Case Study 29 : ADVANCE MEDICAL DIRECTIVE
Challenges
A 60-year old widow, G8P8, was admitted because of abdominal pain. The abdomen was partially distended, tender especially in the lower half, with fullness to palpation. Physicians diagnosed her with cervical carcinoma, stage III-B. No operation was contemplated due to the advanced stage of the disease. The doctors advise the family to help her draft an Advance Medical Directive.
Question
What is an “Advance Medical Directive”?
Solutions
An “Advance Medical Directive” (or “AMD”, sometimes simply called an “Advance Directive” or a “Living Will”) is a legal document written by the patient, with or without the assistance of an attorney, that takes effect when the patient becomes incompetent, and which specifies what medical procedures are to be given or avoided. As such, it is a form of an advance directive – it gives instructions for a future situation. (One other example of an advance directive is the “Durable Power of Attorney”, discussed in another issue of Bioethics Bits.)
Advance directives in general facilitate the family’s or proxy’s task of decision-making. Once they are made, copies are distributed to all concerned. The patient should review them periodically, and when revisions are made, previous copies are preferably destroyed.
If the instructions contained in the Advance Medical Directive are too specific, however, the document becomes inflexible and looses much of its usefulness; this is true especially if present circumstances are significantly different from the situation when the Directive was drafted. The document might even hinder the caregivers’ freedom to make good decisions, and problems of interpretation could arise. Furthermore, how much informed consent the patient possesses at the time of its writing could be a big question, since it entails a decision regarding a future medical condition, which cannot be completely known in advance. In view of all these, the patient should try to focus on general goals rather than on specific medical procedures (or use the Durable Power of Attorney as an alternative). (Reference: National Catholic Bioethics Center, A Catholic Guide to End-of-Life Decisions, 1997.)
