Planning Ahead for Health Care Decisions
By Elisabeth Lopukhin
“Give rest, O Christ, to the soul of thy servant where there is neither sickness, nor sorrow, nor sighing, but life everlasting ...” For centuries these words have solaced and given strength to dying persons and their loved ones. Yet today, with the advent of medical technology, what used to be so final, a clear will of God, is now blurred. In a prayer for the sick, we ask Christ “the Physician of our souls and bodies . . . to bless the means employed to cure . . . .” Who is to judge what treatment is blessed and what treatment will only prolong the dying process? Up until recently this question was seldom raised, but now the rapid development of medical technology forces us to search our beliefs for answers.
Because of cardio-pulmonary resuscitation (CPR) techniques and because of the respirator, death can no longer be defined medically as it had been previously - the “cessation of heart-beat and respiration.” Life (or is it dying?) can now be prolonged by the use of sophisticated machinery such as feeding-tubes and respirators. Death now becomes defined as the “cessation of brain functions,” also determined by a complicated process. The American Medical Association stated to the Council on Ethical and Judicial Affairs: “Life-prolonging treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating the terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burden. At all times the dignity of the patient should be maintained.
LONGER LIFE SPAN CREATES NEW PROBLEMS
As life expectancy has increased by twenty years in this past generation, with all its obvious benefits to the active elderly, it has also created new problems. Elderly patients are usually admitted to hospitals and nursing homes with diseases that do not cause death rapidly, but bring about a long slow illness, with little hope for recovery. Patients are often minimally aware of their condition, non-responsive and often unable to discuss treatment meaningfully with their doctors. These are the patients who soon become tube-fed as they can no longer eat well enough on their own and have frequent hospitalizations. Statistics indicate that this segment of the population will continue to rise.
There is little doubt about the value of advance discussions about treatment choices such as CPR in the event of cardiac arrest by doctors with their patients (no matter of what advanced age they may be) while the patients can still state their choices clearly. But there is much less clarity “about what should become of those people who are not ‘competent’ to decide their own fates. Discussions about who should decide, when the decision should be made, and how this process should occur and be monitored have been generally unsatisfactory to date. We have replaced the natural death process with a system driven by both death-delaying technology and a death-delaying social ethic.” (Chambers, Prible and Harper in New
Directions in Religion and Aging). The dilemma of whether treatment for “terminal,” “incurable” or “irreversible” conditions is life-sustaining or becomes a tool for prolonging dying - is immense. Our society has not only confused its search to prolong life with efforts at prolonging dying, but the issue for us also becomes one of how best to accept God’s willto prolong life at whatever burden because of available technology, or to allow a person to die naturally, with care and medication to ease the pain, and as much comfort as possible?
This difficult situation is further aggravated by criteria less philosophical and religious. There is the fear of lawsuits as well as loss of income on the part of care-givers, and on the other hand, the realization by governmental agencies that the progressive increase in government supported reimbursements for health care assurance will become too great a financial burden in the not too distant future, as fewer workers contribute to the funds for a greater number of beneficiaries.
NEW LEGISLATION ENACTED
In attempts to safeguard personal rights and beliefs, as well as medical ethics, and to alleviate the possibility of frequent law suits, many states have enacted Natural Death Acts. As of December 1986 only Kentucky, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, and South Dakota did not have any. Since that time, New York has just passed the “Do Not Resuscitate Order” law. (Every patient is expected to desire CPR in case of cardiac arrest when terminally ill, unless specifically requesting not to have CPR.) It is also working on Living Wills and Health Care Proxy legislations. Each state varies in their requirements for criteria to be met for the execution of allowable advance directives.
More information can be obtained from the very useful publication “Planning for Difficult TimesA Matter of Choice: Planning Ahead for Health Care Decisions” which is available at the American Association of Retired Persons (AARP) Special Projects Section, Program Department, 1909 K Street, NW, Washington, D.C., 20049. However, even for states without Natural Death Acts, advance health directives can be useful tools to ensure one’s rights for health care choices. Another important reason for advance directives is that should one become physically or mentally incapacitated, these documents would ease the burden of those who become responsible to make those decisions on one’s behalf.
Up until recently, the most usual means to protect the financial security and physical safety of people who were no longer able to do so themselves was the appointment of “power of attorney,” “Guardian” or “Conservator.” Wills ensured the desired distribution of property after death as executed during competency. For health care decisions, however, when a person is no longer judged to be competent medically, the old way of having family members make those decisions is no longer adequate. Too often disagreements among family members as to what should be done, or disagreements between health care givers and the families have resulted in court cases, some of them receiving much publicity. Thus the movement to establish advance directives is gaining in scope.
LIVING WILLS / DURABLE POWER OF ATTORNEY
The most widely accepted formats are the Living Wills and the Durable Power of Attorney. The latter has legal weight in all states and is very similar to Health Care Proxy. A Living Will may be a statement in your own words as long as it is witnessed by two persons. You can specify what treatments you want performed or withheld and under what conditions, should you lose the ability to communicate yourself. The more specific you are in these statements, the easier it will be for the decision-maker to execute your intentions. The document should be discussed with your doctor and your family or friends and copies should be given to each. This document can also specify your wishes regarding organ donations.
For a sample of a Living Will, see Appendix A. The Durable Power of Attorney (Appendix B), on the other hand, is a broader concept as it allows you to designate someone to make all health care decisions on your behalf should you lose that capacity. Alternate designations are suggested to ensure the continuity of your rights. This form can also stipulate specific instructions about treatments or procedures. The attached sample forms are recommended by the AARP “Matter of Choice” booklet. Appendix C lists the living will legislations in existence to facilitate your checking on specific state legislations.
Because of the sensitivity of the issues, many people have difficulty in communicating on the subject. As a result, some physicians may not have a full understanding of their patient’s wishes about CPR, tube-feedings or other extraordinary treatments. Also, because of increased legal proceedings about malpractice and because of minimal guidelines and policies, health-care givers and agencies are not always clear about how to honor written and oral advance directives. Lawyers should be encouraged to discuss not only financial wills with their clients but health care planning as well. Clergy members should encourage their parishioners to better understand the dilemmas, both physical and spiritual, that accompany illness and old age. And primarily, it is up to each one of us, as Orthodox Christians, not only to introspect and to reconcile our own beliefs about modern medical technology and God’s will, but especially to talk openly about these difficult issues with loved ones. In this way we can hopefully pre-empt their need to make very hard decisions on our behalf, while asking God’s help to “bless the means employed.”