End of Life Ethics

It is common for people to have a will in place, even those who expect a long and healthy life for years to come.  However, there are other documents which are helpful to have in place, and can have a profound impact on the medical care you receive at the end of life.  These documents are advance directives and durable powers of attorney for healthcare.

A durable power of attorney for healthcare, which is a different document than a typical power of attorney executed primarily for execution of financial decisions, specifies an individual who is authorized to make healthcare decisions for you in the event that you cannot make them for yourself. 

Examples of when this would become effective would be if an individual was unconscious, developed dementia, or was in another way determined incompetent to make healthcare decisions or give consent for treatment. 

It is important to be clear on the role of the individual named: it is not their responsibility to make your decisions for you.  It is their responsibility to make the decisions that it is most likely you would make were you able to speak and/or decide for yourself.

A durable power of attorney for healthcare allows you to name more than one person.  The way this usually works is that a primary agent is named, then an alternate.  This is not a bad idea.  This way, if the primary agent is for some reason unavailable or unable to act on your behalf, there is another person in place. 

A second practice is to name joint powers of attorney, such as giving two adult children equal power so that feelings are not hurt by picking one over another.  Having spoken with several healthcare professionals who specialize in end-of-life care, the advice is nearly unanimous: don’t do this. 

If the two parties disagree, things can turn very bitter very quickly.  It is better to make a clear decision of one person who you trust to enact your wishes.  This is comparable to dividing your estate equally among your children in your will.  It is more like selecting an executor; you select the person whom you most trust for the task at hand. 

Another document is an advance directive which specifies the medical treatment you would or would not desire in the event that there is “no reasonable expectation of…recovery from a seriously incapacitating or terminal illness or condition,” as phrased in the document cited below. 

There is a limit to how much detail you can provide in this document, so it is helpful to have a durable power of attorney for healthcare in addition to an advance directive.

Dr. Maria Dans of Barnes-Jewish Hospital in St. Louis, MO observed from her experience in both intensive care and palliative care that these documents are very helpful to have completed with copies located both with your primary-care doctor and family members so that your choices are documented if you are unable to speak for yourself in a time of medical crisis. 

However, she made a very good point that can be echoed by many medical personnel: these documents carry far more weight if you have discussed them with your family so that they are aware of them and familiar with your medical choices. 

The importance of this being a family effort cannot be emphasized enough.  Information from the MO Bar Association on writing your advance directives can be found at http://members.mobar.org/pdfs/publications/public/dpa.pdf