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Advance Directives

Advance Directives

Advance Directives

Advance Directives: Making Difficult Decisions

  1. St. Mary’s Policy

    As an adult with the capacity to make your own decisions, you have the right to participate in decisions concerning your health care and medical treatment. Many people choose to indicate their wishes in an advance directive, such as a living will, appointment of a health care representative, or power of attorney for health care purposes. These documents allow you to convey to your family and physicians your wishes concerning your medical treatment.

    It is our policy to respect and honor your rights to the extent allowed by Indiana Law, the Patient Self-Determination Act, and the Ethical and Religious Directives for Catholic Health Care Services 5th Edition. We will not condition your treatment or discriminate against you in any way based on whether or not you have executed an advance directive. If you have an advance directive, you must provide a current, signed copy for your medical record each time you are admitted in order for your physician and those providing your care to be aware of your current wishes in making treatment decisions.

    Our Philosophy of Personhood and Service

    St. Mary’s believes that God creates each person in God’s own image and likeness. We further believe that each person, as a unity of body, mind, and spirit, has been endowed with unique human dignity, rights and responsibilities. We believe that the dignity and rights of each person must be protected and promoted with the utmost care, from the moment of conception throughout life and death.

  2. What Are Advance Directives?

    Formal advance directives are written documents that state a person’s choices about treatment or name someone to make such choices if the patient is unable to make decisions. Through advance directives patients can make legally valid decisions about their future medical treatment.

    Questions about medical care at the end of life are of great concern today, partly because of the growing ability of medical technology to prolong life and the highly publicized legal cases involving unconscious or dying patients. Many people want to avoid drawing out personal and family suffering by artificial prolongation of life for patients with no hope of recovery. The best way for the patient to assure that his or her wishes are carried out is to record those preferences for medical care in an advance directive.

  3. Laws Governing Advance Directives
    1. Indiana Law

      Indiana Law recognizes your right to consent to or refuse medical treatment. Before you become unable to make your own decisions, you can document your wishes through the use of advance directives. Advance directives established under Indiana Law include: living will declaration, appointment of a health care representative, power of attorney for health care purposes, and durable power of attorney.

    2. Other Laws On Advance Directives

      Laws differ from state to state, but in general, a patient’s expressed wishes will be honored. No law or court has invalidated the concept of advance directives and an increasing number of statutes and court decisions support it. However, an advance directive prepared in one state may or may not be honored in a different state.

      The Patient Self-Determination Act of 1990 requires all hospitals participating in Medicare or Medicaid to ask all adult inpatients if they have advance directives, document their answers, and provide information on state laws and hospital policies regarding advance directives.

  4. Your Rights And Responsibilities
    1. Time For Decisions

      There may be many decisions that you, as a patient, must make together with your family and doctor while you are in the hospital. Some may be easy, but many might be extraordinarily hard, such as deciding whether to agree to an operation. Some decisions involve soul-searching, such as deciding whether to be placed on a respirator, should the need arise.

      These decisions may require a lot of time and thought, and you may need to ask many questions. Few people make good decisions when they feel that they are pressured and rushed, so it is helpful to think about these before they occur.

      What Happens If You Become Unable To Make Your Own Health Care Decisions?

      If you become unable to make decisions about medical treatments for yourself, someone will have to make those decisions for you. However, you can influence the decisions made on your behalf by either specifying your wishes in advance or designating someone to make the decisions for you. Thinking about and discussing with family and friends such personal issues as the significance of death, fear of total dependency on others, the role family finances play in medical care, conditions that would make life tolerable, and the way artificial life support would affect the dying process can help clarify preferences. The patient’s physician should answer questions about the kinds of procedures that are often used when recovery is unlikely. Ideally, this decision-making process should begin as early as possible, take place over time, and merely need modification and more specificity as a person faces a serious illness.

      How Can You Make Your Decisions Known?

      You can make your decisions known by having one or more advance directives. These are documents that you create to protect your right to make your own medical decisions and to help your family and your doctor understand your health care wishes.

      If You Have An Advance Directive, Do You Lose Your Right To Make Your Own Health Care Decisions?

      Your advance directive will not take away your right to continue to decide for yourself the type and extent of medical treatment that you want. Your advance directive will take effect and speak for you only when you are unable to speak for yourself or when your doctor determines that you are no longer able to consent to your own health care.

      What Can You Do Now To Express Your Health Care Wishes If You Become Unable To Consent For Yourself?

