A living will is a document in which you can write down in advance your wishes regarding life-sustaining treatments should you become terminally ill and unable to convey your decisions to your physician. For example, in a living will you can direct that, should you become terminally ill and mentally incapacitated, you do not want to be kept alive on a respirator. You can also enumerate the circumstances in which you wish to receive life- sustaining treatments. Thus, you could direct in a living will, that should you become incapacitated, you want to be kept alive by artificial nutrition and hydration. Directions in living wills will not be followed as long you are capable of making your own treatment decisions. In addition, the creation of a living will is entirely voluntary, and therefore no one can require you to do so.

Are living wills recognized in every state?
Laws authorizing living wills have been enacted in over 40 states. However, these laws can vary in important ways. For example, according to some state laws, instructions in living wills must be followed only when individuals are suffering from a disease that will shortly lead to their deaths, regardless of medical interventions. Other states’ laws provide that living will instructions are effective even if a person is in an irreversible coma that will not cause the person’s death. In some states, individuals may write living wills at any time while in others, individuals may not write living wills once they have acquired a terminal illness. Some states recognize living wills for specific periods of time, for example five years, while other states place no time limits on the effectiveness of living wills. Significantly, some states will not legally acknowledge instructions in living wills that direct the removal of feeding tubes that provide nutrition and hydration. 

Advantages and disadvantages of living wills
Using a living will allows you to specify the circumstances under which you wish to receive particular types of life-sustaining treatment. Thus, living wills can give you some control over your medical care when life and death decisions need to be made. However, living wills are ordinarily not used to delineate treatment decisions you would wish put into effect in the event you were to suffer from a nonterminal illness and lose your ability to make treatment decisions. For example, if you were to become unconscious as a result of a non-life-threatening fall, the instructions in your living will would usually be irrelevant. In addition, even in a terminal illness context, it is impossible to anticipate in a living will all of the possible treatment choices with which you might be faced. Thus, regardless of how detailed you make your living will, there still may arise unexpected circumstances not covered by it. Another difficulty with using living wills is that conflicts can arise over its proper interpretation when treatment decisions need to be made.

Health Care Proxies
Most states have laws that permit you to appoint a health care agent to make medical decisions for you should you become unable to make such decisions yourself. The appointment of these health care agents is most often accomplished through the filling out of forms known as health care proxies. Some health care proxy forms allow you to direct your agent to make specific medical treatment decisions in particular situations.

State laws generally grant health care agents the power to make all medical decisions for incapacitated persons, including decisions concerning life-sustaining medical interventions. For example, if a man appoints his wife as his health-care agent and then becomes incompetent due to Alzheimer disease, the wife is empowered to decide his course of treatment Some states, however, restrict the ability of health care agents to make decisions about the insertion or removal of feeding tubes that provide patients with nutrition and hydration. Regardless of the scope of their powers, health care agents have no authority to make any medical decisions for you before it’s been determined that you cannot make the decisions for yourself. The  health care proxy laws generally permit you to list alternate health care agents so that someone will be able make medical decisions for you should your original proxy be unavailable. Like the living will, the appointment of a health care agent is entirely voluntary.

Who should you appoint as your health care agent?
Generally, you can appoint any adult to be your health care agent, although you should first determine whether that person is willing to serve as your agent. People who appoint health care agents generally choose someone who knows them well, cares about them, and whom they can trust. For example, some people appoint spouses or other close family members as their proxies, while others appoint close friends.

Regardless of who you appoint as your health-care agent, it is a good idea for you discuss with him or her medical treatment issues that are important to you. An example of such an issue is the use of artificial nutrition and hydration should you become incompetent and have little chance of regaining your mental faculties. By discussing these issues with your health-care agent, the agent will be more likely to have the information necessary to determine the types of medical decisions you would want made for you should you become incapacitated. Even if you do not discuss these issues with your agent, your agent will still have the power to make medical decisions for you if you are unable to do so yourself.
 

