Act Now, in Health, on ‘Pulling the Plug’
The horror stories are multiplying. The following two are typical:
In San Diego a 92-year-old woman with Alzheimer’s disease lies in a coma, a result of choking on some food. She has been unconscious for nine months. Her daughter wants all life-sustaining treatment stopped, arguing that her mother would never have wanted to live this way. Her physician of seven years says that he has no idea what she would have wanted because she never discussed it with him. He is unwilling to withdraw the nasogastric feeding tube that keeps her alive.
In Los Angeles a man in the last stages of Alzheimer’s--bedridden, incontinent and unable to speak, read, write, feed himself or chew his food--contracted pneumonia. His wife asked that no heroic treatment be given him. Antibiotics cured the pneumonia, but he could no longer swallow. His wife was told that a nasogastric tube was required by law. A year later he continues to live because of his strong heart, his wife’s loving attention and the steady supply of nourishment via the tube.
The idea that care givers might withhold food from patients and thereby let them die is a troubling one. Many people feel that it is one thing to stop respirators, quite another to stop feeding. Others argue that artificially supplied food is logically no different from artificially supplied air.
In 1985 New Jersey’s Supreme Court, the first state court to rule on such a case, held that there are circumstances in which artificial feeding may be withheld or withdrawn from an incompetent patient who remains conscious. Because it is not always easy to tell whether the decision is based on a belief that death would be best for the patient or best for the family and care givers, the court established procedures to prevent abuse.
Unfortunately, the law in California about forgoing artificial feeding is not entirely clear, despite what the Los Angeles man’s wife was told. In 1983 a California appellate court held that family members may refuse treatment for an incompetent patient, and that “medical” feeding (feeding by artificial means) is treatment and not basic nursing care. That case, however, involved a patient who was permanently unconscious. As difficult as it is, we are more comfortable allowing a permanently unconscious patient to die than we are a patient who is still conscious. No California higher court has ruled on a case in which the patient was incompetent and conscious and had not previously expressed his or her wishes about artificial feeding.
In several cases California judges have fervently affirmed the right of patients to refuse life-sustaining procedures. But if they want to refuse artificial feeding, they must specify that when they are still competent to make the choice for themselves.
Fortunately, there is a legally recognized device available in California to achieve this end, a document that grants “durable power of attorney for health care.” Any competent adult can sign a durable power, in which some trusted person is named to make decisions about treatment should one become incompetent. In addition, the document can include preferences about specific kinds of treatment. A physician is obliged to honor the patient’s wishes as they are expressed, or transfer the patient’s care to another physician who will.
The document is valid for seven years. If the person becomes incompetent during that time, it remains valid until he or she regains competence.
The legislation allowing durable power for health care was passed in 1983. The man and the woman cited here were perhaps not competent at that time, and thus could not have signed the document and benefited from its legal protections. But it is readily available today to anyone who fears sharing their fate--anyone who fears being kept alive in a hopeless state solely by artificial nourishment.
Forms for the durable power of attorney for health care can be purchased from stationery stores; a version that is much easier to understand is available from the California Medical Assn. Forms also should be available in hospitals and from physicians.
Signing the form does not require a lawyer’s assistance. The durable power of attorney for health care is different from the durable power of attorney used to handle financial matters.
Individuals may want to discuss the document with their physician before they sign it, and they should surely give a signed copy to the physician as well as to the person who is named the “attorney in fact.”
For years people have been decrying situations in which dying persons received more treatment than some thought was necessary. These cases have often been heart-rending. They will continue to be difficult and to grievously burden all who are involved--family, nurses, physicians, judges and attorneys--if the decisions have to be made by others. We can make the decision ourselves, however, but only if we get the form and sign on the dotted line. This means that we have to sign it when we don’t need it. If we procrastinate, and the day comes when we need a durable power of attorney for our health care, we will have waited too long.