      While you are still able to make your own health care decisions, there are three ways in which you can communicate your wishes to those who will be responsible in the event you are unable to do so.

      • Directly communicate your wishes to your family and doctor;
      • Appoint someone you trust to speak or make decisions for you; and/or
      • Write some specific instructions regarding your health care.


  5. What Kinds Of Advance Directives Are There?
    1. Psychiatric Advance Directive

      Any person may make a psychiatric advance directive if he/she has legal capacity. This written document expresses your preferences and consent to treatment measures for a specific diagnosis. The directive sets forth the care and treatment of a mental illness during periods of incapacity. This directive requires certain items in order for the directive to be valid. Indiana Code § 16-36-1.7 provides the requirements for this type of advance directive.

    2. Living Wills

      A living will is a document authorized under law that sets forth the kind and extent of life-prolonging procedures that you want used in the event you have a terminal condition, and you are unable to make your own medical decisions.

      1. What is required for a Living Will to be valid?

        A person who is of sound mind and at least eighteen years of age may execute a living will. In Indiana, a living will must be in writing. Oral statements are not recognized in a court of law. In addition, your living will must be made voluntarily, dated, and signed by you or by another person in your presence and at your direction. The living will must be signed by at least two competent witnesses who are at least eighteen years of age. In Indiana, the Living Will Act disqualifies certain people from being a witness, including the person who signed the living will on your behalf, your parent, your spouse, your child, an heir to your estate, anyone who is directly responsible for the cost of your medical care, or anyone who is directly responsible for providing your medical care.

      2. When does a Living Will take effect?

        Your living will takes effect when your doctor has determined that:

        • You have an incurable injury, disease, or illness that is a terminal condition; and
        • Your death will result from the terminal condition within a short period of time, whether or not life-prolonging procedures are used.


      3. What kinds of health care decisions does a Living Will cover?

        A living will sets forth the kinds of life-prolonging procedures you want withheld or withdrawn. The living will directs that life-prolonging procedures be withheld or withdrawn and that you be permitted to die naturally with only:

        • The provision of appropriate nutrition and hydration, unless you specifically decline such nutrition and hydration;
        • The administration of medication; and
        • The performance of any medical procedure necessary to provide you with comfort, care or alleviate your pain.

        Your living will may also contain other specific directions, such as organ and tissue donations.

      4. Does your doctor have to follow your Living Will?

        You must notify your doctor that you have a living will. You should provide your doctor with a signed original copy of your living will. However, your doctor has no legal duty to carry out the requests set forth in the living will. Your living will is only evidence of your desires concerning the use of life-prolonging procedures. If your doctor refuses to follow your living will, he or she must transfer you to another doctor who will honor your directive unless your doctor:

        • Has reason to believe that the living will was not validly executed; or
        • Believes that the living will no longer reflects your desires.

        Furthermore, your living will has no effect during any period when you are pregnant.

      5. What effect does a Living Will have on life insurance?

        The Living Will Act specifically states that a death caused by the withholding or withdrawal of life-prolonging procedures has no effect on the sale or issuance of a life insurance policy, even if there is a term in your insurance policy to the contrary.

      6. Can a Living Will be cancelled or revoked?

        You can revoke your living will by:

        • Signing and dating a written instrument that says you want to revoke your living will;
        • Physically canceling or destroying the living will; or
        • Orally expressing your intent to revoke the living will.

        However, the revocation is only effective when your doctor is told.

      7. Are there limitations on the scope of a Living Will as an advance directive?

        A living will only applies if you have a terminal condition from which your death is expected within a short period of time. It does not take effect if you have a terminal condition, but your death is not expected to occur within a short period of time.

        In addition, it does not take effect if you are in a coma or a persistent vegetative state with no prospect of recovery, yet you are not facing imminent death.

    3. Life-Prolonging Procedures Declaration

      A life-prolonging procedure declaration reflects your desire to use health care treatments aimed at extending your life in case you have a terminal illness from which your death is expected to result in a short period of time.

      Your life-prolonging procedures declaration must also be witnessed by two competent adults who are at least 18 years of age. However, there are no other qualifications for witnesses for your life-prolonging procedures declaration.

      Unlike a living will, your doctor must use life-prolonging procedures as you requested in your life-prolonging procedures declaration.

    4. Health Care Representative

      A health care representative is a person appointed by you under the Indiana Health Care Consent Act to make health care decisions for you when you are not able to make such decisions for yourself.

