“I’m trying to die correctly, but it’s very difficult you know” (Lawrence Durrell 1988)
Although the concept of a right to die has intrigued philosophers since the time of the Greeks, only in modern times has it become a widespread social concern. There is a strong push in this country to have everyone create advanced care directives concerning the care they wish to receive if they contract a terminal illness or condition. Advance Directives are specific instructions, prepared in advance, that are intended to direct medical care and decision making for an individual should he or she be unable to communicate these wishes in the future. Living Wills, medical powers of attorney for health care, DNR orders (Do Not Resuscitate), and completed Organ Donor Cards are all examples of Advance Directives. Interestingly, although surveys show that up to 75% of Americans approve of Advance Directives, only 7–20% have developed the Directives for themselves. The time to prepare your quality of death is now. . .when you take living and logical thinking for granted.
We all would like to imagine that our deaths will be quick and painless; we fear unpredictable circumstances; we cogitate and vacillate and procrastinate. . .but in the process, we may be too late in defining our fate. The process of creating advance directives can be difficult–one must consider both quality of life and the potential for death. The implications of choosing or refusing specific forms of treatment need to be evaluated. In the creation of advance directives, an individual should confer with health care providers, family, friends, and in some cases, even legal counsel. We fear the unknown; we don’t want to suffer. Why not commit some time and energy now to directing our wishes at the end of our lives? ” To fear death, my friends, is only to think ourselves wise, without being wise: for it is to think that we know what we do not know. For anything that men can tell, death may be the greatest good that can happen to them: but they fear it as if they knew quite well that it was the greatest of evils. And what is this but that shameful ignorance of thinking that we know what we do not know?” (Socrates 469-399 B.C.)
Fifty states and the District of Columbia have laws authorizing the use of some type of advance directive. But these laws do vary from state to state, and an individual should try to enforce advance directives that reflect the most recent changes in state law. As a threshold goal, most people should execute both a Health Care Power of Attorney that names a trusted person as agent or proxy and a Living Will that provides guidance about one’s wishes. At the appropriate time, an agent under the power of attorney can respond to the specific, sometimes complicated circumstances of a patient’s terminal illness with full knowledge of the patient’s values. It is a mistaken assumption that Advance Directives mean “don’t treat.” True, most people do use them to avoid being kept alive against their wishes when death is near; but Advance Directives are also used to indicate that a patient wants all possible treatments within the range of generally accepted standards. And, no Advance Directives preclude an individual from pain control, comfort care, and respect for dignity during the dying process.
Several other misconceptions are worth noting. Some people assume that lawyers are needed to execute Advance Directives. Though lawyers can be a helpful resource, official forms can be obtained from individual state agencies, physicians’ offices and even from the Internet. Just remember, you are free to add or modify the language to reflect your wishes more accurately. Whatever the circumstances, make sure your directives are witnessed appropriately. Don ‘t mistakenly expect your families to know what you would want or to agree unanimously on best courses of action if you have no Advance Directives. In such cases, disagreement may undermine family consent, and a hospital physician or specialist who does not know you well may ultimately become the default decisionmaker. Additionally, when you do not make your wishes clear in Advance Directives, you may generate needless agony in your family members and others close to you as they struggle to make life and death decisions without clear guidance from you.
Do not think of Advance Directives as an “old person’s” issue. If you remember, the most well-known landmark court cases in this country were those of Nancy Cruzan and Karen Ann Quinlan. . . both in their 20s. Although we tend to think of death and dying as old age issues, the stakes are actually higher for younger persons. If we develop incurable diseases at a younger age, we have the potential to be kept alive for decades in conditions we would not want.
Woody Allen is quoted as saying “It’s not that I’m afraid to die, I just don’t want to be there when it happens.” Be proactive and finalize your Advance Directives now. It’s never too early. . .and if you’re too late, you have no say in whatever transpires. Remember, you give up no authority or choice by doing an Advance Directive. As long as you remain able to make decisions, your consent must be obtained to continue or discontinue any medical treatments; you may override the proxy or revoke the directives at any time. Please take the appropriate steps now to specify directives at the end of your life. You’ll be doing everything in your power to be dead right. .
Stephen L. Hines, M.D.
April 2000
