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Advance Directive Documents

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A Step-By-Step Guide To Preparing Advance Directive Documents


OF MINDGIFT OF PEACE

A Step-By-Step Guide To Preparing Advance Directive Documents

By MARIAN A. BRENTON, M.P.A, R.N.

Project CoordinatorAnd

LON N. LARSON, PH.D.Project Director

DRAKE CENTER FOR HEALTH ISSUESDrake University

Des Moines, Iowa 50311

Published in Des Moines, Iowa by the Drake Center for Health Issues

Revised and Updated, Oct. 2000

GIFT OF PEACEThe


OF MIND

Reprint of this project was made possible in part by the

Iowa Department of Elder Affairsthrough Older Americans

Act funding.

Permission is grantedto duplicate thispublication for

educationalpurposes or

individual use.

This publication isalso available in Braille,

large type or tapeversion for thesight-impaired.Call or write the

Iowa Departmentfor the Blind,524 4th St.,

Des Moines, Iowa50309,

515/281-1333.

Primary references:

Emanuel LL, Emanuel EJ. “TheMed ica l D i r ec t i ve : A NewComprehensive Advance CareDocument.,” Journal of theAmerican Medical Association,June 9, ‘89; 261:3290. Copyright1990. It does not reflect theofficial policy of the AmericanMedical Association.

Reprint permission from Drs. Linda L.and Ezekiel J. Emanuel.

“Tak ing S teps To P lan fo rCritical Health Care Decisions,”Vermont Ethics Network.

Other references:

Gillick MR, Hesse K, MazzapicaN., Medical Technology at theEnd o f L i f e : Wha t Wou l dPhysicians and Nurses Want forThemselves? Archives of InternalMedicine, 1993; 153:2542-2547

“ H e a l t h C a r e P o w e r s o fAttorney,” Commission on LegalP r ob l em s o f t h e E l d e r l y ,American Bar Association.

“Planning for Incapacity: A Self-Help Guide,” Legal Counsel forthe Elderly, Sponsored by theAmerican Association of RetiredPersons.

This project was supported by agrant from the State of Iowa andadmin i s t e r ed by the IowaDepartment of Public Health.Initial printing costs were sup-por ted by Iowa Method i s tMed i c a l Cen t e r and IowaLutheran Hospital.

REFERENCES GRANT SUPPORT

The following individuals served on the Advisory Committee for thisproject. Their effort, expertise and experience added depth andaccuracy to this publication, for which the Center is most grateful:

CAROLYN S. ADAMS, M.P.A.,Iowa Department of Public Health

DANIEL J. BALDI, D.O.,Iowa Osteopathic Medical Association

DOUGLAS W. BRENTON, M.D.,Iowa Medical Society

DEANNA CLINGAN-FISCHER, J.D.,Iowa Department of Elder Affairsand the Iowa State Bar Association

REVEREND RANDY EHRHARDT,West Des Moines Christian Church

KATHRYN FREILINGERIowa Health System – Central Region

KAREN HANSON, J.D.,Iowa Hospital Association

LISA LACHER, M.A.,Drake University Department of Marketingand Communications

MAUREEN MCGUIRE, J.D.,Office of the Attorney General

TOM WESTBROOK, PH.D.,Drake University Adult Student Resource Center

ADVISORY COMMITTEE

This educational booklet wasp r o d u c e d b y t h e D r a k eUniversity Center for HealthIssues, a mult i -discipl inaryorganization dedicated to publiceducation about economic andethical issues in health care. It isabout making health care deci-sions in advance and creatingpeace of mind for you and yourfamily regarding these deci-sions.

If you suddenly became so illthat you were unable to makemedical treatment decisions foryourself, the burden of decidingwould fall to your family andloved ones. It is for them thatyou read this booklet and com-plete the enclosed advancedirective documents.

Medical technology can extendlife, but the quality of that lifev a r i e s f o r e a c h p e r s o n .Decisions about what is tolera-ble in l i fe and in the dyingprocess are personal and shouldbe made individually before theopportunity is lost.

Advance directives, such as theLiving Will and the DurablePower of Attorney for HealthCare have grown out of a desireto maintain individual controlover one’s life. These docu-ments work by extending theright of self-determination intothe future. By recording ourchoices now (as competent per-sons), we can influence health-care decisions made for us inthe future.

“The Gift of Peace of Mind: ForYourself, For Your Family” isintended for use by heal thprov iders when ta lk ing topatients about advance direc-tives, as well as by lay personswho wish to complete advancedirectives as individuals or ingroup settings. It is a detailedguide to the steps involved infilling out advance directivedocuments. We encourage youto duplicate it for your use.

This booklet is intended forinformational purposes onlyand is subject to revision if lawsshould change.

INTRODUCTION

The purpose of this bookletis to educate the public aboutadvance directives. By doing so,we hope to increase the use ofadvance directives, as well asthe quality and accuracy of thedocuments themselves. Thereader is led through a series ofsteps that ultimately lead tofilling out the advance directivedocuments in an informedmanner.

This booklet can be used in avariety of ways.

For example:

• An individual, couple orfamily member can use itwhen planning for thefuture.

• A health educator orhuman resources directorcan use it in large groupeducation programs.

• A physician, nurse or healthcare facility employee canuse it when talking withpatients or clients aboutfuture health decisions.

You may make as manycopies of the booklet itself,the advance directive formsand instructions, and thevalues survey as you need.

The Living Will and DurablePower of Attorney for HealthCare forms included in thisb o o k l e t a r e m e a n t t o b eduplicated and used by individ-uals. Duplicate copies are legaldocuments i f properly wit-nessed or notarized. The valuessurvey and medical situationw o r k s h e e t a r e n o t l e g a ldocuments themselves, but areintended for use in guidingdecision making. For additionalcopies of this publication, callor write the Iowa Department ofElder Affairs, 200 10th Street,3rd Floor, Des Moines, Iowa50309, 515/242-3333.

