Advanced Health Care Directives

One of the fundamental tenets of the law, both in Washington State and throughout this country, is that you have the right to refuse medical treatment, even if that refusal will hasten your death.  While you can exercise that right at any time, it becomes particularly important if you are dying and any further treatment will only prolong your death.  Unfortunately, it’s very likely that you’ll be unconscious when that time comes, and won’t be able to tell your doctor what you want to do.

A way to make your wishes clear ahead of time is to prepare an advanced health care directive.  This document sets out which types of care you want (and even more important, the type of care you don’t want) when you can no longer communicate your wishes to your doctor.

In Washington, the rules for advanced health care directives are set out in the Natural Death Act (Revised Code of Washington Chapter 70.122).  Under the Act, you can prepare a document that states your wishes about withholding or withdrawing life-sustaining treatment when you are in a “terminal condition” or a “permanent unconscious condition.”

The Act defines a terminal condition as:

An incurable and irreversible condition … that, within reasonable medical judgment, will cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment serves only to prolong the process of dying.

It goes on to define a permanent unconscious condition as:

an incurable and irreversible condition in which the patient is medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

Your attending physician makes the determination as to whether you are in a terminal condition, but it requires two physicians to agree that you are in a permanently unconscious state.  Obviously, if you are in a terminal condition but can still speak to your doctor, the directive will not apply.

Now that we know when an advanced directive comes into effect, what can you put in your directive?  The Act makes it very clear that you have total control over the contents of your directive, as long as what you put in is limited to what treatments you want to be withheld at the time your directive become effective.  You cannot use an advance directive to authorize your doctor to give you medication to end your life.

The central decision you have to make in the course of preparing your directive is whether you want, or do not want, artificial nutrition and/or artificial hydration.  Withholding one or both of these may hasten your passing.  You can also specify a number of other things in your directive, such as not wanting a feeding tube, having antibiotics withheld, making it clear that you want pain medication, etc.

Another thing to keep in mind is that, like almost all of the legal documents we’ve discussed in past posts, your advanced directive has to be correctly executed to be valid.  You have to sign your directive in front of two witnesses, but you have to be careful about who acts as your witnesses.

An advanced health care directive is not valid if either of your witnesses is (1) related to you by blood or marriage, (2) a beneficiary of your will, (3) one of your heirs-at-law, (4) your attending physician, (5) an employee of the attending physician or a health facility in which you are a patient, or (6) anyone who has a claim against any portion of your estate.

Executing an advanced directive is the surest way to have control over the last days of your life.  In addition, making your wishes known ahead of time spares your family from the burden, along with possible guilt and second-guessing, of having to make a very important and emotional decision on your behalf.