      1. When does your Health Care Representative’s authority take effect?

        Your health care representative’s authority is not limited to situations where you have a terminal condition. Your health care representative’s authority is effective whenever your doctor determines that you are incapable of making your own decisions regarding your health care.

        The health care representative’s authority ceases when you regain the ability to make your own health care decisions.

      2. Does your Health Care Representative’s appointment have to be in any particular form?

        The Health Care Consent Act does not prescribe any particular form for your designation of a health care representative. Instead, the Act states that you may specify the terms and conditions of your appointment. However, the Act does prescribe particular language that must be used if you want your health care representative to have the authority to withhold and withdraw artificial nutrition and hydration.

      3. What is required for your health care representative appointment to be valid?

        Your appointment must be in writing, signed by you or someone else that you direct to sign for you, and witnessed by an adult other than your designated health care representative.

      4. What kinds of health care decisions can your health care representative make?

        Your health care representative can decide which medical treatments you will or will not receive when you are unable to express your own wishes.

        You may also give your representative the authority to decide whether food and water should be artificially provided as part of your medical treatment.

      5. What are the obligations and rights of your health care representative?

        Your health care representative must act in your best interest, consistent with your desires expressed in the writing appointing the representative, and in good faith. The representative is given the same rights as you have to receive medical information and to consent to the disclosure of your medical records. Your health care representative does not become personally liable for the cost of health care administered as a result of the representative’s consent.

      6. Can certain persons be excluded from having the authority to make health care decisions?

        You may disqualify anyone you wish from being your health care representative by a signed, written instrument to that effect. This power may be significant, because under certain circumstances another person may be allowed or appointed to make health care decisions on your behalf. For example, you may be incapable of consenting to your own health care but do not have an appointed health care representative, or your appointed health care representative may be unable to serve.

    5. Health Care Power of Attorney

      The health care power of attorney allows you to appoint another person as your agent or attorney-in-fact who is then authorized to act for you in matters of health care under the Indiana Power of Attorney Act.

      That Act allows you to give someone the power to act for you in various matters, including health care. Because your attorney-in-fact will be acting for you in matters of extreme importance, you should only appoint someone that you trust.

      1. What health care powers are specifically granted by the Act to your attorney-in-fact?

        If you give your attorney-in-fact general authority with respect to health care, then the Act specifies certain powers that your attorney-in-fact automatically has, including:

        • Employing or contracting with servants, companions, or health care providers;
        • Admitting or releasing you from a hospital or health care facility;
        • Having access to your records, including medical records, concerning your condition;
        • Making anatomical gifts on your behalf;
        • Requesting an autopsy; and
        • Making plans for disposition of your body.


      2. When does your health care power of attorney take effect, and how long does it last?

        You must specify when the power becomes effective, such as immediately upon the determination by your doctor that you are incapable of consenting to your health care. Your health care provider must consult with your attorney-in-fact if the health care provider believes that you may lack the capacity to give informed consent to the health care provider.

        The health care power of attorney remains effective until your death, unless you earlier revoke the power of attorney. You may revoke your power of attorney at any time by signing a written cancellation and delivering the cancellation to your attorney-in-fact.

      3. Does your doctor have to comply with the decisions made by your attorney-in-fact?

        Your health care provider should comply with a health care decision made by your attorney-in-fact if the decision is communicated to your health care provider. However, if your health care provider is unwilling to comply, the provider must notify your attorney-in-fact and take all steps necessary to transfer you to another health care provider designated by your attorney-in-fact.

        It is a good idea for you to determine ahead of time if your physician will follow your treatment requests.

      4. What are the duties of your attorney-in-fact?

        Your health care attorney-in-fact is not required to exercise the health care powers you grant him or her under your power of attorney. Therefore, you should discuss your wishes with the person to whom you intend to grant your power of attorney and make sure that he or she knows your wishes and is willing to act for you in carrying out your wishes.

        When your attorney-in-fact acts for you, he or she is obligated to use due care. Your attorney-in-fact is liable for the exercise or failure to exercise health care powers only if he or she acts in bad faith.

  6. Which Advance Directive Should I Use?

    The decision about which advance directive to use is best made with the advice of an attorney. However, many people will need two advance directives. First, many people will choose to prepare either a Living Will or a Life Prolonging Procedures Declaration. Second, most people will choose to prepare either a Designation of Health Care Representative or a Durable Health Care Power of Attorney. The first document addresses issues that may arise when a patient is unlikely to recover. The second document addresses issues that may arise when the patient is expected to recover but may be temporarily unable to make his or her own health care decisions.

