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DPOA: Who Chooses?
by Pat Winer
Imagine this scenario. You are in the advanced stages of a disease. You’ve actively pursued treatments that might provide a cure, but nothing has worked. You consider the disease and the side effects of its treatment to be torture, and you decide that if your situation worsens, you don’t want your life prolonged. You create a living will that states this preference. Your situation deteriorates and you’re rushed to the hospital. A copy of your living will is in your chart. Your friends sit at your bedside comforting you and saying their goodbyes. You are ready to let go.
Then another branch of the family arrives. Some of them haven’t seen you for 5 years and they are not prepared for what they find. Grief turns to panic and the family insists on aggressive, invasive treatment. You are too young (too much of a fighter, too important, too much a lover of life, whatever) to let go, they say. Despite your living will, in the face of family not in agreement with your preferences, the physician yields to the wishes of the family. Your goals for your own treatment and your own death are overlooked in the presence of a grieving family and a doctor concerned about legal action.
Do you remember when the word “cancer” was always spoken in a whisper? The incidence of cancer has increased so much that we’re talking openly and frankly about it now. There is hardly a family that hasn’t been touched by a cancer experience. Now, “death” is the word that is whispered. We are a culture that glorifies youth and ignores aging; we have technology that can heal or maintain and repair sick and broken bodies, and in some cases forestall the inevitable shut-down of those bodies – that’s how we resist the concept of death. Old, young, ill, well; at any point along the continuum, it is important to look frankly at what is ahead, worst case scenarios as well as less dramatic circumstances.
A living will is a document that states a person’s wishes if he or she is no longer able to communicate coherently. The living will states “If I have a terminal condition, and there is no hope of recovery, I do/do not want my life prolonged by artificial means.” Every one of us should have one.
But what exactly does “terminal” mean? We’re all terminal. “No hope for recovery” is difficult for a stressed and frightened family to determine; further, many physicians’ concerns about their liability can shape their interpretations and their decisions. Another disadvantage to the living will is a physician’s tendency to defer to a living family member rather than complying with a written document.
Appointing a person to hold your medical durable power of attorney avoids the conflicts that a living will might create. In this document, you designate someone to exercise the legal authority to make any and all health care decisions for you should you become unconscious or mentally incapacitated. The document is not open to interpretation. The appointed holder of the DPOA is solely responsible, with your previous input, for decisions regarding your health care.
Choosing the person who will be your DPOA – who can be any legally competent adult – requires you to be clear about your health care preferences before an emergency arises. Discussion should include the issues below.
What does “quality of life” mean to you?
What symptoms and limitations would you be willing to live with for an undetermined period of time? What would be intolerable to live with? Understanding some of the major quality-of-life issues is important, because these decisions are rarely black and white.
Know what options exist for you in the hospital during a life-threatening event.
Options include aggressive treatment, including intubation and placement on a respirator, feeding tube placement, intravenous fluids (for hydration), cardio-pulmonary resuscitation (chest compressions to move blood and oxygen when your heart is not beating on its own, coupled with breathing assistance) and/or electric shocks to restart your heart. At the other end of the spectrum is “comfort care only,” which includes adequate pain medication and a general focus on your quality of life and controlling your symptoms rather than prolonging your life. Consider that withholding treatment (based on your stated preferences) and withdrawing treatment have different implications.
There are 3 possible outcomes of medical treatment: cure, stabilization, or preparing for a dignified death. Consider these outcomes when you consider your preferences.
Begin this process before a critical illness or accident.
Part of the advantage to this process is to spare your family, in whatever form it takes, the stress and uncertainty that accompany making decisions in urgent situations.
Review your preferences with the person who holds your DPOA periodically.
There should be periodic check-ins. Have you changed your mind? Has your medical condition improved or worsened? Has there been a medical or treatment breakthrough that might make a condition survivable or improve your quality of life?
If you have one diagnosis, don’t assume that’s the only thing that will hospitalize you in a critical condition.
The person whop holds your DPOA will have a very different set of circumstances to deal with if you are in an accident and have become a quadriplegic rather than facing an expected decline due to a long-term illness. Discuss all the eventualities, including paralysis and brain damage.
Enlist the help of your physician, nurse practitioner, and spiritual advisor (pastor, rabbi, imam, roshi-sensei-rinpoche, priest or priestess) in making these challenging decisions. Also talking with someone who has lived the experience – either as a patient who recovered or as the holder of the DPOA – is valuable.
Living will and DPOA forms (also known as Advance Directives) are available through hospital and hospice social workers, through your health care provider, on the Internet, and the Vermont Ethics Network.
Living Will and Durable Power of Attorney documents can also be found online at www.rainbowlaw.com or www.gaywill.com
Pat Winer lives in Huntington.