An effort has been made toanswer as many questions ascould be anticipated on thesubject of advance directives. Ifquestions remain, we urge youto discuss them with your healthprovider or your lawyer.

HOW TO USE THIS BOOKLET

STEP II

Understanding Legal and Medical Terms . . . . . . . . . . . . . 8-11

STEP III

Values Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-13

What do you value most about your life? . . . . . . . . . . . . . . . . . 12

What kinds of mental or physical conditions wouldmake you think that treatments that prolong dyingshould no longer be used? . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

How might your personal relationships andresponsibilities affect your own medical decisions? . . . . . . . . . . 12

How do you feel about death and dying? . . . . . . . . . . . . . . . . . 13

STEP IV

Medical Situation Worksheets . . . . . . . . . . . . . . . . . . . . 14-18

STEP V

Completing the Documents. . . . . . . . . . . . . . . . . . . . . . 19-32

Completing a Durable Power of Attorney for Health Care. . . . 19-20

Instructions for the Durable Power of Attorneyfor Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-22

Durable Power of Attorney for Health Care . . . . . . . . . . . . . 24-26

Completing a Living Will . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Instructions for the Living Will . . . . . . . . . . . . . . . . . . . . . . 28-29

The Living Will, Declaration Relating to the Useof Life-Sustaining Procedures . . . . . . . . . . . . . . . . . . . . . . . 30-32

STEP VI

Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . 33-34

Questions for an agent to ask the medical team. . . . . . . . . . . . . 33

Sample wallet card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

TABLE OF CONTENTS

STEP I

Understanding Advance Directives . . . . . . . . . . . . . . . . . . 1-7

What is an advance directive? . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Can health care decisions be made forme without advance directives? . . . . . . . . . . . . . . . . . . . . . . . . 1

Who can legally complete an advance directive? . . . . . . . . . . . . . 1

Which advance directive documents are legaland available in Iowa? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-3

Do I need to complete both documents? . . . . . . . . . . . . . . . . . . 3

Where can I get a Durable Power of Attorneyfor Health Care or a Living Will form? . . . . . . . . . . . . . . . . . . . . 3

How do I complete advance directives? . . . . . . . . . . . . . . . . . . . 3

What should I do with the completed advance directives? . . . . . . 4

What if I change my mind? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What if a doctor is unwilling to comply withmy Living Will or my agent’s decisions? . . . . . . . . . . . . . . . . . . . 5

If I move to another state, will myadvance directives be valid? . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

If I were in an accident, how would the police andambulance crews learn of my advance directives? . . . . . . . . . . . . 5

Can I be required to sign these documents as acondition for admission to a health care facility? . . . . . . . . . . . . . 6

Do I need an attorney to complete anadvance directive document? . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Who should be my agent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

What if I don’t have anyone to be my agent?. . . . . . . . . . . . . . . . 7

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based on what he or shebelieves to be in your bestinterest. Your agent is giventhe right to examine yourmedical records.

T h e D u r a b l e P o w e r o fAttorney for Health Caremust be filled out and wit-nessed while you are stillcapable of making decisionsfor yourself. Any incapacityyou may suffer later in yourlife will then be covered byt h e D u r a b l e P o w e r o fAttorney for Health Care.

T h e D u r a b l e P o w e r o fAttorney for Health Carecomes into play when yourdoctor has determined thatyou are unable to makehealth decisions for yourself,even when the situation istemporary, such as after a caraccident or a severe, suddenillness. Unlike a Living Will,which is the second type ofadvance direct ive and isdiscussed on page 3, theDurable Power of Attorneyfor Health Care is not restrict-ed to patients with perma-nent unconsciousness, with acondition that will lead totheir death (often called aterminal or fatal condition)or to decisions about proce-dures that delay the dyingprocess ( l i fe - sus ta in ingprocedures).

1. The following are tasksinvolved when filling outthe Durable Power ofAttorney for Health Care;

• Choosing an agent (some-one who acts for you) tomake health care decisionsfor you whenever, in thejudgment of your doctor,you are unable to makehealth care decisionsbecause of loss of conscious-ness or loss of ability tothink and reason. As long asyou are able to make yourown decisions you, not youragent, have the authority tomake treatment decisions.Typically, an adult child, aspouse, or a friend is chosenas a health care agent.

• Making decisions regard-ing specific health caretreatments that you do ordo not want in certainsituations.

• Having the documentwitnessed or notarized.

• Distributing the DurablePower of Attorney forHealth Care to theappropriate people.

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What are advance directives?

Advance directives are doc-uments that enable you tomake decisions now aboutyour medical care in thefuture. They offer guidanceto your family and doctorswhen you cannot speak foryourself, and help to assurethat your values and impor-tant wishes are carried out.There a re two advancedirective documents recog-nized legally in Iowa. Theyare explained below.

Can health care decisionsbe made for me withoutadvance directives?

Yes. If you have not com-pleted an advance directiveand are unable to makedecisions, family memberswill make health care deci-sions for you, after talkingwith your doctors aboutyour condition. However, itis best that these peopleunderstand your wishes andvalues. Completing advancedirective documents cangive you greater assurancethat your wishes will be car-ried out. They also can giveyour family members peaceof mind that they are doingas you would prefer.

Who can legally complete anadvance directive?

Any competent adult (18years or older) can com-plete an advance directive.A competent adult is onewho has the capacity tounderstand the nature andpossible results of his or hermedical condition and tomake independent deci-sions regarding treatment.

Which advance directivedocuments are legal andavailable in Iowa?