    What Should I Do With An Advance Directive After It Is Executed?

    You need to make sure that as many people as possible know that you have an advance health care directive. You can keep a card in your wallet stating that you have an advance directive and where to find it. You should give your physician a signed copy of your advance directive, and your physician should keep a copy in your medical records. In fact, for a living will declaration, to be effective, you must notify your doctor of its existence, and your doctor must then keep the declaration or a copy of the declaration in your medical records. You should take a copy with you to the hospital when you know you are going to be admitted.

    You should also discuss your advance directive with your family and close friends, making sure that they know not only that you have an advance directive, but also what your wishes are regarding health care treatment in various situations. You may even want to give a copy to a relative or friend that is likely to be notified in a medical emergency. Finally, if you appoint a health care representative or a health care power of attorney, be sure to give a copy to your representative or attorney-in-fact.

  7. Additional Questions

    This information often prompts additional questions concerning your legal rights. Since these decisions affect you, as well as your family, you are encouraged to discuss these matters with them. St. Mary’s Spiritual Care Department is available to discuss these matters with you, answer certain questions, and assist you in filling out a pre-printed advance directive, if you wish. You are also encouraged to discuss these issues with your personal physician, who can assist you in making choices that will affect your health care.

    Use of advance directives has legal implications, and our employees cannot provide legal advice; therefore, you are encouraged to discuss these matters with your attorney.

    Ask Questions

    You are entitled to receive information about your medical condition, a proposed course of treatment, and prospects for recovery. If you don’t understand the medical terms, please ask.

    Your doctor should be the primary source of your answers since you will be making many decisions together. The other members of St. Mary’s health team, such as nurses, social workers, therapists, and chaplains, can help.

    Be Informed

    As a patient you have the right and a responsibility to be informed. Once you have been given the information and have thought it over, you can agree to a procedure or treatment with more confidence. To enable you to make these decisions, you might ask the following questions:

    • Why is this necessary now?
    • Are there any other reasonable alternatives?
    • What are the risks involved?
    • What outcome should I expect?


    Who Makes Treatment Decisions?

    The doctor diagnoses the disease and recommends treatment. In some cases, there may be alternative treatments available, and you will be involved in the decision. When deciding on a treatment, your personal lifestyle and values will be important factors to consider.

    Often treatment must continue for a long time, and more decisions will need to be made as the treatment progresses. At this point, you may want to discuss the following questions with your physician:

    • How will this treatment affect my condition?
    • What are the benefits of the treatment?
    • What are the burdens of the treatment?
    • For how long will the treatment need to continue?

    When discussing reasonable treatments with your doctor, be as open as you can about your personal feelings and views, and any particular concerns or fears you may have.

    If an illness progresses, there may be more serious decisions that the patient and family will need to consider. Many times, patients are unable to make these decisions, so others – usually the next of kin – must do so. That is why discussing your feelings about the issues presented in this brochure with your family and friends sometimes helps them to make a tough decision, should that become necessary. These decisions may involve life support systems, resuscitation procedures, organ donation, and tissue transplantation.

    Decisions About Life Support Systems

    People tend to think of life support systems as machines that keep you alive, such as a ventilator that breathes for you when you need help or are unable to breathe on your own. In the broad sense, however, a life support system can be something as simple as an intravenous solution (IV) that delivers nourishment to you.

    Many of us have heard about people being kept alive on machines and want no part of it. But life support systems are used every day to help people overcome an illness. Ventilators, for example, are often used after surgery to support the patient’s breathing until s/he can breathe on his/her own. Unfortunately, there are situations that occur in the course of serious illness that may require you or your family to make a decision about prolonging life when there is little hope for a meaningful recovery. You should discuss with your doctor what a “meaningful recovery” means to you.

    As a Catholic hospital which adheres to the Ethical and Religious Directives for Catholic Health Care Services 2001 Edition, St. Mary’s believes that life is a basic good to be preserved and regarded in relation to other values and the belief in a life after physical death. In some situations, continuation of treatment may merely extend the time of dying and perhaps interfere with the expression of religious and spiritual values held by the patient.

    When it is apparent that there is no chance for meaningful recovery despite all that is being done, many people would prefer not to be placed or kept on life-sustaining systems. Deciding to forego life-sustaining measures in no way means that all medical care stops.

