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Advance Directive
Usually when you are ill, you are able to discuss treatment options with your doctor. You can then jointly reach a decision about any future treatment. As a mentally competent adult you cannot be given medical treatment without your valid consent. However you may be admitted to hospital when unconscious or unable, on a temporary or permanent basis, to communicate your wishes. A time may come when you are not able to process information and understand the implications of treatment being proposed. This may be the case if you have a car accident or a stroke or if you develop a form of dementia.
In these situations you would not be considered competent to participate in making a decision about your treatment. Should such situations arise, doctors have a legal and ethical obligation to act in your best interests. You could prepare this in the form of an advance statement. Alternatively you could make an advance directive, which is also known as a ‘living’ will.
What is an advance statement?
This is a general statement of your wishes and views. It allows you to state your preferences and indicate what forms of medical treatment you would or would not like to receive should you, in the future, be unable to decide or communicate your wishes for yourself. However an advance statement would not bind doctors to a particular course of action if it conflicts with their professional judgment. There is only one form of advance statement that is legally binding - an advance directive.
What is an advance directive or ‘living’ will?
An advance directive indicates:
¨ Your specific wish to refuse all or some forms of medical treatment and ¨ The circumstances under which this refusal would apply.
It must be prepared when you are mentally capable and is only used once you have lost capacity to participate in the decision making process. It does not have to be in writing but casual remarks about health care should not be used as the basis of an advance directive. Witnessed verbal instructions should be respected but it is possible that a refusal of treatment would be ignored unless the patient spoke to a senior member of the medical team.
Are there advantages or disadvantages in deciding in advance?
You may wish to make an advance statement or directive if you have strong feelings about a particular situation that could arise in the future. This might relate to having a limb amputated following an accident or having a blood transfusion.
More commonly, a person may have been told they have a terminal illness or form of dementia. They may therefore wish to prepare an advance statement indicating the type of treatment they would find acceptable or prefer not to receive if they become unable to make their own treatment decisions.
Is an advance directive legally enforceable?
Advance directives are recognised and must be upheld under common law. A doctor is bound to comply with an advance directive if it meets the validity criteria explained in the next section.
What criteria apply for advance directives to be valid?
You: ¨ must have been 18 or over at the time the document was prepared and signed; ¨ must have been mentally competent and not suffering from any mental distress at the time the directive was drawn up; ¨ must not have been influenced or harassed by anyone else when preparing the advance directive; ¨ must appear to have been fully informed about the treatment options and their implications when the advance directive was made; ¨ must not have modified the advance directive verbally or in writing since it was signed and dated.
A doctor presented with an advance directive will need to verify that it is referring to the actual situation that has arisen.
Are there requests that cannot be made in an advance directive?
They cannot be used to:
¨ ask for anything that is illegal such as euthanasia or for help to commit suicide; ¨ demand care the healthcare team considers inappropriate in your case; ¨ refuse the offer of food and drink by mouth; ¨ refuse the use of measures solely designed to maintain your comfort such as providing appropriate pain relief; ¨ refuse basic nursing care that is essential to keep you comfortable such as washing, bathing and mouth care.
How often does an advance directive need to be reviewed?
It is important for doctors, who need to access your advance directive, to feel confident that you have not changed your mind since it was prepared. If new or improved medical treatments are now available, its validity may be questioned if you signed it many years ago. You will also want to check it on a regular basis to be sure it continues to reflect your views.
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