Introduction. As part of a person’s right to self-determination, every adult may accept or refuse any recommended medical treatment. This is relatively easy when people are well and can speak. Unfortunately, during serious illness, they are often unconscious or otherwise unable to communicate their wishes – at the very time when many critical decisions need to be made.
The Medical Directive allows you to record your wishes regarding various types of medical treatments in several representative situations so that your desires can be respected. It also lets you appoint a proxy, someone to make medical decisions in your place if you should become unable to make them on your own.
The Medical Directive comes into effect only if you become incompetent (unable to make decisions and too sick to have wishes). You can change it at any time until then. As long as you are competent, you should discuss your care directly with your physician.
Completing the form. You should, if possible complete the form in the context of a discussion with your physician. Ideally, this should occur in the presence of your proxy. This lets your physician and your proxy know how you think about these decisions, and it provides you and your physician the opportunity to give or clarify relevant personal or medical information. You may also wish to discuss the issues with your family, friends, or religious mentor.
The Medical Directive contains six illness situations that include incompetence. For each one, you should consider the possible interventions and goals of medical care. Situation A is permanent coma; B is near death; C is with weeks to live in and out of consciousness; D is extreme dementia; E is a situation you describe; and F is temporary inability to make decisions.
For each scenario, you should identify your general goals for care and specific intervention choices. The interventions are divided into six groups: (1) CPR or major surgery, (2) mechanical breathing or dialysis, (3) blood transfusions or blood products, (4) artificial nutrition and hydration; (5) simple diagnostic tests or antibiotics, and (6) pain medications, even if they dull consciousness and indirectly shorten life. Most of these treatments are described briefly. If you have further questions, consult your physician.
Your wishes for treatment options (I want this treatment; I want this treatment tried, but stopped if there is no clear improvement; I am undecided; I do not want this treatment) should be indicated. If you choose a trial of treatment, you should understand that this indicates that you want the treatment withdrawn if your physician and proxy believe that it has become futile.
The Personal Statement section allows you to explain your choices, and say anything you wish to those who may make decisions for you concerning the limits of your life and the goals of intervention. For example, in situation B, if you wish to define “uncertain chance” with numerical probability, you may do so here (Fig. 37-2).
©1995 by Emanuel and Emanuel.
An earlier version of this form was originally published as part of an article by Emanuel and Emanuel.2 It does not reflect the official policy of the American Medical Association.
Next you may express your preferences concerning organ donation. Do you wish to donate your body or some or all of your organs after your death? If so, for what purpose(s) and to which physician or institution? If not, this should also be indicated in the appropriate box.
In the final section, you may designate one or more proxies, who would be asked to make choices under circumstances in which your wishes are unclear. You can indicate whether or not the decisions of the proxy should override your wishes if there are differences. And, should you name more than one proxy, you can state who is to have the final say if there is disagreement. Your proxy must understand that this role usually involves making judgments that you would have made for yourself, had you been able – and making them by the criteria you have outlined. Proxy decisions should ideally be made in discussion with your family, friends, and physician.
What to do with the form. Once you have completed the form, you and two adult witnesses (other than your proxy) who have no interest in your estate need to sign and date it.
Many states have legislation covering documents of this sort. To determine the laws in your state, you should call the state attorney general’s office or consult a lawyer. If your state has a statutory document, you may wish to use the Medical Directive and append it to this form.
You should give a copy of the completed document to your physician. His or her signature is desirable but not mandatory. The Directive should be placed in your medical records and flagged so that anyone who might be involved in your care can be aware of its presence. Your proxy, a family member, and/or a friend should also have a copy. In addition, you may want to carry a wallet card noting that you have such a document and where it can be found.