Living Wills: What You Need to Know
Q: My friend had a stroke and is being kept alive by a machine. This is not what I would want. How do I ensure that my wishes are fulfilled?
Dr. Zachary Levine answers: You are not alone. In fact, a study showed that 70 to 95 per cent of people would rather refuse aggressive medical treatment than have their lives medically prolonged in an incompetent or permanently vegetative state. And even with the tremendous advances in medicine and the fact that we are able to diagnose illness earlier and treat it more effectively, in some cases, this technology can prolong duration of life without maintaining quality of life. There may come a time when medical treatment decisions need to be made, but the patient is unable to understand or communicate his or her will. This is the role of an advance directive.
An advance medical directive gives incapacitated patients a way to make decisions about the course of their medical treatment. It may give instructions as to which measures are or are not desired (a living will) or it may appoint a health care proxy (substitute decision maker) to make care decisions in case one is no longer able to make or communicate choices for oneself (a power of attorney for personal care). Each province has its own laws, so it is important to learn the regulations.
A person has the right to change their decision at any time, and the advance directive only comes into play if the person is unable to understand and communicate their treatment decision. In the case of a power of attorney for personal care, the substitute decision maker (SDM) makes decisions that can involve cardiopulmonary resuscitation (CPR), feeding tubes, breathing tubes and machines, tests, medicines, surgeries and blood transfusions.
If an advance directive exists, then the SDM is expected to make decisions that are compatible with the wishes of the patient. Emergency treatment can be given without patient or SDM’s consent only if it is not possible to communicate with either person and if delay would put the patient at risk for serious harm.
In the case where a person becomes incapacitated but has not written an advance directive and has not appointed an SDM one will be designated in accordance with the hierarchy set out by the government. In Ontario, for example, the hierarchy is set out in the Health Care Consent Act, and the order is guardian, a person with power of attorney for personal care, representative appointed by the consent and capacity board, a spouse or partner, a child, custodial parent or other person entitled to give consent in place of the parent, a parent with right of access only, a sibling, any other relative and, finally, Office of the Public Guardian and Trustee. (It is worth noting that having a “DNR” (do not resuscitate) order, which can be specified in an advance directive, does not mean no care, nor does it allow for euthanasia. All efforts should still be made to ensure that the person remains comfortable, regardless of DNR status.) Whoever the SDM is, if the wishes of the patient are not known, then he or she is expected to make decisions in the patient’s best interest.