Making Life Decisions for the Very Ill

An ambulance rushes a critically injured 65-year-old man to the hospital. But the doctors are too late to help. The patient falls into a deep coma, with what doctors describe as almost no chance of recovery. Should the patient be given life-sustaining treatment, or should the doctors pull the plug?

That’s a theoretical question that doctors, lawyers and philosophers can debate at their bioethics conferences.

But in a real-life case, who should decide? Who should tell the doctor what treatment the patient would have authorized if he’d been able to speak? The man’s ex-wife? His live-in lover? His children? His grandchildren?

State Legislation

The “Durable Power of Attorney for Health Care” was created by the state Legislature to allow people to appoint someone in advance to make health-care decisions if they are unable to make the decisions themselves.

By properly completing and signing the durable-power document, you can appoint someone to act as your agent for health-care decisions. The person you appoint will only make those decisions if you are unable to give your informed consent to treatment.

The durable power of attorney for health care is not intended to be used only by the terminally ill.

“We think it would be a good idea for everyone to execute one,” says Roger Purdy, the California Medical Assn.’s director of research.

“Certain categories of people may have more need for it: elderly people, people about to undergo major surgery, terminally ill people, but we think it’s a good idea for any adult resident of California,” he added. “You never know when you might be in a car accident and wind up in a coma.”

And it may be easier for elderly or seriously ill patients to sign the document if everyone in the family fills one out, notes Vicki Michel, co-chair of the L.A. County Bar Bioethics Committee. It may draw less attention to the sad facts of the disease.

There are many people, especially older people in nursing homes, who do not have relatives who can consult with a doctor when it is necessary to make health-care decisions. Having a durable power, Purdy notes, may alleviate the need to go to court to have a guardian appointed to make decisions about continuing life-sustaining equipment for an incompetent patient.

The “proxy” created by the appointment of an agent may also help head off family squabbles at an emotional, intense time.

“A husband and wife might disagree about whether grandma’s plug should be pulled,” Purdy says. “If she had specified that one or the other would be the person making the decision, then a lot of those conflicts could be precluded.”

Printed Forms

Printed durable-power forms, authorized by law, contain a warning in boldface type explaining the power you are conferring on your agent: “This document gives the agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose, or treat a physical or mental condition.”

The appointment will be in effect for seven years unless you set an earlier termination date in the document.

In addition, unless you specify otherwise, the document gives your agent the power to authorize an autopsy, donate body parts for transplant or research and to direct the disposition of your remains.

However, your agent does not have the right to consent to psychosurgery, sterilization, abortion, convulsive treatment, or commitment to a mental-health facility.

Although the law has been in effect for several years, it is still difficult to assess whether the health-care powers of attorney are working well. The California Medical Assn. has, with the help of health-law specialists, developed its own form and a pamphlet describing how the durable power works.

CMA has distributed more than 200,000 copies of the form and does not know of any dispute that has arisen from it, but it is also impossible to know how many people have actually signed them.

Intimidating Document

Dr. Kenneth Landis, a pulmonary specialist who has given several speeches on the subject, says he distributed many CMA forms but isn’t sure who actually fills them out. Many people, after they see the lengthy form with bold-face warnings and various options, may feel as if they need a lawyer before they should sign it. But, he correctly notes, it is “not as intimidating as it looks.”

The CMA form includes a helpful checklist that describes those people you cannot appoint as your agent (such as your doctor) and explains how to have the form notarized or properly witnessed.

Your agent must comply with your wishes, which you can describe in the document itself. To help you focus on your own desires, the CMA form contains three options on life-sustaining treatment, ranging from opposition to certain life-sustaining measures to a general statement that you want your life “prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures.”

And if your agent is not complying with your stated desires, your spouse or children can seek a court hearing to determine whether he is properly carrying out your wishes or acting in your best interests.

Obtaining a Form

You can obtain the CMA form, a wallet identification card alerting emergency personnel that you have executed a health-care power, and the companion pamphlet, “Your Health Care: Who Will Decide When You Can’t,” for $1.50 plus local sales tax. Send your request and money to Sutter Publications, P.O. Box 7690, San Francisco, Calif. 94120. You can also order them in larger quantities; 25 copies are $9.75 plus tax.

In addition, some doctors and hospitals have the forms and pamphlets available at no charge to their patients.

The L.A. County Bar Bioethics Committee has a speakers bureau if you are interested in having a speaker talk about the durable power of attorney for health care. Contact Griffith Thomas at (818) 986-4494 or (213) 872-3444, 15233 Ventura Blvd., Penthouse Suite 10, Sherman Oaks, Calif. 91403.