Iowa law prov ides twotypes of advance directives:

The Durable Power ofAttorney for Health Care

The Du r ab l e Powe r o fAttorney for Health Care is alegal document that allowsyou to choose someone asyour agent (someone whoacts for you) to make healthcare decisions wheneveryou cannot, due to uncon-sciousness or loss of abilityto think and reason. Thisagent is required to makedec i s ions accord ing todirections you provide inwriting or verbally to him orher. If your wishes are notc lear ly unders tood anddefined, then your agentw i l l m a k e d e c i s i o n s

STEP I:UNDERSTANDING ADVANCE DIRECTIVES

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Legal requirements for wit-nessing are the same forboth the Living Will and theDurable Power of Attorneyfor Health Care. Each formmust be signed and datedand then, either two peopleover the age of 18 must wit-ness your signature and signon the lines labeled for wit-nesses, or you must get theform notarized. At least oneof the witnesses must notbe related to you by blood,marriage, or adoption. Ifyou use a notary, witnessesare not necessary. The fol-lowing persons cannotlegally act as a witness foryou:

• Someone who has beenappointed as your agent onthe Durable Power ofAttorney for Health Careform

• Someone who is treatingyou as a patient, such asyour doctor or nurse

• An employee of anyonetreating you (including anyemployee of your doctor, thehospital, nursing home orhospice where you mayobtain medical treatment),unless the employee is alsoyour relative

What should I do withthe completed advancedirectives?

Copies must be made andgiven to family members,your health care agent, yourfamily doctor and, if appro-priate for you, your pastor,priest or rabbi. It is alsoimportant to remember thata copy should be taken tothe hospital with you everytime you are admitted, toensure that hospital staff areaware of it.

It is important to communi-cate with your loved onesand doctors about the exis-tence of your completedadvance di rec t ives andabout the information theycontain. This will make yourfamily, agent and doctorsmore certain of your wishesand more comfo r t ab l emaking decisions for you.

Your doctor or nurse can bea very valuable source ofinformation when you havequest ions about cer ta inmedical treatments. Theycan help you understandwhat types of si tuationsmight arise and what yourtreatment options might bein such cases. Schedule atime to talk with him or herabout these concerns.

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2. The Living Will,known in Iowa as TheDeclaration Relating toUse of Life-SustainingProcedures.

A Living Will is a documentdirecting your physician towithhold or withdraw cer-tain treatments (life-sustain-ing procedures) that couldprolong the dying process.Th i s advance d i r ec t i vebecomes effective only at apoint when, in the writtenopin ion of your doc tor(confirmed by one otherdoctor), you are expected todie soon and you are unableto make health decisions foryourself (because you areunconscious or unable tothink and reason) or you aredetermined to be perma-nently unconscious (irre-versible coma, persistentvegetative state).

Do I need to complete bothdocuments?

It is up to you. The LivingWill and the Durable Powerof Attorney for Health Careare legal documents that,when considered together,provide a very clear pictureof your wishes. Through aDurable Power of Attorneyfor Health Care, your agentcan make all of your healthcare decisions, even thosethat would be covered by a

Living Will. However, if youknow you do not want tohave your death prolongedby machines, drugs or treat-ments, you may also want tosign a Living Will since itprovides information toyour doctor if you don’thave an agent or DurablePowe r o f A t t o r ney f o rHealth Care or your agent isnot available.

Where can I get a LivingWill or Durable Powerof Attorney for HealthCare form?

Forms and directions can befound on pages 19-34. Youare welcome to copy theseforms to use for yourself orto give to family and friends.For additional copies of thisbooklet, call or write theIowa Department of ElderAffairs, 200 10th Street, 3rdFloor, Des Moines, Iowa50309, 515/242-3333.

How do I complete advancedirectives?

As you read this booklet,you will find very detailedinstructions on how to fillout the documents. Afterthey are fi l led out, yoursignature must be witnessedor notarized or be legallyrecognized.

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booklet.

Can I be required to signthese documents as a condi-tion for admission to ahealth care facility?

No. A hospital or nursinghome canno t r e fu se toadmit you just because youhave not signed a LivingWill or Durable Power ofAttorney for Health Care. Ifany health care facility triesto force you to s ign anadvance d i rec t i ve , youshould contact the IowaDepartment of Inspectionsand Appeals, Lucas StateO f f i c e B u i l d i n g , D e sMoines, Iowa 50319-0075,515/281-4115. All such facil-ities are required by law,however, to ask you if youhave an advance directiveand to offer you informationabout them.

Do I need an attorney tocomplete advance directives?

No. An attorney is not nec-essary to legally completethese documents. However,it is important that they becompleted correctly andhaving an attorney involvedmay g ive you peace o fmind. You also may wish tocontact your attorney withany questions or concernsabout the effect of thesedocuments.5

What if I change my mind?

You may change or cancelthese documents at anytime, regardless of yourphysical or mental condi-tion. If changes are made inwri t ing, you should putyour initials and a date byeach change, and sign anddate it again at the bottomof the form. Copies of thechanged advance directivesshould be made and distrib-uted as before. If you wishto cancel the form, you musttell your doctor and it’s alsoa good idea to destroy thedocument. Iowa law doesnot require you to canceleither document in writing.It can be done verbally.

S i t u a t i o n s a n d v a l u e schange as you age and it isimportant to re-evaluateyour advance direct ivesevery year to ensure thatthey remain accurate.

What if a doctor is unwillingto comply with my Living Willor my agent’s decisions?

If, in the future, a doctor oradministrator of a hospitalor health care faci l i ty isunwilling to follow yourwishes as recorded in youradvance directive docu-ments, or as made by youragent, the doctor or admin-i s t r a t o r m u s t t a k e a l lpossible steps to arrange to

t rans fer you to anotherdoctor or faci l i ty that iswilling to do so.

If I move to another state,will my advance directivebe valid?

They should be honored inany state, as they are evi-dence of your wishes noma t t e r whe r e you a r e .However, the legal require-ments for advance directivedocuments vary from stateto state. If you want to beabsolutely safe when youmove to another state, it is agood idea to complete newdocuments that meet thelegal requirements of thatstate. This is also true if youlive in another state for aportion of the year.

