Planning Your Medical Future: Detailed Information

Most people want to make their own decisions about their medical care. They do not want doctors to decide for them what medical care to give or withhold, especially at the end of life. Yet, a majority of adults have not put their desires in writing, leaving their loved ones to struggle with doctors and among themselves about critical health care choices. Although talking with your loved ones about the specific care you want can be upsetting, it can protect your family from the trauma of making these decisions without your input should you become incapacitated.

What does it mean to plan for your medical future with legal documents?

Planning for your health care future is important to ensure that your desires for your medical care are carried out according to your intentions. Although you may have only limited control over the progress of your disease, with proper planning, you can affect how decisions concerning your medical care will be made after you become unable to do so yourself.

Why is it important for cancer survivors to use legal documents to plan for their medical future?

The cancer experience often includes making choices among a variety of complex medical decisions. One such decision is the kind of care you want to have in advanced stages of illness or prior to death. Because it is your life, you should be the ultimate decision maker about whether to continue medical treatment. Most doctors are trained to provide all reasonable life-sustaining treatment.

Throughout their lives, many cancer survivors are able to make decisions about their health care. However, cancer or a new medical condition may leave survivors physically or mentally unable to express their preferences. Because of this possibility, express your desires in advance.

What are advance health directives?

Advance health directives are signed legal documents that inform your family and doctors of your choices for future medical care, including whether you want to stop or not even start life-sustaining treatment. The two most recognized types of advance health directives are a durable power of attorney for health care and a living will.

A properly signed and witnessed directive acts as a contract between you and your doctor. Your doctor must honor your instructions or transfer you to the care of another doctor who will follow your directive. If you have not expressed your desires in advance, your doctors, after talking with your close relatives, will use their best judgment to choose medical care in your best interest. Every state has laws recognizing advance health directives, but they differ from state to state. Survivors must know the laws of their home state.

What is a durable power of attorney for health care?

A durable power of attorney for health care is a legal document that lets you appoint someone to speak for you. This appointed person is your agent or proxy. A durable power of attorney for health care allows you to transfer your legal right to make health decisions to your agent or proxy. Durable means that your agent can make decisions for you only when you are unable to. You can give any adult your power of attorney for health care. Your agent need not be an attorney; most people choose a close family member or friend. Make sure the family member or friend knows you well and will make decisions that follow your wishes.

What information should I include in a durable power of attorney for health care?

Preparing a durable power of attorney for health care is the best way to ensure that you receive the medical care that you want. You can specify any type of medical care. Doctors can prolong life in many ways, including with surgery, medicines, respirators, tube feeding, IV fluids and kidney dialysis. The more specific you are, the more likely you will receive the care that you would have chosen.

Give detailed instructions concerning:

• Whether and under what conditions you should receive life-sustaining treatment
• Whether and under what conditions you should have a do not resuscitate (DNR) order
• Whether and under what conditions you should receive pain medication, artificial nutrition and hydration, or surgery
• Your preference for where you want to receive treatments (hospital, hospice or home)
• General language that covers unanticipated events in your health, finances or available medical treatment
• Your agents’ names and addresses

Avoid vague words such as hopeless, extreme and heroic. Be specific when using words such as terminal or irreversible. You may consider your cancer terminal if your doctor tells you that you are unlikely to live for more than two years; your doctor may consider your cancer terminal only when you are within days of death. Specify under what circumstances you would want your doctors to withhold certain care or stop treating you. For example:

• When your doctors agree that treatment would improve neither the quality nor length of your life
• When your doctor believes that you are likely to die within a certain number of days, weeks or months
• When you have exhausted all traditional medical treatment without success

Specify the type of treatment you want. For example:

• Artificial nutrition and hydration (being fed through a tube placed in the stomach, upper intestine or vein)
• Mechanical ventilation (a machine helps you breathe)

What is a living will?

A living will is a statement that tells your family and your doctor that you do not want your life prolonged by medical procedures if you are near death without any chance for recovery. Some of the topics in a living will include artificial feeding and use of a respirator if the person cannot breathe on his or her own. Similar to your right to refuse medical treatment, you have the right to state in advance of being incapacitated that you do not want to be kept alive by certain procedures.

A living will is not as effective as a durable power of attorney for health care because it simply expresses your preferences to your doctors. Your doctor may struggle with medical, legal, ethical and personal values that conflict with your living will if medical circumstances or pressure from a family member intervene. Your doctor and family may not want to lose you, even though you prefer to die with dignity. A durable power of attorney for health care gives legal authority to a person (not a piece of paper), someone you know and trust to act in your place. Your agent can serve as your advocate to ensure that your wishes are carried out.

How do I make future health care choices?

The best ways to influence future medical decisions are to complete the types of health care directives recognized by your state and to discuss your decisions with your family and doctors to make sure that they will honor your wishes. Most states recognize both a durable power of attorney for health care and a living will. These laws vary widely as to when and how you may express future medical decisions, how old you must be, and how the law is enforced.

To ensure that your doctors and family respect your wishes, provide written clear and convincing evidence of your desires in an advance health directive. Clear and convincing evidence is the level of proof a court requires to accept an incapacitated patient’s wishes. If you are writing or revising a will, ask your attorney to prepare a durable power of attorney for health care and/or living will as part of your financial and health care planning.

You do not have to hire an attorney, however, to make a durable power of attorney for health care or a living will. Most states provide a form to complete and have signed by witnesses.

When should I make an advance health care directive?

Advance health directives should be created at the time of diagnosis. Your wishes should be documented before you begin treatment. The Federal Patient Self-Determination Act requires all facilities that receive Medicare or Medicaid, such as hospitals or nursing homes, to discuss health care directives with newly admitted patients. The law also requires the facility to record your health care directives as part of your medical records.

How should I choose an agent or proxy?

Choose someone you are confident will be willing and able to carry out your wishes as your agent or proxy. You may wish to appoint two proxies, the second to make decisions if the first is unable to do so. Critical medical decisions, such as withdrawing life support equipment, are very difficult. They should be entrusted only to those family members or friends who would make the same decisions that you would make about your treatment.

How often should I review my advance health care directive?

To keep your advance health directive current, review it regularly, and write your initials and the date you reviewed it on the document. If you change your mind about an instruction, write in your new instruction, initial and date it. If you decide not to have a directive any more, destroy each copy.

This document was produced in collaboration with:
Barbara Hoffman, JD