A living will can be an enormous benefit to clients. A legal document, it spells out a person’s wishes concerning medical treatment in the event he or she suffers an incapacitating physical or mental disability.
But it must be properly executed, and its contents carefully reviewed with those charged with carrying out the instructions.
Advisors who have a number of seniors in their practice should be prepared to help clients successfully navigate this complex area. If the document is not up to scratch, those dealing with the situation can face an emotionally difficult time. Consider the harrowing experience suffered by one Toronto woman, whom we’ll call Anne.
When Anne’s 74-year-old father suffered a stroke last winter, he was rushed to hospital in a coma. He’d drawn up a living will, conveying his wishes in the event of a physical or mental disability, and had given Anne legal authorization to act on his behalf.
But he’d never discussed the contents with her.
In the hospital, Anne’s dad was put on a respirator, given blood thinners and connected to a feeding tube. In the will, however, she found he’d stipulated no intervention was to be made to maintain his life through life-support systems. He had given her authority to consent to or refuse treatment.
“But at what point did he want treatment stopped?” she asks today. “At what point would he consider life not worth living?”
From the start, Anne was told by medical staff that she should start thinking about the quality of life her father might have if he survived. When 72 hours had passed, she was told the left side of his brain was damaged and was asked to consider removing him from the respirator to see if he could breathe on his own. She discussed it with her family and decided against it.
A week passed. “He had tubes down his nose and throat, which were irritating him,” she says. “We had to make a decision — remove the tubes or perform a tracheotomy [cutting into the trachea through the neck].
Stopping treatment was too difficult a decision, so we agreed to the tracheotomy.”
By the end of the third week, treatment had begun to work against him: his blood sugar had soared and blood thinners were causing internal bleeding.
Although Anne had the authority to discontinue the feed and the blood thinners, she wanted her family’s backing, and some members of her family did not want treatment stopped. Finally, she asked the doctor to be completely frank. “He said Dad would never walk out of the hospital or even leave in a wheelchair. The best-case scenario was he’d recognize us, but there was a good chance he wouldn’t be capable of that.”
Events began to move quickly. The trach tube and then the food tube fell out as a result of the patient’s movements, and weren’t reconnected by hospital staff. Anne’s dad died two days later.
He’d been in the hospital a month. “It was a terrible time,” Anne recalls. “I had no idea what he wanted, and I was asked to make decisions every step of the way. The worst thing was deciding to stop treatment.
Luckily, we never had to do that. There’s a big difference in stopping treatment and not restarting it.”
If her father’s living will had been more specific, Anne and her family would have been spared some of these decisions.
“Regardless of who has legal authority,” she says, “it really comes down to a family decision.”
For the patient, a living will may be more important than the will itself, says Norman Goldberg, a family physician in Brampton, Ont. “It ensures him of some control over his treatment when he can’t communicate.
“It also relieves family and friends of the burden of making decisions. Different family members may want different things. The living will tells them what Dad wants. He may have said: ‘I have $1 million. I can afford the best care.'”
There are two types of advance directives:
> health- and personal-care instructions describing measures to take and not to take; and
> proxy directives, naming a person who understands the future patient’s views on treatment and care.
Ideally, a living will should have both, says Dianne Godkin, a post-doctoral fellow at the Joint Centre for Bioethics at the University of Toronto. “But they can contain just one. If a person finds considering a future illness difficult, he may only want to complete the proxy directive.” But this can lead to the problems Anne faced.