The Differences Between Living Wills and Health Care Proxies
As opposed to living wills, health care proxy forms do not require you to specify what treatments you would wish to undergo in particular circumstances. Rather, they permit you to appoint an agent who is empowered to make virtually any health care decision for you should you lose decision-making capacity. In addition, while living wills generally cover only decisions about life-sustaining treatments in circumstances where an incapacitated individual has a terminal illness or is in an irreversible coma, health care agents may make medical decisions in all circumstances in which an individual becomes incapacitated. In many ways, therefore, the appointment of a health care agent allows for greater flexibility than does the writing of a living will.
 

When and How to Write a Living Will and Fill Out Health Care Proxy Forms
Many people associate health care proxy forms and living wills with the elderly or very ill. However, some of the most prominent cases that illustrate the need for these documents involved young adults in tragic accidents who became incapacitated and required decisions to be made for them about life-sustaining treatments. Because the occurrence of serious injuries or sudden changes in health status cannot be predicted with any certainty, it is a good idea for you to fill out one or both of these documents as soon as you are able no matter what your age or health status.

Some state departments of health and nonprofit organizations such as Choice in Dying can provide you with detailed, state-specific information about health care proxies and living wills. Hospitals and other medical providers that receive federal funds are required by federal law to provide you, upon your admission as a patient, with information about your rights under state law to create advance directives such as living wills and health care proxies.

After you have written a living will or have filled out a health care proxy form you should let your family and close friends know about its existence and location, so that they can readily access the document should the need arise.

Summary
Living wills and health care proxies are advance directives that allow you to retain control over your medical care if you become incapacitated and are no longer able to make medical decisions for yourself. In a living will, you are able to specify circumstances under which you wish to be given particular life-sustaining treatments, while health care proxies enable you to appoint an agent to make medical decisions for you. Regardless of your age or state of health, these are important documents to have.

© 2000 Healthology, Inc.

What is long-term care?

Most Americans know about the kind of health insurance that pays doctor and hospital bills. But the kind that pays for long-term care in a nursing home or at home is not as familiar.

Long-term care goes beyond medical care and nursing care to include all the assistance you could need if you ever have a chronic illness or disability that leaves you unable to care for yourself for an extended period of time. You can receive long-term care in a nursing home, or in your own home, in the form of help with such activities as bathing or dressing. Long-term care can be of help to a young or middle-aged person who has been in an accident or suffered a debilitating illness. But most long-term care services are used by older people.

Beyond nursing homes, there is a range of services available in the community to help meet long-term care needs. Care given by family members can be supplemented by visiting nurses, home health aides, friendly visitor programs, home-delivered meals, chore services, adult daycare centers, and respite services for caregivers who need a break from daily responsibilities.

These services are becoming more widely available. Some or all of them may be found in your community. Your local Area Agency on Aging or Office on Aging can help you locate the services you need. Call the Elder care Locator at 800-677-1116 to identify your local office.

Are you likely to need long-term care?

This year about seven million men and women over the age of 65 will need long-term care. By the year 2005, the number will increase to nine million. By the year 2020, 12 million older Americans will need long-term care. Most will be cared for at home; family members and friends are the sole caregivers for 70 percent of elderly people. But a study by the U.S. Department of Health and Human Services indicates that people of age 65 face at least a 40 percent lifetime risk of entering a nursing home. About 10 percent will stay there five years or longer.

The American population is growing older, and the group over age 85 is now the fastest-growing segment of the population. The odds of entering a nursing home, and staying for longer periods, increase with age. In fact, statistics show that at any given time, 22 percent of those age 85 and older are in a nursing home. Because women generally outlive men by several years, they face a 50 percent greater likelihood than men of entering a nursing home after age 65.

You may never need a nursing home. But the longer you live, the greater the chance that you will need some form of long-term care.

Copyright © 2000 Health Insurance Association of America

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