which is medically incurable and which can be expected to cause death…and includes but is not limited to conditions where death is imminent, as well as chronic and debilitating conditions from which there is no reasonable hope for recovery.”(2) Under such guidelines, ordinary medical treatment could be withheld from patients with ailments such as heart disease and diabetes!

Is an “attending physician” the physician whom you just met, who knows nothing about your medical history? In the course of one day in a hospital, you could see as many as three “attending physicians.”

Does “medical treatment” include such basic necessities as food and water? Courts have ruled that food and water may be considered “medical treatment.”(3)

These vague statements are open to interpretation and definition–not by you (the patient), but by others.

How you feel when you sign a Living Will may be different than how you will feel when you actually need care

When a healthy person signs a Living Will, he or she may be thinking about wanting to die a peaceful death when the time comes–without ineffective or gravely burdensome (extraordinary) treatment.(4) However, once a Living Will is signed, there is no way to control how its instructions will be carried out. Physicians also have recognized this problem saying, “Patients may find it difficult to understand all the medical issues [at the time of signing a Living Will] or they may change their decisions. Moreover, the clinical circumstances may be different from what the patient anticipated, making it necessary to adapt the patient’s explicitly stated preferences to the actual situation.”(5) But if you are unable to communicate your exact wishes to others at the time you need care, the broad, vague statements in the Living Will may speak for you!

You are not required to sign a Living Will or any other advance directive

Some people are under the impression that federal law requires you to sign a Living Will. This is false!

In 1991, the federal Patient Self-Determination Act (PSDA) went into effect. This law requires most health care facilities and programs that participate in Medicare or Medicaid to share information about advance directives such as Living Wills with all adult patients.

However, you are not legally bound to sign any document! You may not be denied health care for refusing to sign an advance directive.

Signing a Living Will is not a simple matter, nor is it necessary. In fact, your Living Will could become your death contract.

You already have the legal power to control decisions surrounding your health care. No law or ethical standard requires you to accept completely ineffective or gravely burdensome measures to prolong your life. Even without a Living Will, you are still in control.

But, you must exercise this control properly. The absolute sanctity and inherent quality and equality of every human life requires us to use ordinary means of medical treatment and care to preserve our lives. In contrast, the Living Will shares the philosophy of the euthanasia movement that certain lives don’t need to be preserved because of their so-called “low quality.” To the extent that a Living Will allows the omission of ordinary means, it reflects this philosophy and can lead to the practice of euthanasia (an act or omission that of itself or by intention causes death).

It is important to talk about your wishes for end-of-life care with your physician and family members. It is also necessary, especially today in an environment of health care cost-cutting and discriminatory “quality-of-life” judgments, to take measures to protect yourself from euthanasia. A pro-life alternative to the Living Will is available from American Life League.

References

(1) See “History of Euthanasia in U.S.: Concept for Our Time,” Euthanasia News, Vol. 1(4), November 1975 (publication of the Euthanasia Educational Council [educational arm of the Euthanasia Society of America]), pg. 3.

(2) Veterans Administration policy guidelines. November 18, 1991. Policy M-2, part 1, Chapter 31, pages 31-32.

(3) See Cruzan v. Director, Mo. Dep’t of Health, 110 S.Ct. 2841, 2849-50 (1990) (citing In re Estate of Longeway, 133 Ill. 2d 33, 549 N.E.2d 292 (1989); In re Conroy, 98 N.J. 321, 486 A.2d 1209 (1985)).

(4) For further discussion of ordinary-extraordinary means, consult Life, Life Support, and Death.

(5) Emanuel, Linda and Ezekiel, “Decisions at the End of Life,” Hastings Center Report, Vol. 23(5), September-October 1993, pages 6-7.