BACKGROUND.
Prior to the advent of medical directives,
verbal expression was the only mechanism of individual communication; such
expression was subject to vagaries and interpretive biases.
Now the use of written instruments has become accepted in Canada.
(1)
DOCUMENTATIONS.
The various forms of living wills provide specific
instructions to care-givers in the event of a declarant's incapacitating
illness. (2).
Should the specifics of a particular situation not
be covered in the living will it is possible to pre-appoint a health-care
proxy (in Canada, most commonly referred to as the Power of
Attorney for Personal Care, or PAPC).
Other adjunctive documentations have been formulated to provide
even more specificity: the so-called Medical Directive
invites responses to specific scenarios, and lists the kinds of interventions
that may or may not be requested by the declarant. (3)(4)(5).
A Values History is utilised
to provide background information to clarify the intent of advance directives.(6)
Such a History may include moral, social, religious, and philosophical
details and may also include the declarant's personal health experiences
and corroborated medical diagnoses.
All of these records may be utilised in medical decision-making should
a person be rendered medically incompetent.
THE ISSUE OF
COMPETENCE.
The assessment of competence is receiving special
attention . (7).
Competence is dependent upon the integration of four
processes:
-
the initial reception of information,
-
the subsequent analysis,
-
the enactment of an appropriate response.
-
and finally the sustainability of the analysis and response
Physical disability alone does not render a
patient incapable of decision-making; it may however, obfuscate cognition
and expression, and may hinder accurate assessment of competence.
DOCUMENTATION
OBJECTIVES.
When incompetence is deemed to have arisen, helpful intervention is required.
The necessary degrees of intervention outlined in an advance directive,
should fulfil several objectives. These are:
-
to satisfy the wishes of the declarant,
-
to alleviate decisional stress from immediate friends and relatives,
-
and to release medical practitioners from legal and ethical repercussions.
THE RECOGNISED
NEED.
There has been an increasing institutional use of advance directives; but
the use of these instruments by the general public is still low.
It is extremely difficult and stressful for a patient to complete a
directive whilst in the throes of a disease process. Therefore it makes
good sense to advocate the initiation of the
documents whilst individuals are relatively healthy.
Once accomplished, the completed directives should be viewed as dynamic
rather than static; they should be updated whenever there is a change in
the declarant's status eg. health, marital status, address etc. The documents'
currency should also be ensured by timely review, (we suggest every two
years).
There continues to be lively discussion on the merits of living wills.
and there are numerous excellent, and varied, formulations of these documents.
THE REGISTRY.
The Living Wills Registry (Canada) - LWR - has been initiated by the co-founders,
to facilitate the use of living wills.
For simplicity sake the Registry will initially provide four documents
for subscibers to consider:
-
a) Living Will,
-
b) Power of Attorney for Personal Care,
-
c) A Personal Values Statement,
-
d) An Organ Donation Statement.
Enclosed with these four documents will be short guides
to aid in their completion.
These guides are by no means exhaustive and subscribers may be advised
to seek additional MEDICAL advice.
There are many formats of living wills.
-
Dr. D. Molloy, in Hamilton, has been a staunch proponent with his "Let
Me Decide" directive, and has pioneered their use in Canada.
(9)
-
Dr Peter Singer at the Centre for Medical Bioethics in Toronto has been
instrumental in producing the Centre's own Living Will.
-
The Right to Die Society has a living will package, and a political agenda
which includes the legalisation of physician-assisted suicide.
THIS LIST IS VERY ABBREVIATED; PLEASE LET US KNOW IF YOU
HAVE A SIMILAR RESOURCE AND WOULD LIKE TO BE INCLUDED IN OUR NEXT UPDATE.
PHILOSOPHY
OF THE REGISTRY.
LWR's mandate:
-
-the promotion and education of patients'
self-determination in health care,
-
-the reinforcement of the doctor/patient relationship
in palliative care,
-
-the facilitation of organ donation.
POSITION
STATEMENT.
The Registry:
-
- will maintain an independent posture, notwithstanding
the influence of government and minority special interest groups.
-
- cautions registrants against statements that
counsel activities contravening the Criminal Code. (Specifically, euthanasia
and suicide are presently illegal in Canada.)
-
- will not undertake critique of individual's statements. A living will
represents the feelings of one person alone, the declarant.
