October,
2005
Advance
Directives
Making Your Health Care Decisions
The Facts About
Living Wills and
Durable Power of Attorney for
health Care and Related Matters
Forward
Many people today are worried about the medical care they
would be given if they should become terminally ill and unable
to communicate their wishes. They don't want to spend months
or years dependent on life-support machines, and they don't
want to cause unnecessary emotional or financial distress
for their loved ones.
That's why a growing number of people are taking an active
role in their care before they become seriously ill. They
are stating their health care preferences in writing, while
they are still healthy and able to make such decisions, through
legal documents called advance directives.
In 1990, Congress passed a law entitled the Patient Self-determination
Act. This federal law requires most hospitals and other health
care providers to provide their adult patients with information
about their legal right to make decisions concerning their
medical care - including the right to decide whether to accept
or refuse medical treatment. It also requires health care
providers to ask patients if they have signed advance directives
such as living wills or durable power of attorney for health
care.
Before deciding what choices about your care at the end of
life are best, you should talk over the issues with your family
and physician, and decide which type of advance directive
is best for you. This brochure provides information about
the two forms of advance directives legally accepted in the
state of Rhode Island to get you started on making your wishes
known.
St. Joseph Health Services of Rhode Island
St. Joseph Health Services of RI, as a Catholic institution
and a community health care provider, recognizes the right
of every patient to make his/her own health care decisions
to the maximum extent of his/her capacity and as allowed by
law. Federal law requires St. Joseph Health Services of Rhode
Island to provide information to adults (age 18 and over)
upon inpatient admission regarding their right to make choices
involving health care.
St. Joseph Health Services holds this right to make his/her
own health care decisions to be both moral and fundamental
based on the belief that life is a gift of God. As individuals
we are charged with being stewards of this gift. St. Joseph
Health Services believes all individuals have a moral obligation
to seek medical care that offers a reasonable chance for recovery.
However, we do not believe anyone is morally bound to begin
or continue medical treatment which is judged to be medically
futile or burdensome and henceforth morally disproportionate.
St. Joseph Health Services does not believe that any person
has the right to intentionally end his/her life or assist
in ending the life of another.
Individuals will encounter limitations associated with human
life (i.e., illness, injury) that can interfere with their
ability to make medical decisions. When persons lack the capacity
to make health care decisions for themselves, others such
as family or loved ones have the moral right to speak for
the patient. These surrogate decision makers should understand
the beliefs and values of the patient so that the appropriate
decision can be made. To ensure that a patient's wishes are
carried out, St. Joseph Health Services supports and encourages
all competent adults to execute legally recognized written
instructions regarding their medical choices before illness,
trauma or another condition makes such decision making impossible.
These instructions should be based on their values and beliefs.
St. Joseph Health Services shall not in any way discriminate
against an individual based upon whether or not the individual
has executed an advance directive. The fact that a person
has executed an advance directive shall in no way diminish
the quality of medical and nursing care provided at St. Joseph
Health Services. Also, the existence of an advance directive
shall not be construed to deny the patient any measures necessary
for the patient's comfort, care and dignity.
Rhode Island law provides for two forms of advance directives,
the Living Will and the Durable Power of Attorney for Health
Care. Due to its flexibility, St. Joseph Health Services considers
the durable power of attorney for health care to be the preferred
approach. Samples are available upon request from the Pastoral
Care Department. We encourage you to take the time to consider
and discuss this subject with your family and physician.
Question
and Answer Section
| Q. |
Who decides what medical care I receive? |
| A. |
In the state of Rhode Island, if you are
an adult (18 years of age or older), you have the right
to make decisions about your own medical care, including
the right to refuse any life-sustaining medical treatment
or procedure. As long as you have the ability to understand
the nature of your medical condition and the benefits,
risks, and burdens of the treatment recommended by your
physician, as well as alternatives to that treatment -
and are able to reach and informed decision - you have
the right to make your own health care decisions. |
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| Q. |
Who will inform me about medical care? |
| A. |
Your physician or allied health care professional
has the responsibility of explaining the following to
you, in terms you can understand:
• Your
medical condition
• The diagnostic
tests and treatments he or she feels is necessary
• The risks
and benefits of the treatment he or she recommends
• Any alternatives
to those procedures
• The risks
of refusing treatment
Your physician or allied health care professional can
tell you what treatments may help you and how they work,
but he or she can't tell you which treatment you should
want or even whether you want any treatment at all. Those
choices depend on you and your own personal values. Once
informed of your medical options, you may then exercise
your right to accept or refuse the tests or treatments.
