Report No. 196

(B) States in US

In the States in US, an 'advance directive' means a document which a person must fill stating in advance what kind of treatment he wants or does not want under special, or serious medical conditions. Such a directive allows a person to state his choices of health-care, or to name someone to make those choices for him if he is unable to do so. It enables the person to make decisions about future medical treatment, to say yes to treatment he wants or no to treatment he does not want. An advance directive can limit life-prolonging measures when an event occurs from which there is little or no chance of recovery.

If a person is not comfortable with a Natural Death Act Declaration, he can fill out a non-statutory living will to state when he would or would not want to be treated.

A person is not limited to one or the other of these forms; he may execute both of them if he wishes. Once that has been done, one may change them at any time by informing all the appropriate people that there is a change in one's mind. The old copies can be destroyed.

The consent must be informed consent and hence following are important issues one has to consider. For example in the case of dialysis, one has to consider the following aspects:

(1) What are the most important goals of dialysis treatment?

(2) Would I want dialysis to continue if it just seemed delaying death?

(3) Under what circumstances would I want it to be stopped?

(4) How much treatment would I want if there were little chance of recovery from a serious side-effect?

(5) Would I want dialysis to continue if I were permanently conscious?

Some other issues which one should think in making decisions on treatment are:

(1) Relief of pain

(2) Ability to think and communicate

(3) Financial costs

(4) Suffering and anxiety to others

(5) Control of bodily functions (bowel, bladder etc.)

(6) Ability to move about

(7) Religious needs

(8) Dependency

Some suggestions which patients may give to their family or friends are as follows:

(1) In case of doubt, err on the side of life.

(2) I want those treatments that offer reasonable hope to restore me to a condition that my loved ones think I would find acceptable.

(3) I do not want treatment that might postpone death but probably would not restore me to a quality of life that I find acceptable.

(4) I do/do not want a treatment if there is some small, remote chance that it might help me.

(5) I want treatment decisions made with a view to my overall condition and the treatments' ability to improve this.

(6) I want sufficient pain medication to keep me free of pain even if the dosage may shorten my life.

(7) I want the cost of treatment and its financial impact on my family/community to be considered in making decisions.

(8) If I lose consciousness with no reasonable hope of ever regaining it, I want all treatment stopped (including food and fluids).

(9) I want my loved ones/professionals to make decisions about my care the way they think I would make them, were I able.

In California, an Advance Directive in the form of a Durable Power of Attorney for Heath Care is available from the California medical Association PO Box 7600, San Francisco or phone 415-882-5175 etc. The form has to be witnessed by two persons. One of them has to be someone who is not related and who is not named in any testamentary document as a person who will inherit property of the patient. A copy has to be given to the proxy/agent, to your doctor and your dialysis head-nurse or administrator. Original will remain with the patient in a safe place.

If one does not want to approve another to make decisions for him, he can sign a National Death Act Declaration to direct that life-saving measure may not be used if certain situations arise.