When you create an Advance Healthcare Directive (AHCD) as part of your complete estate plan, you are often asked to imagine the unimaginable. Some attorneys will give you several options for end of life decisions, such as preserving your life as long as possible at one end of the spectrum and denying all attempts to save your life at the other end of the spectrum. Several, more nuanced approaches exist, such as withdrawing life support after being in a coma for a pre-determined amount of time. Still other attorneys will allow you to direct certain types of treatment with an “I would never want x” clause where “x” might be amputation, artificial nutrition or hydration, or cardiopulmonary resuscitation (CPR).
In California, the body of law regarding the right to refuse medical treatment and direct yourself down the path of a natural, if expedited, death has been developing for several decades. The obligation for the state to protect lives generally, the obligation for physicians to perform needed medical procedures, and the right of the ill individual are often at a crossroads in such cases. As the law has been developed, the courts have allowed individuals increasing ability to direct their own course of treatment.
In a 1986 case, Bouvia v. Superior Court, a California appellate court allowed a woman with severe cerebral palsy to have a feeding tube withdrawn, despite that fact that she could be expected to live 15 or 20 more years. In their decision, the court emphasized the importance of allowing a person to determine that his or her quality of life would be so diminished, that his or her remaining quantity of life could be outweighed. Although it is an extreme case, it is important to reflect seriously about what your quality of life means to you when discussing your AHCD with your attorney, family, and prospective health care agents. It is also absolutely essential to revisit these considerations as you age.
Similarly, when creating your AHCD, you and your attorney should work together to balance how much flexibility to leave your agent. Your agent’s authority will generally only be effective once you have lost capacity to make your own health care decisions. As such, your input may be non-existent at the time when emergency or end of life decisions will be made regarding your treatment and procedures. Your AHCD is where you allow your voice to be heard.
To that end, you may allow your voice to be a whisper, giving your trusted agent some general guidelines to make decisions as you would, given the facts and circumstances at the time the agent’s decision is requested. You can temper your agent’s authority with an obligation to consult with other family in non-emergency situations, or obtain a second opinion or allow your agent the autonomy necessary to make weighty decisions without the interference of others. If you feel strongly about particular courses of treatment, you may also give yourself a louder voice to express the quality of life you require in order for life to be worth continuing.
Your decisions regarding how strongly to state your healthcare preferences may depend on your age, general health, family situation, and agent selection, among other factors. Thinking about these issues now can alleviate needless physical suffering for yourself and needless emotional suffering for your loved ones.
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