    Decisions About Resuscitation

    Code Blue is used at St. Mary’s as a potentially lifesaving set of procedures carried out on a person whose heart and/or lungs have suddenly stopped functioning. This resuscitation measure includes: external compression over the breast bone to stimulate the heart, electric shock to the heart, placing a tube in the windpipe and breathing for the patient, and using drugs to restore the blood pressure. This type of resuscitation involves using life support systems in a concentrated effort to save a life.

    There are situations, of course, where resuscitation is usually not appropriate. For example, at the end of a terminal illness, the patient or family members may not want lifesaving measures to be performed. This decision would be appropriate if a reasonable rational decision was made by the doctor that lifesaving measures would be of no benefit to the patient.

    In other situations, however, resuscitation is appropriate to assist with a sudden, sometimes unexpected, episode that may be corrected with quick, proper medical assistance. An example of this is an unexpected reaction to medication that may cause temporary breathing difficulties of a correctable nature.

    Your doctor may bring up the question of whether resuscitation should be performed, and you may feel free to ask about this at any time. It is important that, whenever possible, such a decision be discussed with your family and your wishes be made known to your doctor.

    What Is Comfort Care?

    All patients are entitled to adequate relief of pain and suffering. Whatever the patient’s choice about life support, resuscitation, or other end-of-life measures, the patient is entitled at all times to adequate relief of pain and suffering. Patients will be provided adequate analgesia to relieve pain, may be supplied supplemental oxygen to relieve breathing difficulties, may be provided X-ray treatments designed to relieve pain, and will be provided whatever other treatments are necessary to ensure that the patient is comfortable at all times.

    What Is Brain Death?

    There are occasions when life support systems are no longer appropriate. The State of Indiana passed a law expanding the concept of death to include not only heart and lung failure, but also total brain failure.

    Technology has allowed us to mechanically maintain the heart and lung functions of those who have lost complete functioning of the brain. When such a situation occurs and brain death is verified by a thorough assessment of the nervous system, the patient will be declared legally dead. This definition is important for two reasons.

    First, if the patient has not addressed the issue of organ donation in an advanced directive, you may be approached about organ donation. In order for organs to be viable for transplant, the patient’s body must be kept on a ventilator until the organs are removed. Second, if for any reason the patient is not a candidate for organ donation, ventilator support will be terminated.

    Decisions About Organ And Tissue Donation

    The State of Indiana requires all hospitals to approach the legal next of kin at or near the death of a patient to inquire about organ and tissue donation. A request will not be made if it is known that the patient did not wish to donate or is not an acceptable donor. You may wish to discuss this with your physician.

    St. Mary’s Spiritual Care staff, along with our Medical Center’s health care professionals, is prepared to assist you in making decisions about organ and tissue donation.

    Making A Decision For A Loved One

    As a relative, you may have had a chance to discuss the patient’s wishes with him or her at an earlier time.

    If so, by letting the doctor know your loved one’s preferences, you can help carry out his or her wishes and thereby respect the personal dignity of the individual.

    If you have not discussed this with your loved one, then you need to think seriously about the values that are important to him or her. Your doctor, nurse, social worker, or chaplain may help you decide what your loved one might have wanted in the situation if he or she were still able to express a preference. The decision that is made should convey, as far as possible, what the patient would want and not your own ideas or feelings.

    A Team Of Caring Professionals

    In addition to your family, physician, and clergy, the staffs of the following departments at St. Mary’s are prepared to help you through the decision-making process:

    Spiritual Care. St. Mary’s Spiritual Care Department provides support and counseling for patients and their families. Chaplains are available to help explore alternatives from a spiritual perspective. They can be reached at (812) 485-4150.

    Social Services. The Social Services Department helps with problems relating to health care after discharge and adjusting to lifestyle changes. Staff members can contact appropriate community resources to assist the patient. For more information about these services, please call (812) 485-4462.

    St. Mary’s Medical Center Ethics Committee.

    The St. Mary’s Medical Center Ethics Committee provides counsel and support, promotes communication, shares information, and clarifies ethical principles and concepts for patients, families, and the health care team. The committee can be contacted through the Spiritual Care office at (812) 485-4150.

    Our Commitment To You.

    Decisions like the ones addressed in this brochure are very hard to make, but they are facts of life that cannot be ignored. Fortunately, these dilemmas can be made easier to face through thoughtful discussion.

Disclaimer: The information provided is subject to constant change and therefore should serve only as a foundation for further investigation and inquiry. The information provided is for general use and is not intended to substitute for legal advice.

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