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| Q. |
What if I can't make my own decisions? |
| A. |
An adult who is not able to make health
care decisions has the same right as anyone else to receive
or refuse medical treatment. However, if you should become
unable to make health care decisions or communicate them
to others, an advance directive is the most effective
way for your health care professionals to know what your
decisions would have been or who should make them for
you. |
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| Q. |
What is an advance directive? |
| A. |
An advance directive is a written document,
made in advance of serious illness or trauma, that states
your choices for health care or names someone to express
those choices for you if you become unable to make health
care decisions for yourself. An advance directive can
take either of the following forms:
• Living
Will
• Durable
Power of Attorney for Health Care
Rhode Island recognizes both forms of advance directives,
and you may have either one, neither one, or both. |
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| Q. |
What is a Living Will? |
| A. |
A living will is a document that allows
you to tell your physician to withhold or withdraw life-sustaining
medical procedures in case you develop a terminal condition
and can't communicate your wishes. Your instructions will
then be followed if you are unable to make or state your
decisions at a time a medical decision must be made. |
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| Q. |
What is a Durable Power of Attorney for
Health Care? |
| A. |
A durable power of attorney for health care
is a document in which you name another person as an agent
to make health care decisions for you in case you become
unable to make those decisions for yourself. Your agent
will have the legal authority to make the medical treatment
choices you would have made for yourself, if you had been
able to do so, including a decision to withhold or withdraw
life-sustaining procedures in case you develop a terminal
illness. Your agent also has the responsibility to inform
your family or next-of-kin if you wish to be an organ/tissue
donor. If you know in advance that you would prefer to
have or avoid certain treatments, such as surgery or artificial
nutrition or hydration, you may include such instructions
in the document. |
What's
the difference between the Durable Power of Attorney for
Health Care and the Living Will?
|
Durable Power of Attorney
for Health Care
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Living Will
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Appointed someone to make health care
decisions for you that permits you to specify guidelines
and limitations, if you wish
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Spells out in writing
under what circumstances you want
medical care withheld or withdrawn
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Encompasses all health care decisions,
including requesting or refusing treatment of care
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Refers only to withholding
or withdrawing care
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Applies to any kind of illness or injury
that incapacitates you
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Applies to terminal
conditions that leave you unable to
make or communicate decisions
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Requires that you have someone you trust
who is willing to take on this responsibility
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Does not put decision-making
responsibility on a specific person
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Can be flexible to changing circumstances
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Is static and may
not cover every possible medical situation
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Is easily revoked, orally or in writing
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Is easily revoked,
orally or in writing
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Need not specifically address nutrition
and hydration
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Must specifically
address nutrition or hydration
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Q.
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What is a "terminal condition"? |
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A.
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A terminal condition is an incurable or
irreversible condition that, in your physician's opinion,
would result in death without the use of life-sustaining
medical procedures |
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Q.
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What is a "Life-sustaining Medical
Procedure"? |
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A.
|
A life-sustaining medical procedure is any
medical treatment or procedure that only prolongs the
dying process of a patient in a terminal condition, but
does not include procedures that your physician may order
to provide care and comfort, or to alleviate pain. Questions
about the kinds of procedures that are often used when
illness is severe, especially when recovery is unlikely,
should be answered by your physician. Some examples of
life-sustaining medical procedures include:
• Cardiopulmonary
resuscitation (CPR): a medical procedure that may involve
forceful pressure on the chest, the administration of
drugs, or electric shock,
to restore the heart beat at the time of cardiac arrest.
• Ventilator:
a machine that moves air into the lungs if you are unable
to breathe
naturally.
• Artificial
nutrition and hydration: a method of delivering food and
water to a person
who cannot eat or drink. A person may be fed through a
tube inserted
directly into the stomach, the nose and throat, or through
an intravenous
tube. These terms do not describe the natural process
of eating foods
and drinking fluids. |
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Q.
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Must I have an advance directive? |
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A.
|
Whether to sign an advance directive is
entirely your decision. The law requires that you be told
about your legal rights to fill out an advance directive,
and that the health care provider must note in your medical
record if you have signed one. No one may refuse to provide
you with health care services or insurance, if you choose
not to sign an advance directive |
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Q.
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Should I sign an advance directive? |
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A.
