Advance Health Care
Directives
Daryl Pullman, Ph.D.
Faculty of Medicine
Objectives
 To better understand something of the
context in which AHCDs are prepared
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i.e. some important issues and distinctions
with regard to end-of-life care
 To understand the nature and effective
utilization of Advance Health Care Directives
 To review some salient features of the N&L
legislation on AHCDs
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The Ambiguity of Death
 Temporal Ambiguity
 Emotional Ambiguity
 Cultural Ambiguity
 Conceptual Ambiguity
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Temporal Ambiguity
“Life used to be like a
light bulb. . . We’d burn
brightly for a time and
then we’d burn out.
That was it! Now it’s like
we’re on a dimmer
switch. It isn’t clear
when the light should
go out, or who should
turn the switch off . . .”
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Death has become a negotiated event
 Patients are less
likely to die from the
underlying disease,
and more likely to
die from withdrawal
of intervention
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Emotional ambiguity
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Frustration, Remorse and Guilt
The dying process brings with it a wide range
of intense emotions for the patient, the family,
and for caregivers alike
Infamous “daughter-from-away”
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Cultural Ambiguity
 The context of death—from home, to hospital, to
home
 The institutionalization and medicalization of death
has contributed to our death denying culture
 Too early to tell whether quicker and sicker
discharges will lead to greater understanding and
acceptance . . .
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Conceptual Ambiguity
 Advancing medical technologies
continually stretch the concepts
by which we define and attempt
to manage medical interventions
 Death of the body vs death of the
person . . .
 Heroic/Extraordinary intervention
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Terri Schiavo
Dialysis
Respirator
Nutrition & hydration
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Concepts . . .
Futility
Are proposed interventions physiologically futile
or reasonably certain not to achieve the desired
outcome?
"medical futility"; "strict futility"; "objective
futility"
"futility of means"
Are proposed interventions futile in terms of the
expressed goals of the patient or their
surrogates?
"subjective futility“
"futility of ends"
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Advance Health Care
Directives
A means by which competent individuals can
express their wishes with regard to health care
decisions in the event they are no longer
competent to communicate
Types of Advance Directives
 Instructional Directives
 Proxy Directives—
Substitute decision maker
 Value Based Directives
 Disease Based Directives
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Instructional Directives (Living Wills)
 Contains a person’s preferences regarding
specific medical interventions

Usually related to end-of-life care, but not
limited to this
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The majority of instructional advance
directives are used to…
 Instruct health care professionals to
withdraw or withhold medical treatments
such as
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cardiopulmonary resuscitation
mechanical ventilation
dialysis
antibiotics
surgery
invasive diagnostic procedures
or artificial nutrition and hydration
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Substitute Decision Maker
 Proxy Directive
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“Durable Power of
Attorney for Personal
Care”
Designates a person (or
persons) who can make
medical decisions on the
incompetent patient’s
behalf
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Values-based Directive
 Expresses the person’s attitudes towards
various aspects of human life including:
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Physical and mental functioning
Pain
Social interaction (e.g. ability to
communicate)
Spiritual values
Other elements of quality of life
Medical intervention
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Disease Specific Directives
 A type of
instructional
directive that
focuses on issues
pertaining to a
specific disease
 Diabetes, heart
disease, lung
disease etc.
All of the above types can be combined into one
comprehensive directive MUNPA 09
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Example of a complex directive
CPR
VENTILATOR
SURGERY
BLOOD
TRANSFUSION
ANTIBIOTICS
TUBE
FEEDING
CURRENT HEALTH WITH
POTENTIALLY REVERSIBLE
ILLNESS
CHRONIC ILLNESS WITH
PHYSICAL DISABILITY
MILD
DEMENTIA
MODERATE
DEMENTIA
SEVERE
DEMENTIA
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ADVANCE HEALTH CARE
DIRECTIVES ACT (1995)
 Newfoundland & Labrador passed the
Advance Health Care Directives Act in
1995
 The Act allows residents to prepare a
document setting out instructions or
general principles regarding health care
treatment
 The Act permits the naming of a proxy to
make decisions on a person's behalf in the
event of incapacity
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Advance Health Care Directives Act
 Advance health care directive may contain:
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Instructions or general principles re
health care treatment and/or
Appointment of substitute decisionmaker [s. 2]
 Formal requirements—The AHCD must be:
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In writing,
Signed by the maker, and
Have two independent witnesses [s. 6]
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So there is an advance directive:
What gets done with it?
 An advance health care directive comes into effect when maker
ceases to be competent to make and communicate health care
decisions, and lasts for duration of incompetence [s. 4]
 As long as patient is competent, can revoke/ revise advance
health care directive [s. 8]
 A health care professional who has a copy of an advance health
care directive must include it in patient’s medical record [s. 17]
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When there is no pre-appointed substitute
decision maker
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Determination of decision maker (must be 19 + yrs)
(a) the incompetent person's spouse;
(b) children;
(c) parents;
(d) siblings;
(e) grandchildren;
(f) grandparents;
(g) uncles and aunts;
(h) nephews or nieces;
(i) another relative of the incompetent person; and
(j) the incompetent person's health care professional who is
responsible for the proposed health care.
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What does the substitute decision
maker (proxy) do?
 If joint SDM’s, majority rules [s. 11]
 SDM must act in accordance with:
(a) directions in advance health care directive;
(b) the wishes of the patient as expressed to SDM
when competent; or
(c) what the SDM believes to be the best interests of
patient (if (a) and (b) not available) [s. 12]
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Emergency exception
Substitute Decision
Maker’s consent not
required if:
 Health care is
necessary to preserve
life or health, and . . .
 Delay in finding SDM
may pose significant
risk to patient [s. 9]
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Consent Requirements
The fact that a document such as
a living will or advance directive
is on a patient's chart does not
remove the obligation of
physicians or other health care
practitioners to obtain proper
consent to treatment
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Arguments in Favour of ADs
 They extend a person’s autonomy
 They promote fair treatment of incompetent
patients
 They reduce emotional anguish for patient’s
and families
 Can reduce distress for care-givers
 May increase communication
(patient/physician; patient/family)
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Arguments against AD
 May be inappropriate to project the
autonomous wishes of healthy, competent
persons onto the future situations of
unhealthy, incompetent persons
 People change their minds but may not
change their directives
 Paradoxical problems of generality and
specificity
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Directive too specific? too vague?
 If too specific to a particular set of
circumstances, then it will have no force
when those circumstances (or ones similar)
do not exist.
 On the other hand, if so general that it applies
to all possible events that could arise it is
usually too vague to give any usable direction
to the physician.
 In either case physicians will have to rely on
their professional judgment to reach a
decision.
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Some concluding thoughts on ADs
 ADs are not a panacea for the many complex
issues that can arise around end-of-life
decision making
 ADs can be a catalyst to get people talking
about end-of-life issues
 They should be viewed and used as the
beginning of an on-going conversation (with
family members & physicians) not as the end
of a discussion
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www.practicalbioethics.org/cpb.aspx?pgID=886
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