If I am in an accident, howwill the police and ambu-lance crews know about myadvance directives?

In case you are involved ina car accident in Iowa, oranother state, you shouldcarry a wal le t card thatshows that you have signedan advance direct ive inIowa and how to get intouch with your agent. Thiscannot guarantee that yourwishes will be carried out,but will go far in letting oth-ers know of them. A walletcard is inc luded on theinside back cover of this

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Advance directive -

A general term for legaldocuments (such as a LivingWill or a Durable Power ofAttorney for Health Care)that state a person’s wishesfor medical treatments incase he or she is not ableto make his or her owndecisions.

Agent -

Someone who acts for you;the same as “attorney-in-fact.”

Antibiotics -

Drugs given to fight infec-t ion. The most commontypes of life-threateninginfections in critically illpatients include pneumoniaand urinary tract infections(kidney or bladder).

Artificial provision ofnutrition and fluids(“tube-feeding”) -

Used either temporarily orp e r m a n e n t l y t o f e e dpat ien t s when they areunable to swallow. Therea re th ree ways to feedpatients artificially:

• A tube inserted through thenose and down to the stom-ach (nasogastric tube)

• A tube inserted through thestomach wall with surgery(gastrostomy tube)

• Tubes placed into veins inthe arms or the chest (intra-venous tubes or IVs)

Iowa law permits persons torefuse tube-feeding, just asthey may refuse other med-ical treatments.

Cardiopulmonaryresuscitation (CPR) -

The procedure used whens omeone who s e h e a r tand/o r b rea th ing havestopped is brought backwith the following actions:

• Pressing on the chest tosqueeze the heart so thatblood begins to circulateagain

• Mechanical breathing (orother artificial breathingwith a mouthpiece or tubeand a bag) to push air intothe lungs

STEP II:UNDERSTANDING LEGAL AND MEDICAL TERMS

The following glossary of medical and legal terms, while accurate, isexplanatory in nature and should not be considered as legal defini-tions. For further information, contact your physician or attorney.

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Who should be my agent?

The choice of your agent(known legally as the “attor-ney-in-fact”) is one of themost important parts ofc omp l e t i n g a Du r a b l ePowe r o f A t t o r ney f o rHealth Care. Your agent willhave direct control overyour health if you becomeunable to make health caredecisions.

Therefore, it is necessarythat your agent be someoneyou trust, and someone whois capable of understandingthe responsibilities involvedin being a health care agent.Many peop le choose aspouse or an adult child, butthe agent does not have tobe a member of your family.Some peop le choose afriend, spiritual leader ortheir personal attorney. Becertain to spend time withthe person you appointensuring they understand indetail your values and spe-c i f i c medica l t rea tmentwishes. The values surveyand medical situation work-sheet included in this book-let can be very valuabletools when talking aboutthese issues.

In Iowa , the fo l lowingpersons cannot be appoint-ed as an agent:

• Someone who is treatingyou as a patient, such asyour doctor or nurse

• An employee of anyonetreating you (including anyemployee of your doctor, orthe hospital, nursing homeor hospice where you mayobtain medical treatment),unless the employee also isyour relative.

Durable Power of Attorneyfor Health Care -

A document that allows youto appoint another person(called your agent or attor-ney-in-fact) to make med-ical care decisions for you ifyou are unable to makeyour own decisions. Thereis a copy of one that is legalin Iowa, along with direc-tions for filling it out, onpages 19-26.

Execute -

To follow the guidelines setdown in law for completinga document so that it is legaland enforceable. This mayinclude having witnessesattest to your signing of thedocument.

Fatal (terminal) condition -

See “terminal condition”.

Informed consent -

Agreeing to a plan of treat-ment after you or your agenthave been given informa-tion about your medicalcondition and the treatmentoptions.

Life-sustaining procedures -

Drugs, medical equipment,or treatments that can keeppeople alive who wouldotherwise die within a short,although uncertain, lengthof time.

Living Will -

A document , known inIowa as the Declarat ionRela t ing to Use of L i fe -Sustaining Procedures, thatgives your attending physi-cian direction to withhold orwithdraw procedures thatmerely prolong the dyingprocess and are not neces-sary for comfort or freedomfrom pain. There is a copyof one that is legal in Iowa,along with directions for fill-ing it out, on pages 27-32.

Mechanical breathing -

Breathing by a machine(ventilator or respirator)when a patient is unable todo so for themselves. This isdone by inserting a tubeinto the windpipe throughthe nose or mouth (endotra-cheal tube), or through ahole cut in the windpipe atthe front of the neck (tra-cheostomy). The endotra-chea l tube i s the moreuncomfortable because itprevents the patient fromta lk ing and eat ing, andcauses a gag reflex. The tra-cheostomy requires surgery,but can allow the patient toeat and talk when they areoff the respirator for shortperiods of time. This type ofmachine is very useful foremergency situations.

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• Electrical shocks to the chestto start the heart beatingagain (defibrillation)

• Medications given througha vein or directly into theheart

The best results from CPRoccur in a generally healthyperson whose heart stopssuddenly. If CPR is startedquickly, it can save a person’slife and prevent damage tot h e b o d y ’s t i s s u e s a n dorgans. On the other hand,permanent brain damage iscommon if more than about4 minutes have gone bybefore CPR is started.

Coma -

A sleep-like (eyes closed)condition resulting fromdamage to the brain from anaccident or a disease. Acoma can be temporary(with either complete orpartial recovery) or perma-nent.

Comfort care -

Care to keep someone ascomfortable as possible,including pain medication,lip ointment and ice chips,turning and positioning ofthe body frequent ly (orusing special mattresses) toprevent bed sores , andbathing. This type of careeases the dying process butdoes not stop it.

