What is a living will?

Introduction

A living will is a legal document, often part of a three-part advance directive that also includes a durable medical power of attorney and a do-not-resuscitate (DNR) order. A living will tells what medical treatment a person does or does not want, such as artificial nutrition and hydration, mechanical ventilation, or kidney dialysis. A durable medical power of attorney is a legal document that appoints a proxy to make medically related decisions for a person if that person becomes unable to speak. A DNR is a document that directs medical staff not to use heroic measures, such as cardiopulmonary resuscitation (CPR), if a patient’s heart stops or the patient stops breathing. Advance directives should be notarized, if possible, and a copy should be placed in a patient’s medical record. A person must be eighteen years of age to sign a living will or advance directive. Most states do not allow the withdrawal of life support from a pregnant patient.

The concept of a living will was first introduced in 1969 when it became apparent that medical technology had advanced to a level where a person could be kept alive in a permanently unconscious state for years using artificial life support machines. While artificial life support is an important medical tool that can save lives and help stabilize patients waiting to receive other medical treatments, many people do not want to receive artificial life support if it is intended only to prolong life rather than to treat or improve a medical condition.

Features

A living will can be a simple form or a complex document describing specific treatment preferences for specific conditions. Living will forms are available at hospitals, nursing facilities, and many medical treatment centers. US hospitals and nursing facilities are required by federal law to ask patients when they are admitted if they have a living will or would like to fill out a living will form. If a patient is unconscious or unable to communicate his or her wishes for medical treatment and does not have a living will, then the doctor is required to consult with family members to determine the patient’s wishes regarding life-prolonging medical care. Living will forms are also available online at state health department websites. In addition, a lawyer can be hired to write a living will. State laws may vary for living wills, and a living will should be written to comply with the laws in the state in which medical care is provided.

The more specific a living will is, the easier it may be for the medical care team and the family to understand what a person wants. Discussing the living will with family and doctors can ensure that the intent of the living will is understood. Copies of the living will should be placed in the patient’s medical record and shared with family members. Some living wills specify the need for two physicians to concur that the patient’s medical condition is terminal with no chance of recovery before it is valid. A living will can be changed at any time, even when a patient is in the hospital receiving treatment. It is not intended to keep a person from receiving medical care for emergency treatment, even if terminally ill.

Most states offer a living will registry that allows state residents to store a copy of their living wills in a secure online database at no charge. Only authorized health care providers can view the database.

Perspective and Prospects

The California Natural Death Act of 1976 was the first legislation to allow a patient to refuse medical treatment intended to prolong life. The same year, the New Jersey Supreme Court established the right of a dying patient to refuse medical care in the case of Karen Ann Quinlan. Quinlan was twenty-one when she became unconscious, paramedics were unable to revive her, and she lapsed into a vegetative state. She was kept alive on a ventilator for several months. Her parents requested that she be removed from the ventilator, but the hospital refused. A court order was finally issued to remove her from the ventilator, but it allowed artificial nutrition and hydration. Quinlan lived in a nonresponsive coma until 1985, when she died of pneumonia.

Another well-publicized case involved Terri Schiavo, a twenty-six-year-old woman who experienced respiratory and cardiac arrest that left her in a vegetative state. When it became apparent that Schiavo would not recover, her husband requested that her artificial life support be discontinued. Schiavo’s parents disagreed. A lengthy legal battle ensued. Without a living will, it was left to the courts to decide. Throughout the publicized family struggle, an increase in the number of living wills prepared throughout the country was reported. In 2005, Schiavo was removed from life support and died a few weeks later.

In 2014, Margot Bentley, a woman living in a care facility in British Columbia after being diagnosed with Alzheimer's disease, had drawn up a living will years before. The will had expressed her wish not to receive nourishment or liquids if she suffered from extreme mental or physical disability. However, contrary to her family's wishes to uphold the living will after Bentley had lost the ability to speak and essentially move, a court ruled that feeding did not necessarily constitute the type of "heroic measures" mentioned in the will and that the family could not refuse food on her behalf.

An alternative to a living will supported by pro-life groups is a “will to live” form. The emphasis of the form is that the presumption should be for life, regardless of circumstances. Both living will and “will to live” documents can be used to provide details about the specific type of medical care desired by patients who are unable to communicate.

Bibliography

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