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One reason many people want to have an advance
directive is to avoid the cost, delay and emotional hardship
of a legal dispute if they become ill and unable to make
their wishes known. It makes good sense in considering
signing an advance directive, and at the very least to
think about your present health care values before a medical
crisis, while you are still able to do so. You should
think about and discuss with family and friends such personal
issues as:
• The significance
of death
• The conditions
that could make the dying process intolerable
• The way
artificial life support would affect the dying process |
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Q.
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If I have signed an advance directive,
will my physician or hospital refuse to care for me at
all? |
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A.
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Whether you have signed either a durable
power of attorney for health acre or a living will, or
both, your health care providers will continue to provide
the level of comfort and care which is appropriate for
your condition. They will also, if you wish, help alleviate
any pain you may experience. |
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Q.
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Should I sign both a Durable Power of
Attorney for Health Care and a Living Will? |
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A.
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You may choose to sign both a durable power
of attorney for health care and a living will, but you
need not do so. Some people believe a durable power of
attorney for health care is more flexible, because your
agent can participate in discussions with your health
care provider as well as other family members to weigh
the pros and cons of treatment in accordance with your
wishes. Your agent can weigh the risks and consider a
variety of options for your medical treatment |
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Q.
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What if I haven't signed an Advance Directive? |
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A.
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If you do not have an advance directive,
health care decisions for you will be left to a legal
guardian, if one has been appointed. In the absence of
an advance directive or court-appointed legal guardian,
Rhode Island law offers little clear guidance. Usually,
your family, physicians, and hospital can reach an agreement
without resorting to the courts - often with the help
of your physician or the hospital's ethics committee or
similar resources. No one may make any assumptions about
your intentions, however, simply because you chose to
sign, did not sign, or revoked, an advance directive. |
More Information About ADVANCE DIRECTIVES
|
Q.
|
Are there any specific forms for advance
directives? |
|
A.
|
Rhode Island law suggests, but does not
require, a particular form of durable power of attorney
for health care. Whatever form you do use may include,
if you wish, specific instructions to your agent about
any treatment you prefer or want to avoid or any limits
on his/her authority. Rhode Island law also suggests a
form of living will that you may use, but does not require
the use of one particular form. If you do not want artificial
nutrition or hydration, your living will must say so.
Use of either model form provided by Rhode Island law,
however, may help ensure that your physician and hospital
will honor your wishes and not question the validity of
the document at the appropriate time. Advance directive
forms may be obtained from the Department of Health (222-2231)
or the Department of Elderly Affairs (462-3000). |
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Q.
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How long are advance directives valid? |
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A.
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Both the durable power of attorney for health
care and living will remain valid until revoked, unless
you specify a shorter period of time in the document.
There is no "expiration date," unless you set
one, and advance directives do not need to be renewed.
But if you want to make a change in either your durable
power of attorney for health care or your living will,
you must sign a new document and destroy all copies of
the old one. It is a good idea to review all legal documents
periodically. (Incidentally, if you name your spouse as
agent in your durable power of attorney for health care,
he/she will not be able to make health care decisions
for you if you are later divorced.) |
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Q.
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Do I need a lawyer to sign an advance
directive? |
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A.
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You do not need a lawyer to complete and
sign either a durable power of attorney for health care
or a living will. However, if you would like to learn
more about the legal consequences about signing one, you
may want to consult a lawyer. If you do want legal help,
you should check with your own lawyer. If you do not have
a lawyer, ask a trusted friend or relative for a referral.
You may also take advantage of the following resources:
• RI Bar
Association Lawyer Referral Service (421-7799)
• RI Bar
Association Legal Information and Referral Services for
the Elderly (521-5040)
• RI Department
of Elderly Affairs (462-3000) |
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Q.
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What should I do with my advance directive? |
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A.
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Ideally, you would discuss your values and
wishes with your family, friends, and health care providers
as part of the process of making an advance directive.
In any case, let all of these people know that you have
an advance directive. Keep it in a safe place where it
can be easily found if it is needed and give a signed
copy to your physician, who will note it in your medical
record, as well as to your agent. When you enter the hospital
or other health care facility, you will be asked whether
you have an advance directive. If you do the facility
will also note it in your medical record. If you know
you will be admitted to a health care facility, you should
bring copies of your advance directive(s) with you. |
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Q.
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May I change or revoke my advance directive? |
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A.
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You may change or revoke a durable power
of attorney for health care or living will at any time,
in any manner that you are able to communicate your intent
- even if you are no longer competent to make other decisions.
You should notify your physician, your family, and others
who might need to know |
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Q.
