Your Health First
Advantages of Advance Directives
Advance directives help create a healthcare plan.
Let’s face it, it is never easy to write or talk about how we want our medical care to be directed once we cannot make those decisions for ourselves.
I have had dozens of patients who defer to their loved ones instead of making that decision for themselves. When asked why they would rather postpone the decision, I often get, “Well doc, I don’t want to think about that right now.”
The truth is no one knows you as well as yourself. It helps your healthcare team make medical decisions for you when you are not able to do so. It also takes pressure off of loved ones because they do not have to guess what your wishes would have been. If it is difficult for us to make those decisions while we have a clear mind, imagine what family members would go through while attempting to make those medical decisions for us.
For this edition of “Oklahoma Health,” I had the privilege of interviewing Dr. Bryan Struck a member of the Donald W. Reynold Department of Geriatric Medicine at the University of Oklahoma College of Medicine and medical director of the Oklahoma City Veterans Administration Medical Center palliative care program. Struck earned his medical degree and Internal Medicine residency from the University of Texas Houston Medical School. After residency, he studied Geriatrics and Palliative Medicine at Baylor College of Medicine in Houston, Texas.
Q: When should someone fill out an advance directive?
Advance directives are something that anyone over the age of 18 should fill out—regardless of their health status. What the advanced directive does is let the patient tell their families and their doctors how they want to be treated if they get an illness we can’t fix.
Q: Why should someone fill out an advance directive?
There are a couple of reasons why it is important to fill out an advance directive if you reside in the state of Oklahoma. First, Oklahoma does not have any surrogacy laws. By that we mean if you are unable to talk to the doctors there are no legal routes in Oklahoma for who should be making decisions for you. Texas, surrounding states, and the federal laws say the spouse, adult children, parents and such should be making those decisions for you, but we do not have that system in place here in Oklahoma. While we follow that hierarchy, there is nothing that says we have to. I have seen a situation where the individual wanted a different person making medical decisions for him and that decision went to someone else. That’s why it is important to fill out the section of the advance directive pertaining to the healthcare proxy who makes medical decisions for you.
Q: What else does an advance directive entail?
The second part of the advanced directive deals with how patients want to be treated if a terminal illness develops and patients are thought to have 6 months or less to live. The other aspect would be when a patient develops an end-stage disease such as Alzheimer, heart failure or renal failure in which treatments are not going to improve a condition, when death is imminent or the illness will result in a persistent unconscious state where no interaction is possible—a massive stroke for example.
Q: What does Oklahoma law say if there is nothing filled out on paper?
Oklahoma laws, by default, assume that regardless of how ill patients may be or how likely it is that they will soon pass away from their illness they want everything done to keep them living including cardiopulmonary resuscitation (CPR) and intubation with mechanical ventilation (artificial breathing). If patients do not wish to pursue those life-sustaining measures since they will not prolong life in a meaningful way, those wishes need to be documented on paper; otherwise we must proceed as Oklahoma law mandates. I have witnessed such scenarios with the ultimate outcome being poor. That is why everyone should have these forms filled out if they are 18 or older.
Q: How should people go about completing these forms?
There are several options for completing these forms. Organizations such as the Oklahoma Bar Association, Oklahoma Medical Society, a doctor’s office or local hospitals should have copies of advance directives for anyone who wishes to complete them. The healthcare proxy and an alternate should be identified, and resuscitation preferences should be noted under the terminal illness section along with preferences for artificial nutrition and hydration. Those two sections comprise the healthcare proxy and living will. Once the form is signed, it needs to be witnessed by two different people. The Oklahoma form will also have a section on whether an individual would like to become an organ donor. Unlike the estate planning forms that give individuals durable power of attorney for healthcare, advance directives do not need to be notarized.
Q: What if someone has a change of heart about a previously filled form?
People are free to change the content of an advance directive form as frequently as they wish to do so. Only the most recent copy is valid as someone’s most recent wishes. It is very important that close family members are aware of changes in order to ensure there is no disagreement if the situation ever comes up. It is especially important to maintain your healthcare proxy and alternate aware of these changes as they will be the ones carrying out your wishes.
Q: When does the advance directive take effect?
These forms only take effect when a patient is unable to make medical decisions.
This includes patients who are in a persistently unconscious state or an illness that is either terminal or end-stage. Patients are expected to make their own decisions if they are admitted for an acute illness such as a motor vehicle accident. Advance directives will not prohibit you from obtaining such emergent care. It would only be used if someone had a serious injury and ended up going into one of the categories listed above
Q: What is the difference between advance directives and DNR orders?
A Do Not Resuscitate (DNR) order is a separate document that people with very serious illnesses oftentimes complete if they feel that sudden death could happen from their illness. Those patients are usually very sick and have chosen to not undergo resuscitation under any circumstance.
Dr. Gabriel Vidal, MD