Competent -

A competent person is onewho has the capacity tounderstand the nature andpossible results of his or hermedical condition and tomake their own decisionsregarding treatment.

Declarant -

A person who is making astatement about their wish-es, or a declaration, in alegal document.

Do-Not-Resuscitate (DNR) -

A DNR order is not the samething as having an advancedirective. If you want toavoid CPR, your doctormust write a separate orderon your cha r t fo r eachadmission.

Hospitals and some nursinghomes will automaticallyattempt CPR (see defini-tion) on anyone whose heartand/or breath ing stops ,unless there is a “Do-Not-Resusc i tate” or “DNR”order on file for the patient.A DNR order (also called a“no code”) can be writtenby a doctor with permissionof the patient, his or herhealth care agent, or thefamily.

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What do you value mostabout your life? What bringsyou joy?

For example:

• Living as long as possible

• Living an active life

• Enjoying the company offamily and friends

• Remaining independentand in control

If you find that activi ty,i ndependence , and /o rsocial interaction are morevaluable to you than merelyliving a long life, then mak-ing specific choices con-cerning medical situations(such as is found in the nextsection) will be particularlyimportant to you and yourfamily.

Are there certain mental orphysical conditions thatwould make you think thattreatments that prolongdying should no longer beused?

For example:

• Lack of awareness of self orsurroundings

• Inability to appreciate andcontinue the importantrelationships in your life

• Inability to think wellenough to make every-daydecisions

• Severe pain or discomfort

• Physical damage (such asparalyzed or amputatedlegs/arms)

It is important to considersome of the possible effectso ther than death tha t asevere illness or accidentcould cause.

How might your personalrelationships and responsi-bilities affect your ownmedical decision making?

For example:

• The desire to make yourown decisions

STEP III:VALUES SURVEY

The following questions can help you assess your values concerningmedical and end-of-life decisions. You may use these questions todiscuss your views with your agent, doctor and family. Talking withthem about these values will give them peace of mind when thetime arrives for difficult decisions to be made, and will help youmake specific choices about medical procedures.

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Medical technology -

The equipment and treat-ments doctors use to diag-nose and fight disease, treati n j u r i e s o r ma i n t a i n apatient’s mental or physicalcondition. Some examplesare surgery, CAT scans andother x-ray procedures,drugs and hear t bypassmachines.

Pain medication -

Medications that relievepain resulting from injury ordisease. They are a veryimportant part of comfortcare (see definition). Thesemed i c a t i on s may haveadverse side effects. Theymay also inter fere wi thbreathing in very ill patients.These side effects can indi-rectly shorten life.

Persistent vegetative state(PVS) -

A state of permanent uncon-sciousness that is not cur-able. It may take up to threemonths to be certain of adiagnosis of PVS. In patientswith PVS, the centers in thebrain that control thinking,speaking, hunger and thirsthave been destroyed. PVSpatients still have reflexes,such as aimless eye andmuscle movements, yawn-

ing, coughing, and respons-e s t o t o u c h o r s o und .Current medical knowledgeindicates that they do notfeel pain. This diagnosisi n c l ude s pa t i en t s whoappea r t o be awake a ttimes, but does not includethose who are in a deepercoma with their eyes closed.

Principal -

The person who is givingpower to make health caredecisions to a health careagent in the Durable Powerof Attorney for Health Caredocument.

Terminal (fatal) condition -

Iowa law defines a terminalcondit ion as one that isincurable or irreversible,that without the administra-tion of life-sustaining proce-dures, will, in the opinion ofthe at tending physic ian(with confirmation by a sec-ond physician), result indeath within a relativelyshort period of time. Thereis no specific time periodidentified. A terminal condi-tion also can be a state ofpermanent unconsciousnessfrom which, to a reasonabledegree of medical certainty,there can be no recovery.

14

The following worksheets pres-ent four medical situations inwhich advance directives oftenare needed. After the descrip-tion of each situation you willfind a checklist of six possibletreatments or procedures com-monly used by doctors andnurses in hospitals to treat thecondition described. Pleaseread each situation carefully, tryto imagine yourself in the situa-tion, and decide whether youwant, do not want, can’t decide,or prefer that the treatment betr ied first to determine if i twould help you. Put a checkmark in one column by eachnumbered treatment.

This worksheet is not a legaldocument. It is meant to be aguide for you, as well as foryour family, agent, and doctor,not a complete list of all possi-ble medical conditions.

Knowing your wishes in theseparticular situations, however,will offer guidance in other situ-ations. We recommend that youfill out these worksheets anduse this information to fill inSection 2 on the Durable Powerof Attorney for Health Careform, and Sect ion 4 on theLiving Will form. This informa-tion will provide valuable assis-tance and direction to youragent and doctors in the future.

This section was adapted fromEmanuel LL, Emanuel EJ, “TheMed ica l D i r ec t i ve : A NewComprehensive Advance CareDocument,” Journal of theAmerican Medical Association,June 9, ‘89; 261:3290. Copyright1990.

STEP IV:MEDICAL SITUATION WORKSHEETS

13

• The desire to avoid burden-ing your family with diffi-cult decisions

• Wanting to leave your fami-ly with good memories

• Avoiding using up yourfamily savings

Providing your loved onesand caregivers with theinformation they need tomake medical decisions foryou is a wonderful gift. Itc a n s p a r e t h e m g r e a tanguish, emotional stressand conflict. Even thoughlosing you will be difficultfor your family, knowingtha t they are doing theth ings you would havewanted wil l smooth theway.

How do you feel about deathand dying?

For example:

• You fear that death will betoo prolonged, or that youwill be in too much pain.

• You lost someone close toyou and you do not want todie that way yourself.

• You want to die withrespect and control, and ina setting that you choose asbest for you and yourfamily.

• You do not want to sufferfor a long time.

