END OF LIFE PLANNING

Masood N. Khan M.D., F.A.C.P

In the olden days when life was simple and families were bound, end of life also used to be a natural and simple event without much fanfare, medico-legal ramifications or physical indignities due to technological advances a dying person is often subjected to, in today’s world. Human lifestyle has become complicated and vulnerable to a barrage of stresses resulting from a highly mobile society, longevity of life, independent living and advances in medical sciences that no doubt prolong life but often the death too. End-of life planning therefore becomes necessary in order to avoid unnecessary obstacles to one’s departing from this world with peace and dignity. Such planning is technically called “Advance Directives” or ADs.

The American College of Physicians has dedicated its time and resources in developing guidelines for compassionate and competent care of dying persons and making people aware of the legal and ethical rights of informed and alert adults to refuse available lifesustaining medical treatment including withdrawing of already initiated treatments.

The Ads, as they relate to one’s terminal illness and mode of death, essentially are comprised of two aspects in planning the end of life. These are:
1. Health Care Power of Attorney
2. The Living Will (for end of life)

The Health Care Power of Attorney is a legal document in which you nominate two persons in order of priority, (the second one to take charge only if the first nominee is unable to do the job) called “health care agent” to make decisions about your medical care in case you are not able to make them because of illness or injury. The health care agent should be a competent person at least 18 years old who is not your paid health care provider. You should choose your health care agent carefully because that person will have broad authority to make decisions about your terminal care towards end of life. Unless you specifically limit the power of your health care agent, he/she can make all health care decisions for you including:

to communicate with the doctors involved in your care
to access all your medical records as necessary
choose your doctors and facilities
decide about your mental health treatment
start or stop life-prolonging measures
decide about autopsy only if you permit. Such per- mission is applicable to only those deaths where the State Medical Examiner is not involved
decide about disposition of your body
choose to donate your organs if you give this spe- cific permission to him.

Your health care agent will be required to use his/her authority in making above decisions only when your doctor(s) determines that you have lost the ability to make your own health care decisions. It is to be noted that, while you are still competent, unaffected by any illness you may cancel the document and revoke any power of attorney you have executed by simply destroying the document or writing “VOID” across the document and letting your doctor know that you have revoked the document. If you do not have a health care agent, North Carolina law requires health care providers (doctors) to look to the following individuals for making decisions in the order listed below:

Legal guardian
An adult under a general power of attorney (POA) if that person has the right to make health care decisions; spouse
A majority of your parents and adult children
A majority of your adult siblings
An individual who has an established relationship with you who is acting in good faith and who can communicate your wishes. If there is no one, the law allows your doctor to make decisions with a second doctor agreeing to those decisions.

2. The Living Will lets you make either one or both of the following important decisions (A & B below) towards the end of your life due to a terminal illness which includes the following:

You have a condition that cannot be cured and that will result in your death within a relatively short period of time.
You become unconscious and your doctors have determined that to a high degree of certainty you will never regain consciousness.
You suffer from advanced dementia (loss of cognition) or any other condition which results in the substantial loss of your ability to think and your doctors have determined that to a high degree of medical certainty the condition is going to worsen irreversibly.

A. You do not want your life prolonged by any lifeprolonging measures that include invasive procedures such as pacing of the heart, mechanical ventilation (breathing machine) to sustain your breathing, life sustaining treatments such as chemotherapy, radiation therapy, surgical procedures, antibiotics and kidney dialysis etc. and also discontinuation of already existing life-prolonging measures.

B. You do not want to receive any kind of nutritional support through tube feeding when in your terminal illness you are unable to swallow food and have lost appetite due to illness.

In addition to the above definitive and important decisions, the Living Will lets you make two additional corollary decisions which are:

I. “I want my health care providers (doctors) to keep me as clean, comfortable and free of pain as possible even though this care may hasten my death.”

II. If my appointed health care agent gives instructions that differ from the desires expressed in this living will, you have the option to select one of the two following:

Follow the living will as executed.
Follow the changes made by the health care agent.

In order to make your advance directive as elaborated above, you need to complete the documents and put your signature in front of two witnesses who are not supposed to be your relative, your heir, someone who has a claim against you, your doctor or any employee of the hospital where you are a patient. The signing process has to be done in the presence of a notary public who will notarize the documents. Most of the hospitals nowadays have a designated person called ‘Advance Care Planner’ who can assist you in planning your end-of-life care, making the above documents and duly notarizing them free of charge. In case you decide to make end of life planning in advance, it is a good idea to contact the ‘Advance Care Planner’ of any hospital. You will then be guided and walked through the whole procedure which in practice is lot simpler than it appears.