Advance Directives and Powers of Attorney

Advance directives – some issues to consider

Dr Phillipa Malpas, Department of Psychological Medicine
Faculty of Medical and Health Sciences, University of Auckland

Although it has been claimed that advance directives offer individuals "choice, certainty and control over death", it is perhaps more useful to view them as an opportunity for individuals to engage with health professionals and formally communicate their preferences and expectations around medical treatment and care, particularly at the end of life. An advance directive also symbolises medicine's commitment to patient self-determination, reminding health professionals to involve patients in the planning of decisions around their medical treatment.

Even though tremendous, beneficial advances in medicine - especially life supporting technologies - may allow individuals to physically survive for months, if not years, some individuals may feel that such interventions offer no benefit to them.

Making one's preferences (about medical treatment and care) clear and known to health professionals requires that an individual thinks very carefully, not only about what they would want for themselves if they were ever in a situation where they were unable to speak for themselves, but also so that their preferences and instructions are as clear and straightforward as possible.

Unfortunately the preferences of many patients' advance directives are not easy for health professionals to identify and carry out. This is for a variety of reasons. As individuals may have difficulty anticipating what may eventuate for them in the future, the wording of their advance directive may be vague and unclear (such as stating 'no heroic measures', 'no artificial interventions', or 'no extraordinary treatments'). A doctor may reasonably ask, "does stating 'no artificial interventions' mean the patient does not want antibiotics if they were to develop pneumonia"? As a result of this uncertainty, some health professionals may have difficulty interpreting what an individual wanted in a particular situation. Moreover uncertainties around prognosis and treatment decisions can be complex and change very quickly, further complicating what may, or could be done in the circumstances.

Questions may also be raised querying whether an individual may have changed their mind since they wrote their advance directive (especially if it was written years earlier and not updated), or when an advance directive should take effect (and who should decide this - the health professional responsible for one's medical treatment and care, or a family member?).

Understandably when doubt exists, most health professionals will favour continuing with standard medical treatment.

This does not mean advance directives have no value. On the contrary, these factors underpin the importance of individuals thinking carefully about their own preferences for medical treatment and care and ensuring that they speak to a trusted health professional (perhaps one's general practitioner) about what they would like if they were unable to speak for themselves in the future. An opportunity to talk to a trusted health professional may also clarify how you word your preferences around medical treatment.

In terms of recognising an individual's advance directive (and carrying out its instructions), a health professional has to be confident the consumer was competent and sufficiently informed to make the
particular medical treatment and care decision(s), that the decisions were free from undue influence, and that the consumer intended the advance directive to apply in the current circumstances.

Recognition that these conditions are valid means any unreasonable interference with one's advance directive is a breach of the Code of Health and Disability Consumers' Rights.

It is also important that people talk to their families and friends about their preferences. As noted, this is a very sensitive topic for many people and such conversations may be hard to initiate. However, it is important to take the time to begin this conversation with people who care about you and want what is in your best interests.

At the end of the day, making your preferences around medical treatment and care clear and straightforward will give you peace of mind that if you were ever unable to speak for yourself, your wishes would be acknowledged and respected.