All of these questions arevery important to consider,along with decisions aboutmedical treatments.

16

B. If I am unconscious from an accident or severe illness, and there is noknown hope of recovering conscious awareness of my environment(irreversible coma or brain death), but machines and drugs could keepmy body alive for years, then my wishes regarding the use of thefollowing would be:

1. CARDIOPULMONARYRESUSCITATION (CPR)

The use of drugs, art i f icialbreathing, external chest com-pression, and/or electric shockto restart the heart beating.

2. MECHANICAL BREATHING

Breathing by a machine througha tube inserted through themouth or nose.

3. ARTIFICIAL NUTRITION/HYDRATION

Feed ings and f lu id g i venthrough a tube in the veins,nose, or stomach.

4. PAIN MEDICATIONS

(even if they dull consciousnessand indirectly shorten my life).

5. ANTIBIOTICS

Drugs to fight infection.

6. BLOOD OR BLOODPRODUCTS

I WANTI DO NOT

WANTI AM

UNDECIDED

I WANT TO TRY:If No Clear

Improvement,Stop Treatment

15

A. If my doctor has definitely determined that I have a condition thatwill shortly cause my death (fatal or terminal condition), and I amunconscious or otherwise unable to speak for myself, then my wishesregarding the use of the following would be:







4. PAIN MEDICATIONS


5. ANTIBIOTICS



I WANTI DO NOT

WANTI AM

UNDECIDED



18

D. If I am healthy and am in an accident or suffer a sudden illnessmaking me unable to make my wishes known, and my condition ispotentially reversible in the opinion of my doctor, then my wishesregarding the use of the following would be:







4. PAIN MEDICATIONS


5. ANTIBIOTICS



I WANTI DO NOT

WANTI AM

UNDECIDED



17

C. If I become permanently confused or have declined mentally so that Iam not capable of caring for myself or being part of any meaningfulinteraction with family and friends (such as Alzheimer’s Disease,multiple strokes, or dementia), and I become ill, then my wishesregarding the use of the following would be:







4. PAIN MEDICATIONS


5. ANTIBIOTICS



I WANTI DO NOT

WANTI AM

UNDECIDED



■■ 8. MAKE COPIES OF THEDURABLE POWER OFATTORNEY FOR HEALTHCARE.

Make a copy for yourself, andone each for your alternateagent, your doctor, your hospi-tal, and your pastor, priest orrabbi. Make sure each of thesepeople receives a copy. Youmight a l so want to supplycop ies to your fami ly andlawyer. There is space on theform to note where additionalcopies can be located.

■■ 9. GIVE THE ORIGINALDURABLE POWER OFATTORNEY FOR HEALTHCARE TO YOUR AGENT.

2019

■■ 1. REVIEW THE VALUESSURVEY on pages 12-13 of thisbooklet.

■■ 2. COMPLETE THE MED-ICAL SITUATION WORK-SHEETS, IF DESIRED, onpages 14-18 in this booklet.

■■ 3. CHOOSE AN AGENT, andan alternate agent (if possible).

Choos ing an agent i s ve ryimportant because i t is theagent’s job to make sure yourhealth care wishes (as written inyour Durable Power of Attorneyfor Health Care and spoken ver-bally) are carried out. You willbe trusting this person to talk tothe doctors, to think about thechoices available, and to makedecisions that are as close aspossible to those you wouldmake yourself.

Many people choose an adultchild, a spouse, or another closerelative, while others prefer aclose friend. Regardless of yourchoice, your agent should besomeone you trust, who knowsyou well, and who understandsyour values and beliefs. Seepage 6 for a list of those whocannot legally be your agent.

■■ 4. TALK TO YOUR AGENT.

Talk to your agent about yourbeliefs and values as they relateto illness and death. It would bevery beneficial for you to goover the values survey and med-ical situation worksheet fromthis booklet with your agent;these worksheets may help youexpress your thoughts moreclearly. Make sure your agentunderstands your wishes.

■■ 5. TALK TO OTHERS.

Ask your doctor or nurse forany medical information thatyou may need, find out if he orshe supports your decision tocomplete an advance directive,and review your specific deci-sions in the medical situationswith him or her. Talk with yourfamily. You might also want totalk with your pastor, priest orrabbi for guidance and support.

■■ 6. COMPLETE THEDURABLE POWER OFATTORNEY FOR HEALTHCARE

found on pages 24-26 of thisbook l e t b y f o l l ow ing t heinstructions.

■■ 7. SIGN THE DOCUMENT,AND HAVE IT WITNESSEDOR NOTARIZED.

STEP VCOMPLETING THE DOCUMENTS

Completing a Durable Power of Attorney for Health Care

■■ SECTION 4 (ON PAGE 25-26):

You have the option of using anotary, or having two witnessessign your document. A notarypublic must observe you sign-ing the document. Likewise,the two witnesses must see yousign and watch each other sign.Make sure that not more thanone of your witnesses is relatedto you. Your doctor or anemployee of your doctor can-not be a witness, unless theyare also your relative. Also,your agent cannot be a witness.

■■ SECTION 5:

Sign your name as you do forany legal document, then neat-ly type or print your name (asprincipal, or the person granti-ng the power of attorney) andaddress on the lines providedunder you signature. Your sig-nature must be made in thepresence of your witnesses or anotary public.

■■ SECTION 6:

Record the location of eachcopy of the Durable Power ofAttorney for Health Care.

2221

■■ SECTION 1:

Neatly print or type thename (first, middle initial,last) of your agent on thelines provided. An “attor-ney- in- fact” is the legalname for your agent.