-
FUTURE
OF THE REGISTRY.
It is hoped that the stimulation of interest
surrounding advance directives will lead naturally to frank and open public
discussions. LWR will promote self-determination
in health care, and put near-death issues in the hands of the public. We
feel strongly that the pertinent issues should be decided by ongoing consensus
and that intrusive legislation should be minimised.
STATUTORY
STATUS IN CANADA.
The Nancy B decision in Quebec made it clear
that the patient's own wishes on health care took precedence over those
of her physicians. It also considered the position of her doctor vis-a-vis
possible repercussions relating to homicide or abetting suicide.The final
analysis clarified her physician's involvement as being palliative in nature;
subsequently it was considered that there was not any contravention of
the criminal code.
The Mallette vs. Shulman case in Ontario
also underlines the principal of the right of medically incompetent patients
to determine, in advance, their own destiny regarding medical interventions.
Nova Scotia (10) and Quebec (11)
have already recognised Proxy designations for health care; Ontario (12)(13)(14)(15)
and Manitoba (16) have formulated statutes
governing the use of advance directives.
ORGAN DONATION.
In Ontario the Registry has developed an understanding with the Multiple
Organ Retrieval and Exchange Program (MORE) as an extension of the collation
procedure.
The Registry will thus become a facilitative instrument in the field
of potential tissue donation. The Organ Donation
declaration will have no bearing on the implementation of the living will
and the PAPC.
CONCLUDING
STATEMENTS.
The final decision on the usefulness of specific advance directives will
lie with the health care professionals and the registrant's proxy for personal
care. It is intended that the Registry will become a catalyst
for discussion on end-life situations, and not a diversion from physician/patient
dialogue.
The Registry will be adjunctive to
medical decision-making rather than adversarial in stance. This will allow
patient, physician, and proxy, to formulate acceptable decisions, in accord
with subscriber's wishes.
When cure
is impossible, caring can still
prevail. (17)
BIBLIOGRAPHY:
-
CMA Policy Summary. Advance Directives for resuscitation
and other life-saving or sustaining measures: CMAJ 1982; 1072A[back].
-
Collins E.R., Weber Doron: The Complete Guide
to Living Wills, Bantam Books l991.[back]
-
Molloy D.W., Guyatt G.: A Comprehensive Health
Care Directive In A Home For The Aged: CMAJ 1991; 145 (4), 307-311[back].
-
Cranston P., Campion B., Diamond M.: CMAJ Letter 1992; 146 (2) 112.
-
Emanuel L. L., Emanuel E. J.: The Medical Directive: A New Comprehensive
Advance Care Document: JAMA 1989; 261, 3288-3293
-
Lambert P., Gibson J. M., Nathanson P.: The Values
History: An Innovation In Surrogate Medical Decision Making: Law Med Health
Care 1990; 3, 202-212.[back]
-
Kleinman I: The Right to Refuse Treatment: Ethical
considerations for the competent patient: CMAJ 1991; 144, (10), 1219-1222.[back]
-
Singer P, et al: Advance Directives: Are they
an advance?: Advance Directives Seminar Group, Centre for Bioethics, University
of Toronto: CMAJ 1992; 146 (2), 127-134[back].
-
Molloy D. W., Mepham V.: Let Me Decide, 2nd Edition McMaster University
Press, Hamilton, Ontario, l990[back].
-
Medical Consent Act, RSNS 1989, C279.[back]
-
Public Curator Act, SQ 1989, C54.[back]
-
Bill 74, Advocacy Act, 2nd sess., 35th Leg. Ont.
l992[back].
-
Bill 108, Substitute Decisions Act, 2nd sess., 35th Leg. Ont. 1992.
-
Bill 109, Consent to Treatment Act, 2nd sess., 35th Leg. Ont. 1992.
-
Bill 110, Consent and Capacity Statute Law Amendment Act, 2nd sess.,
35th Leg. Ont. 1992.
-
Self Determination in Health Care, Manitoba Law
Reform Commission, Winnipeg 1991.[back]
-
Callahan D.: What Kind of Life. The Limits of
Medical Progress: Simon and Schuster 1990; Ch. 2, 43[back].
[RETURN TO TOP OF PAGE]
-
Copyright © David Williams 1996
Revised: 1st Sept 1997.
