Health care at the end of life has been a popular discussion topic over the last couple of years. It has come up for discussion as we continue to search for ways to deliver compassionate, more cost effective care. Excellent books such as Dr. Atul Gwande's book, Being Mortal: Medicine and What Matters in the End, have also popularized the topic.
As a family physician, I see it as my professional duty to discuss end of life planning and care with my patients. In fact, I would consider it negligent to not hold these discussions when appropriate.
To put this discussion in financial perspective, about 30 percent of Medicare expenditures are paid out in the last six months of Medicare recipients' lives. This equates to about $6 billion a year. This would be money well spent if it went to improving health or quality of life, but most of it does not.
However, this should not be a simple dollars and cents discussion. Determining a patient's wishes regarding end of life treatment is both sensible and humane. Forcing treatments on patients to keep them alive against their stated wishes is irrational and degrading.
I suppose I have served on numerous "death panels." I am guilty of having guided my patients and their families to help them recognize the importance of advance planning as well as carrying out those plans when the time came. It can be heart-wrenching for patients, families and their doctors. Allowing someone to die with dignity is aptly described in the modern Hippocratic Oath: "I will keep them [the sick] from harm and injustice."
To assist patients in discussing and putting their wishes on paper, I want to briefly describe the advance directives that are available in the State of Indiana. Everyone should draft one or more of these documents when they feel the time is appropriate. I like to start the discussion when my patients turn 50 or even younger, particularly if they have other chronic diseases.
It's very important to understand that these documents vary from state to state. If you have executed them in another state, they need to be updated to comply with Indiana law. Many people avoid them because they think they need to hire a lawyer, but they can all be completed without the aid of an attorney.
The Living Will Declaration is a very specific document that is described in the Indiana Code IC 16-36-4-10. This document tells others your intentions when your doctor certifies that you have an incurable condition, that your death will occur in a relatively short period of time, and that life prolonging procedures would only prolong the dying process.
The Living Will allows you to leave instructions as to whether or not you want to receive artificial feeding and hydration (fluids) or whether you make no decision regarding them. The document must be signed by two witnesses who are at least 18 years old, are not immediate family members, do not have a stake in your estate and are not financially responsible for your medical care.
The Life Prolonging Procedures Declaration is essentially the opposite of the Living Will and instructs your family and doctor that you want everything done to prolong your life. This document requires only two witnesses without any restrictions on who they are. The wording of the document can be found in IC 16-36-4-11.
The Out of Hospital Do Not Resuscitate Declaration and Order is a document that can be prepared for patients who have terminal or serious health conditions and do not want to be resuscitated by medical personnel outside the hospital. The wording is defined in IC 16-36-5-15. It requires the same qualifications for witnesses as the Living Will. Unlike the other documents, your physician is required to certify it. You also need to have a copy in your possession and provide your doctor with a copy as well.
The newest advanced directive document in Indiana is the Physician Order for Scope of Treatment or POST. This is an excellent form and much more specific, allowing the person to choose various care options based on medical circumstances. It also requires witnesses and physician certification.
The final document that you should consider having is one appointing a Health Care Representative or Health Care Power of Attorney. This document allows you to appoint someone to make medical decisions for you should you become incapacitated. I recommend you have an attorney draft this document, as it is important to get the wording correct and it has to be signed in front of a notary public. The cost is well worth it and will save your family and loved ones a lot of headaches if there is one person in charge if you become unable to make medical decisions.
More information regarding these documents along with the documents themselves can be found at the Indiana State Department of Health's Advance Directives Resource Center at www.in.gov/isdh/25880.htm.
Dr. John Roberts is a local physician. His column appears in Monday's edition of the Times, and he has a daily health tip on the front page. Dr. Roberts is one of the owners of Sagamore News Media, parent company of The Times.