Advance Directives - Additional Instructions In Advance Directives

Artificial Nutrition and Hydration

Some living wills contain a provision for the withdrawal of nutrition and hydration. (See Table 7.1, Part 2: Instructions for Health Care.) Artificial nutrition and
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FIGURE 7.3 State laws governing surrogate decision-making for terminally ill patients in the absence of advance directives, 2004 "State Statutes Governing Surrogate Decision-Making," in End-of-Life Law Digest, The National Hospice and Palliative Care Organization, 2004hydration are legally considered medical treatments and may, therefore, be refused. But this form of treatment remains controversial in the right-to-die issue because food and drink are the most basic forms of life sustenance yet they are not usually needed by dying persons and may make them less comfortable. The unresolved problem is mirrored in the fact that not all states' advance directive statutes (laws) address this issue. (See Figure 7.4 and Figure 7.5.)

Relief from Pain

Some living wills also enable an individual to give instructions about the management of pain. While a number of studies have shown that pain is not the primary motivation for assisted suicide requests, many people have seen family and friends suffer painful deaths, and they fear the same fate. Experts advise that advance directives should expressly indicate desires for pain control and comfort care, even when individuals have chosen to forego life-sustaining treatments.

In the past, patient pain may not have been adequately treated because medical professionals lacked training or feared overprescribing pain medications. A variety of legislative and education initiatives by states and medical professional societies have dramatically improved pain management. The Federation of State Medical Boards has developed guidelines to help FIGURE 7.4 State laws governing the refusal of artificial nutrition and hydration in living wills, 2004 "Artificial Nutrition and Hydration in Living Will Statutes," in End-of-Life Law Digest, The National Hospice and Palliative Care Organization, 2004physicians use medication to manage pain safely and effectively. Special instruction in pain management for patients with life-limiting illnesses is now offered in many medical and nursing schools.

Further pressure to improve pain management can come from patients and their families. In December 2000 a California jury held a physician liable for prescribing too little pain medication for a patient dying from lung cancer. The children of eighty-five-year-old William Bergman sued his physician for elder abuse on the grounds that the doctor failed to prescribe strong enough medication to control their father's pain before, during, and after his hospitalization in 1998. The jury awarded the family $1.5 million, but to comply with the state limit on such awards, the sum was reduced to $250,000. Advocates for improved end-of-life care hoped the verdict would remind physicians about the importance of pain management.

FIGURE 7.5 State laws governing the refusal of artificial nutrition and hydration by health care agents, 2004 "Artificial Nutrition and Hydration in Statutes Authorizing Health Care Agents," in End-of-Life Law Digest, The National Hospice and Palliative Care Organization, 2004