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What if I make an advance directive in
another state and I am hospitalized in Rhode Island? |
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A.
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A durable power of attorney for health care
or a living will executed in another state in compliance
with laws of that state will be legally effective in Rhode
Island. Because an advance directive is a written expression
of your intent regarding your medical care, however, it
may influence that care no matter where you are hospitalized
or what form you sign. |
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Q.
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Must my physician carry out my decision? |
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A.
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You may want more, or less, treatment than
your physician believes appropriate for someone in your
condition. If your physician cannot follow your wishes
about your medical care, you may transfer, and your physician
must transfer, your care to one who will do so. A physician
can not, however, be forced to give treatment that is
medically inappropriate. |
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Q.
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Will the health care facility carry out
my decisions? |
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A.
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You have the right to be informed, in writing,
of any policies adopted by the hospital or other health
care facility about the way in which the facility will
respect your rights to make health care decisions. The
facility has formal policies to make sure your wishes
about treatment will be followed. If the health care facility
refuses to follow any particular decision, it will let
you know and transfer your care to another institution
that will do so. |
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Q.
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Does my advance directive apply if I
am pregnant? |
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A.
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A durable power of attorney for health care
or a living will not be followed if you are pregnant and
your physician believes the fetus could develop to the
point of live birth with the use of life-sustaining procedures. |
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Q.
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What if I am treated by emergency medical
personnel? |
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A.
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If you have signed a durable power of attorney
for health care or a living will, and are in a terminal
condition, and you do not want to be resuscitated if your
heart stops working, your physician may ask the Rhode
Island Department of Health for an identification bracelet,
called a "Comfort One" bracelet, for you to
wear, that will alert medical emergency personnel - such
as EMTs, fire fighters, and police officers - of your
wishes. |
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Q.
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What if I have more questions? |
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A.
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You should discuss any questions about your
treatment and advance directives with your family, and
physician. The hospital's social worker, patient representative,
or chaplain may be able to assist you, but they can't
provide you with legal advice. If you have a legal question,
you should consult an attorney. |
More Information About LIVING WILLS
|
Q.
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How do I sign a living will? |
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A.
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A living will must be signed by you, dated,
and witnessed by two people who know who you are but are
not related to you. It need not be notarized. Both you
and the witnesses must print your addresses on the document. |
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Q.
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When does a living will become effective? |
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A.
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A living will is effective when it is communicated
to your physician, he/she determines that you are in a
terminal condition, and you are unable to make or communicate
health care decisions for yourself |
More Information About Durable Power
or Attorney for Health Care
|
Q.
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Who should I choose as my agent? |
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A.
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Your agent is usually a family member or
friend. The choice of the agent is the most important
part of this process. Speak to the person you want to
choose beforehand to explain your intentions, values,
attitudes and general philosophy about physical or mental
disability or illness during the final stages of your
life. Your agent must be willing to act on your behalf
and carry out your wishes. One limitation on your choice
of agent is that he/she may not be associated with the
health care provider or facility providing your care or
treatment |
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Q.
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Are there any limitations on my agent's
authority? |
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A.
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Unless you include limitations in the document
itself, the durable power of attorney for health care
applies to all medical decisions. The model form permits
your agent to consent, refuse to consent, or withdraw
consent to any care, treatment, service, or procedure
(even life-prolonging care) intended to maintain, diagnose,
or treat your physical or mental condition and to inform
your next-of-kin if you wish to be an organ/tissue donor.
Remember, you can always change your mind about your agent
or anything else you may have specified in the form. |
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Q.
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How do I sign a durable power of attorney
for health care? |
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A.
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There are two ways to execute a durable
power of attorney for health care. It may be signed, dated,
and witnessed by two people who know you but are not associated
with the health care provider or facility providing your
care or treatment. Also, at least one of the witnesses
must be neither a relative nor a potential heir. Both
you and the witnesses must print your address on the document.
It need not be notarized. Another choice to execute the
durable power of attorney for health care is to sign it
in front of one witness who is a notary public but not
associated with the health care provider or facility. |
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Q.
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May I have more than one agent? |
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A.
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Only one person may act as your agent at any one time.
However, you should consider naming one or two alternate
agents who could step in and make health care decisions
for you if your agent is unable to do so. Your agent
may not delegate the authority to make health care decisions
to anyone else. Always include the name, address, and
telephone number of each person named as an agent, as
well as the order of their priority - that is, the person
designated as your agent, then the first and second
alternatives.
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