• The section followingthe name and addressof your agent legallyidentifies what dutiesand responsibilities areinvolved in being ahealth care agentincluding:

a. the power to makehealth care decisions foryou only if a doctor saysyou are unable to makethem yourself

b. the fact that those deci-sions must be consistentwith your desires

c. the power to consent tothe withholding or with-drawing of medicaltreatments, even if theyare necessary to keepyou alive

d. the power to make thesedecisions for you forany physical or mentalcondition as long asthey are consistent withverbal or writteninstructions. Your agentis also given the right toexamine your medicalrecords.

■■ SECTION 2:

There is a blank area provid-ed for you to write in specif-ic instructions, such as thespecific medical treatmentsthat you wish to avoid and inwhich situations. Use yourmedical worksheets as aguide.

■■ SECTION 3:

Neatly type or print thename, address, and phonenumber of an a l ternateagent who will serve if youragent is unable to do so.This is suggested but notrequired.

INSTRUCTIONS FOR THE DURABLE POWER OF ATTORNEYFOR HEALTH CARE. Please refer to the document on pages 24-26and fill it out as you carefully read these instructions.

24

1. I (the “Principal”) hereby designate

__________________________________________________________

__________________________________________________________

__________________________________________________________

as my attorney-in-fact (my agent) and give to my agent the power tomake health care decisions for me. This power exists only when I amunable, in the judgement of my attending physician, to make thosehealth care decisions. The agent must act consistently with my desiresas stated in this document or otherwise made known.

Except as otherwise specified in this document, this document givesmy agent the power, where otherwise consistent with the laws of theState of Iowa, to consent to my physician not giving health care orstopping health care that is necessary to keep me alive.

This document gives my agent power to make health care decisionson my behalf, including the power to give consent, to refuse to con-sent, or to withdraw consent to any care, treatment, service, or proce-dure to maintain, diagnose, or treat a physical or mental condition.This power is subject to any statement of my desires and any limita-tions included in this document. My agent has the right to examinemy medical records and to consent to disclosure of such records.

2. NOTE:Insert here specific instructions or statement of desires of principal (ifany). (The principal does not have to give any specific instruction orstatement or desires but may do so.)

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

TELEPHONE NUMBER

(TYPE OR PRINT)

23

By signing, I declare that I signed this form in the presence of theother witness and the Principal, and I witnessed the signing by thePrincipal or other person acting on behalf of and at the Principal’sdirection.

Witness (1) Signature

__________________________________________________________

__________________________________________________________

__________________________________________________________


__________________________________________________________

__________________________________________________________

__________________________________________________________

5. Signed this ______________day of __________________ , 20____

__________________________________________________________

__________________________________________________________

__________________________________________________________

6. Copies of this form are located:

26

PRINT FIRST NAME MIDDLE INITIAL LAST NAME

SIGNATURE



SIGNATURE



SIGNATURE OF PRINCIPAL (person granting the Power of Attorney)


(TYPE OR PRINT)

25

3. NOTE:

(The principal may designate one or more alternates as attorney infact but does not have to.) If the person designated above is unableto serve,

I designate

__________________________________________________________

__________________________________________________________

__________________________________________________________to serve as my attorney-in-fact.

4. This Power of Attorney must either be witnessedby two persons or notarized.

STATE OF IOWA ______________, COUNTY, ss: ______________

On this day of _______________________, 20____ before me, the

undersigned, a Notary Public in and for the State of Iowa, personally

appeared __________________________________________________

to me known to be the person named in and who executed the fore-

going instrument, and acknowledged that (he) (she) executed the

same as (his) (her) voluntary act and deed.

________________________________Notary Public in Iowa



TELEPHONE NUMBER

(TYPE OR PRINT)

■■ SECTION 1:

The Declaration Relating tothe Use of Life-SustainingProcedures i s the lega lname given to the LivingWill in Iowa.

■■ SECTION 2:

This statement says that ifyou are found to have a con-dition that will cause yourdeath, you do not want yourlife lengthened by machines,drugs or other treatments.In Iowa law, two doctorsmust have examined youand certified in writing thatyou have a condition thatwill shortly result in deathor permanent unconscious-ness.

■■ SECTION 3:

This statement says that ifyou have a condition thatwill cause you to die soon,and you are also unable tomake your own decisionsdue to unconsciousness orloss of ability to think andreason, you give your doctorpermission to withhold (notstart) or withdraw (stop)treatments that will onlyprolong dying. It is also clearin this statement that anytreatments that make youmore comfortable shouldnot be stopped or avoided.

■■ SECTION 4:

There is a blank area provid-ed for you to write in specif-ic instructions. We recom-mend that you use the med-ical situation worksheets asa guide to record your pref-erences.

■■ SECTION 5:

Use this section if you wishto have the document nota-rized, rather than witnessed.

■■ SECTION 6:

You are the “Declarant.”Use this section if you preferto have the document wit-nessed. You must completeeither Section 5 or 6 for it tobe legal. Two witnesses mustsign your document, andmust know who you are.The two witnesses must seeyou sign and watch eachother sign. Make sure thatonly one of your witnesses isrelated to you, and that nei-ther one is your doctor oran employee of your doctor,unless they are also your rel-ative.

■■ SECTION 7:

Sign your name as you dofor any legal document, thenneatly type or print yourname and address on thelines provided under yoursignature.

28

INSTRUCTIONS FOR THE LIVING WILL. Please refer to thedocument starting on page 30 and fill it out as you read theseinstructions carefully.

27

■■ 1. REVIEW THE VALUESSURVEY.

On page 12 and 13 of thisbooklet.

■■ 2. COMPLETE THEMEDICAL SITUATIONWORKSHEET, IFDESIRED.

On pages 14-18 of thisbooklet.

■■ 3. TALK TO OTHERS.

Ask your doctor for anymedical information thatyou may need, find out ifhe or she supports yourdecision to complete anadvance directive, andreview your specific deci-sions in the medical situa-t ions with him or her.Talk with your family indetail about your valuesand beliefs. Review thevalues survey and med-ical situation worksheetwith them. You mightalso want to talk withyour spiritual leader forguidance and support.

