The Importance of Advance Healthcare Directives in a Pandemic
The COVID-19 pandemic has not only brought the world to a standstill. It has brought us face to face with our own mortality. The news headlines are filled with daily stories about the tragic loss of life and those stories make it clear that this virus is deadly to people of all ages and lifestyles.
A recent piece published by Dr. Asha Shajahan, a primary care physician in metro Detroit, poignantly conveyed the reality of life and death in a COVID-19 unit. Dr. Shajahan opened his piece with the following,
Earlier this week, a 30-year-old patient with COVID-19 passed away on a ventilator. He hadn’t laid out his end-of-life wishes ― what in the medical field are called advance directives. His father, devastated after seeing the numbers related to his condition, didn’t want any further treatment that would prolong the inevitable. His mother wanted to try everything that could possibly be done to save him. If the patient himself had been able to speak, he might have expressed what his wishes were and saved his family a heartbreaking conflict.
But he hadn’t planned to die.
One of the most devastating aspects of COVID-19 is the way it separates hospitalized patients from their loved ones. Because visitation is impossible due to the highly contagious nature of the disease, patients fight for their lives and—sadly—die without anyone at their side.
What makes these heartbreaking scenarios even more painful is the common lack of an advance healthcare directive. Without this critical legal document in place, there is no way for doctors or nurses to know a patient’s wishes if that patient is unable to speak for him or herself. This leaves the most difficult life-and-death decisions in the hands of family members who are already under extreme stress and potentially unprepared to make such decisions.
Dr. Shajahan described a typical situation without an advance healthcare directive,
“I don’t know what he would want ― making this decision for him is too stressful,” the sister of one 37-year-old patient said tearfully. This patient didn’t have advance directives in place. His sister now had the emotional burden of deciding his care. She too was fighting COVID-19 but from home. Her brother was on a ventilator, unable to communicate. To say it’s an overwhelming situation to be in is an understatement.
While it is not pleasant to contemplate the worst-case scenario, doing so ahead of a crisis will save a lot of pain and anguish in the greatest moment of need.
Advance healthcare directives are a key component of your estate plan. Your Last Will and Testament specifies how you want your estate to be distributed upon your death. Your power of attorney appoints someone you trust to take charge of your finances if you become incapacitated. In your advance healthcare directives you will:
- Appoint a healthcare representative, sometimes called healthcare agent or durable power of attorney for healthcare. As with the durable power of attorney for financial decisions, you should appoint someone you trust who will act on your behalf if you are incapable.
- Define the types of medical interventions and life support measures you want—or do not want—at the end of your life. This is called your living Will.
Of the 55 patients Dr. Shajahan was caring for in his Detroit COVID-19 unit, only one had an advanced healthcare directive.
That patient was nonverbal after having a stroke at the age of 54. I phoned his sister, his designated legal guardian, and she read his advance care plan to me. “Doctor, tell him I love him,” she said. It was comforting to know that this patient had a designated advocate.
What is life support?
Some commonly used life support measures include:
- Artificial nutrition and hydration (tube feeding)
- Cardiopulmonary resuscitation
- Mechanical ventilation
- Kidney dialysis
How do you decide which, if any, life support measures to accept? According to the Cleveland Clinic:
“A treatment may be beneficial if it relieves suffering, restores functioning, or enhances the quality of life. The same treatment can be considered burdensome if it causes pain, prolongs the dying process without offering benefit, or adds to the perception of a diminished quality of life.”
What you decide is up to you and you alone. You may want every technological innovation available regardless of your medical condition, or you may choose to have a good quality of life without excessive life-prolonging interventions.
The only way your family members or physicians will know your wishes is if you tell them in a written, legally enforceable document. They may not agree, but they cannot dispute what you have decided if it is unambiguously stated in your Living Will.
Do advance healthcare directives vary by state?
Each state has different legal requirements for Advance Healthcare Directives. In Connecticut, four types of advanced directives are defined but not required by law:
- Appointment of a healthcare representative (similar to a health care power of attorney)
- Living Will (concerning end of life)
- Document of anatomical gifts
- Designation of Conservator of Person for future incapacity (appointed by probate court)
What if I want to change my advance healthcare directives?
Your advance healthcare directives are not written in stone. You should revisit your healthcare wishes every few years or whenever any of the “5 D’s” occurs:
- Decade – when you start each new decade of your life.
- Death – whenever you experience the death of a loved one.
- Divorce – when you experience a divorce or other major family change.
- Diagnosis – when you are diagnosed with a serious health condition.
- Decline – when you experience a significant decline or deterioration of an existing health condition, especially when it diminishes your ability to live independently.
Who should get a copy of my advance directives?
According to the State of Connecticut, you should tell the following people that you have completed an advance healthcare directives and give them copies of the directives you have made:
- Your physician
- The person(s) you have named as your health care representative
- Anyone who will make the existence of your advance directives known if you cannot do so yourself such as family members, close friends, your attorney or your clergy
There is another new Connecticut form you should know about – it is essentially a medical order form that contains your treatment instructions. Unlike the advance healthcare directive, this form goes into effect as soon as it is signed, regardless of your capacity to make decisions. Click here to learn more.
If not for yourself, do it for your loved ones.
These are frightening times for all of us. The risks of COVID-19 are very real and they affect everyone we know and love. Preparing an advance healthcare directive with an estate planning attorney can give you and everyone in your family a little peace of mind in these very trying times.
At the end of his piece, Dr. Shajahan speaks about choosing his own advocate and addressing his end-of-life concerns.
Instead of guilt-ridden regretful thoughts ― “I wish I knew what he would’ve wanted” ― we all have the power to know our family’s wishes now. Talking about death is horribly uncomfortable, but perhaps this pandemic is the harsh nudge we need. Discussing advance directives prior to getting ill can save a lot of emotional pain and help to lessen the fears that surround death.
As is almost always the case, a little bit of proactive preparation can go a long way toward easing things later in a crisis. Though it may be scary to address these questions directly, doing so helps you ensure that your wishes will be honored no matter what happens.
If you would like to learn more or have any questions, we are here and able to consult with you via phone and video conferences. And if you do not yet have your advance healthcare directives in place, we cannot emphasize enough the importance of your taking this vital step.