■■ 4. COMPLETE THELIVING WILL.

Found on pages 30 and31 of this booklet by fol-lowing the instructions.

■■ 5. SIGN THE DOCUMENT,AND HAVE ITWITNESSED ORNOTARIZED.

■■ 6. MAKE COPIES OF THELIVING WILL.

Make a copy for yourdoctor, your hospital, andyour spi r i tua l leader.Make sure each of thesepeople receives a copy.You might also want tosupply copies to yourfamily and lawyer.

■■ 7. PLACE THE ORIGINALDOCUMENT WHERE ITIS PROTECTED BUTNOT DIFFICULT TOFIND.

Your fami ly membersmay need to use theLiving Will someday, somake sure they knowwhere documents arestored. A lock box at thebank or in a safe is nota good place for thisdocument , as fami lymembers may not knowwhere to find the key orcombination.

COMPLETING A LIVING WILL

2. If I should have an incurable or irreversible conditionthat will cause my death within a relatively short time, oram in a state of permanent unconsciousness from which, to areasonable degree of medical certainty there can be no recovery,it is my desire that my life not be prolonged by administration oflife-sustaining procedures.

3. If my condition is terminal and I am unable to participate indecisions regarding my medical treatment, I direct my attendingphysician to withhold or withdraw procedures that merelyprolong the dying process and are not necessary to my comfortor freedom of pain.

4. Other instructions: ____________________________________

______________________________________________________

______________________________________________________

5. STATE OF IOWA____________, COUNTY, ss: ______________

On this day of _______________________, 20____ before me,

the undersigned, a Notary Public in and for the State of Iowa,

personally appeared ____________________________________

to me known to be the person named in and who executed the

foregoing instrument, and acknowledged that (he) (she)

executed the same as (his) (her) voluntary act and deed.

________________________Notary Public in Iowa

30

1. THE LIVING WILL OR DECLARATION RELATING TOTHE USE OF LIFE-SUSTAINING PROCEDURES

29

■■ SECTION 8:

a. The Living Will you justsigned does not takeeffect unless you havebeen diagnosed with acondition that willresult in your death, orare in an irreversiblecoma and you are notcapable of makingdecisions.

b. Pain medicationsand feeding by mouthare not included inthe definition of “life-sustaining” procedures(treatments thatlengthen the processof dying), and thereforewill still be given unlessyou write otherwise.

c. It is your respon-sibility to make surethat your physician andhospital have a copy ofyour Living Will.

d. You can cancel thisLiving Will at any timeby telling (in any waythat you can) yourdoctor or agent that itis no longer in effect,no matter what yourcondition.

8. Note, by Iowa law:

a. This Declaration will be given effect only when the declarant’scondition is determined to be terminal and/or permanentlyunconscious and the declarant is not able to make treatmentdecisions.

b. The provision of nourishment and the administration of anymedical procedure deemed necessary to provide comfort careto alleviate pain are not considered life-sustaining procedures,unless otherwise noted in writing by the declarant.

c. It is the responsibility of the declarant to provide the declarant’sattending physician with this Declaration.

d. This Declaration may be revoked in any manner by which thedeclarant is able to communicate the declarant’s intent torevoke, without regard to mental or physical condition.A revocation is only effective as to the attending physicianupon communication to such physician by the declarant, or byanother to whom the revocation was communicated.

3231

6. The declarant is known to me and voluntarily signed thisdocument in my presence.


______________________________________________________

______________________________________________________

______________________________________________________


______________________________________________________

______________________________________________________

______________________________________________________

7. Signed this ____________day of ________________ , 20____

______________________________________________________

______________________________________________________

______________________________________________________


SIGNATURE



SIGNATURE



SIGNATURE


(TYPE OR PRINT)

I have executed a Living Will

I,

of

have executed a Living Will in accordance with Iowa law. If the situationshould arise in which I am terminally ill or permanently unconscious andthere is no reasonable expectation of recovery, I wish to be allowed to diea natural death without life-sustaining measures. I do, however, wish tohave my pain relieved with as much medication as is necessary, even if itindirectly shortens my life.

✄WALLET CARD

I have executed a Durable Power of Attorney for Health Care.

My agent is

He/she has a copy of my Durable Power of Attorney for HealthCare and will make health care decisions for me if I am unable to do so.

DATE ____________SIGNATURE ______________________________________

IMPORTANT NOTICE TO MEDICAL PERSONNEL

IMPORTANT NOTICE TO MEDICAL PERSONNEL

AGENT’S NAME

AGENT’S ADDRESS

AGENT’S TELEPHONE NUMBER

NAME

ADDRESS

FOLD HERE

33

1. What happens if we justdo nothing?

2. What would you do,Doctor, if this was your(wife/husband, child, par-ent, friend)?

3. You have talked about acomplicated treatmentplan. Do I have to decideon the whole plan at onceor are there separateparts you could tell meabout?

4. Please tell me about all ofthe alternatives andoptions, one at a time.

5. What are the benefits ofeach of the alternatives?

6. What are the possibleproblems with each of thealternatives?

7. What are you hoping toaccomplish by doing thesetreatments? Are you tryingto delay death? Are yousimply relieving pain?

8. Is there any hope of bring-ing the patient back to ahealthy state?

9. Is this an emergency?Why? Do I have to decideright now or do I havetime to think things over?

10. This is what I understandthat you have said:Is that right?

11. Is this the easiest/mostdignified/least painfulway for (this person)to die under the circum-stances?

STEP VI: ADDITIONAL INFORMATION

These are the kinds of questions your health care agent may wish toask the doctors and nurses who are caring for you. Situations inwhich the Durable Power of Attorney for Health Care are used arealmost always very stressful and difficult. Having a list of questionsmay give your agent the confidence and peace of mind he or shewill need to make thoughtful decisions for you.